A few weeks ago, the honourable Health Minister of India promulgated that no ‘No Obligation to Return to India’ certificate will be issued henceforth to USMLE (United States Medical Licensing Examination) aspirants under any circumstance, exempting those above 65 years of age. The NORI is needed by medical students who take up a US residency on an exchange visitor/J1 visa, which entails a compulsory return to India for a minimum period of two years after residency. The US government mandates the provision of this certificate to waive this requirement of home country presence, following which doctors can plan their work and settlement in the United States. Thus, this policy thins the hope of those doctors who, after their residency, wish to settle or even work for some duration in the US, and will force them to come back.
It’s not the first time that newspapers and forums are stormed by such coercive and outrageous propositions. Back in 2012, a similar proposition was made by the then Health Minister, who would go so far as to state that doctors who don’t comply and return to India will be deprived of their right to practise in the United States. The reason cited enthusiastically is a brain drain of doctors leading to shortage of skilled medical workforce in the country. Brain drain or not, the effective doctor shortage in India with a Doctor-Population ratio of 1:1700 ain’t a joke, and needs to be dealt with seriously. But, with a shortage of nearly 7,00,000 doctors in the backdrop, and roughly 1000 doctors embarking for abroad studies every year (one third of whom eventually return to India without coercion) out of nearly 50,000 MBBS doctors produced annually — the fact that the first thing to catch the government’s attention while dealing with doctor shortage is a nominal pool of US goers — that too to an intensity that compels it to formulate coercive policies, is what surprises me and makes this topic very dear to me today. Is it another addition to the list of instances which prove that doctors have become recognised easy targets?
It’s consistent with logic, and it won’t take you to strain much nerve to comprehend that emigration, or leaving a country for another, is a fundamental right. When I want to move into a different country, things lie between me and the nation I want to move into — not the nation I wish to leave, unless I am a fugitive from law, or my departure would produce a grave danger for the populace of the nation. Several declarations have been quoted throughout the media about how this policy violates the fundamental right of doctors. I shall ask for the liberty to present two of them:
The United Nation’s ‘The Universal Declaration of Human Rights’:
(1) Everyone has the right to freedom of movement and residence within the borders of each state.
(2) Everyone has the right to leave any country, including his own, and to return to his country.”
The Constitution of India:
“Article 13 of the Indian Constitution states that: Laws inconsistent with or in derogation of the fundamental rights
(2) The State shall not make any law which takes away or abridges the rights conferred by this Part and any law made in contravention of this clause shall, to the extent of the contravention, be void”.
What astonishes me is how easily one can talk of violating this fundamental right in case of doctors without talking on similar lines about other professionals, like engineers and businessmen, that flock into the United States in far greater numbers. Is the desperate situation concerning the shortage of doctors inciting the rather socialist side of our democratic leaders? Are we approaching an authoritarian state of the likes of China that curtails the right of its citizens to leave the country? If this proposal prevails, I can envision that the government would one day confine me to a state, a district or a village claiming that it needs me more — and I can’t venture to affirm without doubt in my mind, that ten years down the line, I shall not be restricted from marrying a foreigner simply because there are enough options in this country.
Another reason that has been cited repeatedly is that students from government medical colleges enjoy heftily subsidised education, which makes it their duty to pay it back through service to the nation. An AIIMS study reportedly figured out that the government invests nearly Rs 1.6 crore to produce an MBBS doctor through the 4.5 years of the course. The veracity of this figure has been questioned a multitude of times, and many reasons have been presented why Rs 1.6 crore is an inordinately blown up figure. Let us consider amongst them one simple demonstration about MBBS interns. It’s known to everyone that in government medical colleges, except a few, an intern has to play roles and work for hours that are far from what he/she rightly should. Things like supervised training, shadowing with limited clinical responsibilities and learning are farcical in many of them. Together with menial jobs, an intern has to work as a practising doctor, juggling patients that are left to be guinea pigs to them, and bear the brunt of inadequately staffed hospitals. They work for over 100 hours per week, which clearly betrays the provisions of the Indian Labour law that mandates no further than eight hours of work per day. Further, they aren’t entitled even to one mandatory leave per week, again violating the law. With all that in mind, it is in every way reasonable to figure their stipend at around 2/3rd of what residents get, if not totally on par with them, with pay of overtime being additional. One won’t be at fault if he reasons that as interns uncomplainingly accept sums as paltry as Rs 6,000-10,000, they pay a surplus Rs 20,000-30,000 back every month straight to the government. A similar argument can be stretched in case of PG students also. Imagine tens of such arguments over inadequate equipments, inadequate staffing and poor hospital maintenance and the figure ‘Rs 1.6 crore’ would appear downright dubious. Still, there is a rural service stint for doctors to pay back if anything has been hitherto unattended. If an MBBS doctor is still left with any debt, the government can, at the most, make USMLE aspirants sign a bond worth a pertinent amount — which they’ll have to pay if they choose not to return. That would be perfectly reasonable. How can one justify coercing them back into the nation for ever after, simply because they’ve had their education subsidised for four and a half years?
Those who take the road to a US residency have to shell every bit of money out of their own pockets: some sell their cars and property, some draw loans and many have to put in a lifetime of savings. Why doesn’t the government subsidize their expenses if they wish their doctors to return and serve the nation? If you think about the doctors that return to India with high-priced expertise like organ transplantation, such a subsidy would appear to be a worthwhile investment. By precluding doctors from working abroad and earning back the money they spend, such a policy will only dissuade doctors from attending foreign schools and channelling such skills into the nation.
There is a paucity of government PG seats in India. Private seats cost well in the order of crores of rupees. If you can’t afford a private seat (or your logic or conscience repel you from it) it can very possibly take you to cloister yourself into your reading room for months and years together, siphoning your youth away. USMLE, with expenses far less than buying a PG seat, and with a reasonable amount of effort involved, becomes an attractive option for many. This policy of non-issuance of NORI certificates is a step towards strangling this option to death. The number of residency programmes that offer a J1 visa exceeds those that sponsor the H1B working visa (which is exempt from the NORI requirement). With the J1 option turning ugly, the competition for H1B sponsoring programmes will become stiffer. All of this is destined to make USMLE grossly unattractive. Further, considering the fact that many students find a H1B sponsoring programme, and some on J1 visa make into the CONRAD 30 waiver programme, the assumption that coercing a few doctors to return will solve the problem of doctor shortage is fallacious and lacks sense.
There are plenty of people around who are affected with the conviction that doctors leave for abroad out of greed — that they cherish a starry-eyed view of the foreign land which is composed of tall buildings, luxurious cars and stacks of dollars. I won’t repudiate it entirely, but I feel they need to experience what inadequate infrastructure, paucity of staff, inhuman working hours, inadequate security and an ethically compromised system (you have a picture? Add to it stinking corridors and clogged toilets too!) leaves them with, especially after a decade of medical education that leaves them baffled about the purpose and quiddity of life.
Another fact that had been kept at the sidelines is that NRI (non-resident Indian) doctors bring more than just name to the nation. India is a leading receiver of remittances (money transfer from NRIs) accounting to about 70 billion US dollars (2013-14), which even exceeds the FDI (Foreign Direct Investment) into India. Twenty-nine percent of that comes solely from North America.
I don’t mean to shroud the need of taking up the weighty issue of doctor shortage. The problem has roots that have spread far and deep, and to decipher them would take some serious brainstorming and introspection. A policy that curtails fundamental rights and is grossly untenable will only fetch us some malcontent minds and tarnish the image of our nation.
by Dr Soham D Bhaduri