- Email: [email protected]
MEDICINE IN INDIA
1381
The Wider World MEDICINE IN INDIA T. W. MEADE Public Health Department, London School of Tropical Medicine, London W.C.1
No
Hygiene and
democracy faces greater problems in providing
and medical education than India. Its population (520 million)-second only to that of China -makes it the largest free society in the world. Poverty and illiteracy are wide-spread. The Fourth Plan1 (1969-74) has allocated an annual 10s. to be spent on the health of each man, woman, and childone of the world’s lowest figures, and a stark comparison with the C35 allocated in Great Britain. Distances are enormous; road and rail journeys are slow and often difficult, and most people travel by bullock-cart or on foot. Languages present another communications difficulty: 14 languages are spoken by 87% of the people, while the remaining 13% speak no fewer than 812.2 Agricultural progress is still too often offset by the vagaries of the monsoon-and looming over every actual or potential achievement is India’s (and the world’s) greatest problem, overpopulation. The country’s annual rate of natural increase, at 2’5%, means 13 million more mouths to feed in 1970 than in 1969. By the end of the century, India may well have overtaken China with the world’s largest population. Every social and economic advance has to be measured against this crucial index of population growth; too frequently, still, the latter is the greater. India must," in many spheres, run simply to stay in the same place. Individual family planning and the more general concept of population control have barely scratched the surface of the problem. The country’s youthful population, poised to double India’s numbers by the year 2000, finds itself competing in a labour market where 10 million are officially unemployed, to say nothing of the 16 million only partially employed.3 Both of India’s principal neighbours, China and Pakistan, have invaded within the past 8 years. Few, inside or outside India, would seriously contest the existence or size of any of these problems. A free Press, and widespread domestic interest in the (currently swiftly altering) political scene, have ensured that these vital issues are not glossed over or ignored. With a background of this kind it is almost impossible (and difficult even in a developed country) to pick out one topic, and to discuss it in vacuo. To consider the provision of medical care and education, in particular, at once raises questions of policy and priorities in virtually every other area of the country’s economy and planning. There are, however, two basic facts which
medical
provide
care
a
starting point. THE VILLAGES
The first is that India is,
principally,
a
country of
500,000-600,000 villages (mostly of one or two thousand people) scattered over the countryside; 80% of the population lives in these villages. Many villages some
from the nearest centre where even the basic medical facilities might be expected-with
are remote
most
the well-known consequences that distance exerts on attendance.4 The second fact, however, is that some 40% of India’s registered doctors live (and practise) in the 19 or so largest towns and cities, serving only 4% In fact, India, or so of the country’s population.5 with 170 doctors per million population, compares very favourably with 25 per million in Nigeria, and 20 in Malawibut a majority of these doctors provide care mainly for the (usually affluent) few. There is consequently a vast undermanning of the medical services just where they are most needed-in the country and among the villagers. It is intended that there should be a primary health centre (recommended in the Bhore report)with a doctor as the doctor of first contact, in each development block of 60,000 to 100,000. There are in fact just over 4900 such centres ("the base of the integrated structure of medical services in the rural areas") 1-a remarkable advance over the figure of 725 in 1956.2 But these centres mean little when so many are closed, or only partly functioning, because they have no staff; at least 8% have no doctors, many " lack buildings, residential quarters and equipment ", and 350 development blocks have no primary health centre at all. The situation is partially alleviated by paramedical teams. These are expanding, and, in addition to some trained auxiliary staff, are often composed of young men and women who trained and qualified in non-medical subjects and cannot find work in their own fields (engineering is the outstanding example). These people receive further training which enables them to give some elementary medical care, promote health education, and carry out surveys of disease. (This is, incidentally, a situation from which we in this country could learn much in terms of what the non-medically trained can do, and do to a very high standard.) But, encouraging though the para-medical movement is, it lacks what it needs most-direction, supervision, advice, and continuing support from medical staff. India’s most urgent administrative medical need, therefore, as in so much of the world, is somehow to divert doctors (and increasing numbers of auxiliaries) into the rural areas. The most attractive theroretical approach is, of course, to encourage young doctors to spend a year or two in the primary health centres after registration. But even with some kind of financial incentive (which is constantly under review) this is likely to involve the young doctor in considerable isolation, particularly from more senior professional colleagues, at a time when he will especially want their support. He may well not have electricity or piped water in his house; if he is married and has children, there will almost certainly be domestic and educational difficulties. It is not an easy life, or an inviting proposition. Financial incentives so far have not worked: proposals for a system of conscription, or of bondserving (whereby the costs of training are paid in return for an undertaking to serve for a spell in a nominated area), are widely criticised as infringing freedom of choice. A partial solution may be evolving, however. As the number of newly qualified doctors increases, the much-sought city jobs are becoming more and more difficult to secure, and it is hoped that this force of circumstance will make the staffing of rural hospitals and centres easier.
