Dr Mohanan Nair’s paper (1) was an unpleasant but a more or less factual reminder of the state of affairs in the medical colleges of Kerala. It might benefit from a historical perspective and a comparative assessment with other medical institutions in India. The decay of medical colleges in Kerala reflects the general trend in this country where almost all public sector undertakings have failed in their mission. The few exceptions only prove the rule. I have seen once proud academic medical centres becoming centres of revolt, anarchy and political fiefdom. Research has taken a back seat. Many so-called missionary hospitals, which did a lot of charity work in the past, have now become profitable centers catering to the rich rather than the poor.

Harassment by medical teachers

Harassment of medical students is not new. Our teachers too subjected us to harassment. In the 1960s, hardly 11 of the 100 or so in our batch were given an ‘average’ score in the internal assessment of the pre-clinical department, but none of us dared to question our scores. If I remember correctly only 38 of us cleared the first MBBS exam-ination that year in our first try. A similar pass percentage today would probably bring on a medical students’ riot. Teachers in clinical subjects were more liberal in the past, but newspaper reports suggest that changes have come about there as well.

KGMCTA, private practice and research

The Kerala Government Medical College Teachers’ Association (KGMCTA) used to have devoted office bearers, and I believe that they still are. The KGMCTA is not a powerful lobby, as Dr Nair suggests, but it may be true that some members are centres of power.

Like any service organisation, the KGMCTA could do much for the common good through collective bargaining. The most remarkable of its recent achievements is the pay hike in 1997-98 bringing salaries on par with those in the central government, or in autonomous medical institutions where private practice is banned. Till about eight years ago, the maximum monthly salary of a senior professor in a state college was less than Rs 10,000. Now a junior lecturer gets more than that. A professor’s pay scale is now Rs 16,400-22,400 with additional perks and pension. Ostensibly, this pay hike was to stop private practice by medical college teachers. Still, I agree that in a country where a software engineer gets more than Rs 50,000 per month, the present salary scale of a medical college teacher cannot be considered too high.

The KGMCTA had said earlier that it would support an end to ‘private practice’ once the salary structure was on par with that of the central government. However, now that it has happened, the KGMCTA has assumed an ambivalent posture. But, this is a non-issue, since all health ministers except one have declared that private practice is a ‘social’ necessity in Kerala.

Advantages and disadvantages of private practice

As a physician who had the benefits of private practice throughout his career, I can see its pros and cons. When salaries of government medical teachers were just about one-fourth of the present scale, it did not seem inappropriate to permit doctors a restricted private practice from their residences. Most physicians did well with this. However, surgeons often required hospital set-ups for their work. As a result, private patients were given priority in admission and preferential treatment in teaching hospitals, or were admitted in private hospitals where the same surgeon went surreptitiously and operated in his ‘free’ time, against governmental restrictions. The free time was invariably stolen from his ‘hospital’ time. As it was easier to use government hospitals for private practice, poor patients had to wait interminably for their turn. But, even this was certainly better than the situation in government hospitals in the rest of India, as the public and a vigilant media in Kerala would not tolerate gross irregularity for long.

There was another argument in support of private practice. Most research funding from central government agencies was given to national medical institutions, with few exceptions. Research requires a lot of money and is not done when money is not available. Publishing research papers does not benefit medical college teachers in Kerala as publications are not taken into account for promotions or other benefits. Presenting research papers at medical conferences again involves money, which young doctors can ill afford. Before the advent of home personal computers, even making an ordinary projection slide cost about Rs 40. An hour-long lecture requires at least 40 slides. Most of us paid for our travel expenses and slides from our own pocket. The pharmaceutical industry was more concerned with successful individual practitioners and the ‘central’ institutions than ‘research-minded’ medical college teachers. Still, the academic record of the teachers of medical colleges in Kerala was not inferior to that of other similar institutions in the rest of India. ‘Private practice’ certainly helped us to make a decent living.

Again, to get official leave to attend a conference was itself a task. The request had to be processed through a number of authorities from the head of the department to the health minister, with delays at each stage. Often, the order would come after the conference was over. It was possible for teachers in Trivandrum Medical College to use their local contacts to expedite the process. I believe that things are still as bad as before in these medical colleges but not for the staff of other medical colleges. I must confess that despite all these hurdles, one sees excellent papers published from different medical colleges even now, in both clinical and pre-clinical subjects.

Ethical issues

I strongly disagree with Dr Mohanan Nair in his discussion of ethical issues in Kerala medical colleges. Kerala does not have ‘kidney villages’ surrounding any medical college. There are certainly many minor infringements in ethical standards in these medical colleges, but they are insignificant when compared with the state of affairs in the rest of India. Perhaps we will catch up with other metropolitan cities in this matter as well.

Foreign service

Like the sabbatical leave given by some medical institutions, medical college teachers are allowed to take leave. It was for up to 15 long years till recently. I understand that it has been cut to about 10 years, and leave is not given in specialties where there is a shortage of manpower. However, when somebody holds a full-time post in a foreign country throughout his career as a medical teacher here, Nair’s argument becomes embarrassingly valid. It is true that new posts are seldom sanctioned, fresh vacancies go unreported and teaching and other services are affected.

We have all heard horror stories about some of the newly opened private medical colleges in Kerala. Of course, there are a few private medical institutions that are doing excellent teaching, clinical and research work. They are the exceptions.

The rise and fall of Trivandrum Medical College

The history of the first medical college in Kerala is a story of dedication, will, and eminent teachers and students. Dr C O Karunakaran and Dr R Kesavan Nair, two great medical teachers, founded this institution in a record 16 months with an initial funding of Rs 50 lakh. The first batch of 60 MBBS students joined this college in 1951.

The Trivandrum Medical College was a fulfilment of a popular ambition. Most of the students of the initial batches stayed back and were instrumental in bringing out the ‘Kerala model’ of healthcare delivery. Even though some Keralites have criticised the very idea of the ‘Kerala model’, we have achieved a great deal. Many of the alumni went abroad seeking greener pastures. They have all done well in their chosen countries. But greater credit should be given to those who stayed back and developed this institution.

Later, two other institutions came up in the campus of Trivandrum Medical College—the Sree Chitra Tirunal Centre for Medical Sciences and Technology and the Regional Cancer Centre. Both these institutions owe a good part of their success to the alumni of Trivandrum Medical College.

It would be difficult for today’s medical student to imagine that postgraduate theses of Trivandrum Medical College were quoted as authoritative references in standard textbooks way back in the 1960s and 1970s. Those days have gone. The picture has been complicated by the many private colleges, staffed by retired teachers of government colleges. There is bound to be resentment that medical education is being made a commodity for the rich. More than half a dozen private medical colleges have come up in the past 12 months in Kerala. Perhaps it is too early to criticise them but even the prestigious ones among them put up names of non-existing academic members in their staff list.

Most of the issues raised by Dr Nair are applicable to almost every medical institution in India. Variations of the same problems are seen in the so-called central government and autonomous institutions as well. The constant bickering, the dissatisfaction, anomalies in promotions and interpersonal clashes have made some of these places miserable. Patient care also suffers as a result. The basic trouble is that we Indians do not allow anything to flourish. If anything worthwhile happens despite these efforts, we do everything to destroy it. The ultimate beneficiaries are private medical institutions.

It is time now for both the government and medical college teachers to introspect and give proper guidance to the future of medical education in Kerala, where education is considered supreme even by the common folk.