Perhaps no event in the recent past captured the imagination of the mainstream media as much as the protests against the proposal to introduce reservations for other backward classes in some institutions of higher education (1). Although a small but active group of doctors supports reservations, their views were barely covered by the media. The television and print media were instead flooded with reports and images of the protests. Medical students led this agitation and it may be worth keeping track of the increasing presence of the medical profession in political activity of various kinds.

The corporate sector, whose concerns are generally reflected by the media, is anxious to squelch talk of extending reservations to private companies. Media coverage was also influenced by the fact that the protests were held in some of the more prestigious educational institutions in the country. Doctors of the All India Institute of Medical Sciences rarely protest about anything, so any agitation involving them becomes news. It is worth noting that the director of the institute came out in support of the strikers.

The agitation no longer dominates headlines, but it is a good time to highlight some of the key issues involved, especially with reference to the medical education system in India.

First, professional education — including medical education — is by and large an aspiration of the middle class and is seen as the route to financial success. Anti-reservation agitators are driven by the fear that reservations will narrow this avenue of economic advancement; it will reduce their share of the pie, as it were. There is no indication that the protestors are worried about the quality of medical education. Neither do they seemed concerned about whether medical education and the health-care system are meeting their avowed aim of providing affordable and accessible health care to all those who need it.

Most students from the best professional institutes in India either end up in corporate hospitals or migrate to staff health systems of wealthy countries, confident that the Indian government will not enforce bonds requiring them to work in rural areas for a stipulated period after their degree. We suspect that the agitation is more about protecting the income levels of a small group of people who serve the corporate health-care industry, both in India and abroad.

Second, we must respond to protestors who incorrectly equate marks with “merit” and are afraid that caste-based reservations dilute academic standards, thereby reducing the quality of medical care that is available to the public. While the system of reservations may lower entry requirements to permit less-privileged people to enter higher educational institutions, the exit requirements — the assessment of performance — remain the same. The questions the public must ask in this context are: how well does the medical examination system evaluate the quality of graduates? What is done to prevent corruption and maintain high standards?

Third, the “merit” argument presumes that only the brilliant can practise medicine. On the contrary, everyday medical practice depends not on brilliance but on dogged work. It consists of looking at patterns, following protocols for testing and conducting appropriate procedures to treat the condition — at least that is how it should be. We are not talking about Nobel prize-winning work here — and our “merit”-based system has not produced that either in 50 years — but of the day-to-day persistence required to practise good clinical medicine.

Fourth, the anti-reservation agitators have not expressed any opposition to the money-based reservation system of capitation fees and its impact on medical education and practice. The money-based reservation system in fact dominates medical education today. It has led to cohorts of medical professionals for whom their skills are just another way to reap the dividends of their investments in the commercialised medical education system.

The true threat to medical education

The danger to medical education comes not from lowering entry requirements in medical colleges to help the historically disadvantaged. It comes from the wholesale corruption of standards — the shoddy inspections by the Medical Council of India, the lack of professionalism and ethics which has become an endemic disease among medical teachers, the skewed priorities of students who see medicine as a pathway to economic success rather than as a profession. The epitome of all these ills is the colleges, which collect huge bribes under the euphemism of a “capitation fee”. The rot sets in early, with the accepted formula of buying your way through all hurdles.

Reservations are not a threat to medical education; caste and casteism are the real dangers. More than half a century after independence, the vast majority of upper-caste Indians refuse to acknowledge the historical and ongoing oppression of certain caste groups in India. Among the upper castes who dominate the middle-class educational scenario, the lower castes are seen as freeloaders getting concessions that they do not deserve. The few who manage to gain access to the system are held up as examples of, to use Bernard Shaw’s phrase, “the undeserving poor”. This attitude was evident in the recent agitation where medical students openly expressed their contempt for lower castes, equating physical work with low caste and indicating that reservations would open up the “respected” medical profession to people who are only fit for physical and demeaning labour.

The culture of the medical education system is the culture of the dominant castes who form the majority of students and faculty. Students from reserved castes in medical college are isolated from other students and humiliated by teachers (2). For the upper castes, the attitudes taught at home and reinforced during medical education are carried forward into medical practice, where the poor and less privileged are treated differently than the better-off.

The policy of reservations in medical educational institutions requires us to look at the ethical implications of medical care in India. With or without reservations, irrational medical practices persist in a highly commercialised and unregulated system of medical care. This situation is fed by an increasing number of capitation fee colleges churning out graduates whose only aim is to earn back their monetary investment. The government’s response to anti-reservation agitators has been to suggest an increase in medical seats when there is no shortage of doctors in India but a problem of where they are located.

Medical care in India today is by and large a privilege of the urban rich. The government has reduced its own services and also encouraged a situation where doctors and medical facilities are concentrated in urban and semi-urban centres where there are enough people who can afford to pay — or at least manage to pay –for services. Infrastructure in rural India continues to be abysmal and this neglect dissuades all but the most committed doctor from settling there.

Reservations are essential to give the disadvantaged access to education and employment, but much more is needed to change the face of medical practice and health care in India. The entire system in fact needs to be changed. Health care must be viewed as a right. The profession should offer financial security but not great riches. This will reduce its attraction to those enter it primarily for personal advancement. Medicine should be about helping people who are ill, disabled and depressed.

Reservations could be viewed as an ethical requirement in medical education institutions that must build and strengthen a people-oriented health-care system. Reservations may in fact encourage students who have more empathy for the disadvantaged who form the majority of the patient population in India. We may yet get a cadre who is in medical practice out of concern for other human beings.