1382 MEDICAL EDUCATION
In medical education, therefore, the most pressing question is whether there is a better, if more radical, method of producing doctors willing to practise in the villages. This and other needs have led to a situation in medicine in India that mimics, in miniature, the population explosion-the enormous proliferation of medical colleges. In 1937 there were 10 colleges and 27 schools (these gave licentiate training, and no longer exist as such). By 1949, 29 colleges and 3 schools were training 2000 doctors a year. In 1968 there were 91 colleges, and by 1974 the number will be 103, with a capacity of 13,000 admissions annually.! But another acute shortage is teachers of medicine, especially in pre-clinical subjects. Some of the new medical colleges have admitted students with very little provision for later access to clinical material and teaching. Unrest among medical students recently has largely sprung from a not unreasonable concern that full recognition of their courses may be withheld or withdrawn on these grounds. There are by now real fears that quality has been sacrificed too much to quantity, and many people feel that the number of colleges and students should not increase any further until adequate facilities are assured. As a corollary, pressure for fuller recognition to the country’s thousands of indigenous practitioners is mounting. There is, however, an even more fundamental barrier to the provision of medical care to the villagesthe interests of those selected for a medical education,
and their consequent reaction to the needs and demands of their society. Many, probably most, of those who receive medical training come from the cities 9; their families (and family ties are, of course, exceptionally strong) live in cities, and their way of life and their expectations are based in the cities. While they may well understand the needs of the countryside, they are not attracted to practise there, and no-one can really blame them for this. (A substantial number of places in medical colleges are reserved for members of Scheduled Castes and Tribes. The main object of this is social equality, but presumably it may also encourage those who may have some positive motivation for rural
practice.) There are two broad ways in which the problem of rural practice in India could be tackled at the undergraduate level. The first would be to identify and select students whose interests and backgrounds apparently make them more likely than others to spend time in the villages. This would be a difficult job of eliciting and assessing attitudes, motivation for choosing medicine, and so on. Britain’s Todd Report6 made it quite clear, in the little more than one page it devoted to aims and methods of selection, how little is known in this area. But, conversely, no-one has demonstrated that the job is impossible, and Indian medical educators, with the very clear distinction that can be made between the needs and different motivations for rural and urban practice, may be in a unique position for experiments in the selection of medical students which could be of the greatest importance throughout the world. For the health of a developing country, there could be very few more valuable assets than the ability to spot the candidate whose interests
likely to be the rather impersonal prevention of typhoid in fifty healthy people than the much more dramatic and personal treatment of one case. This example points the way to the second method. If one cannot influence the choice of students, one can influence what they are exposed to during their training. Social and preventive medicine (and prevention, whether it be of the water-borne gastrointestinal infections, or of overpopulation, is the key to medical practice in rural India) are compulsory subjects for all medical students, and each college must have a department. But, here again, the gap in our knowledge is general; we have no idea whether exposing medical students to a particular subject makes them any more, or less, interested in it-though no exposure must virtually preclude interest of any kind. As with the question of student selection, the opportunity, as well as the urgent need, exist in Indian medical education for studies that could have far-reaching implications there and in other countries. are more
POPULATION CONTROL
Greater
emphasis on rural practice and preventive is, therefore, of fundamental importance in medical service and medical education in India; its necessity reaches a peak, of course, in the area of family planning and population control. Government and
measures
financed programmes are much in evidence but, apart from a very small number of local and exceptional efforts, there is no evidence that they have had any important effect. This, again, is not disputed by many politicians and others interested in the problem. Since most births and deaths have not hitherto been registered,2,IO it is difficult to be sure of these basic rates. A census is due in 1971, which will provide important data, but the latest estimates suggest little change in the birth-rate, which remains about 42 per thousand living. The crude death-rate, however, has fallen steadily since the war, and is currently between 8 and 13 per thousand living.1O The increasing control of mass killers such as cholera and smallpox, superimposed on the control of malaria and other less specific improvements, has ensured that simple and inexpensive public-health measures have had a relatively enormous effect in making all the difference between dying, on the one hand, and just living (and being able to reproduce), on the other. Medicine in its broadest sense, together with sociology and demography, must be involved in the attack on overpopulation in such a large and diverse a country as India. Doctors must increasingly see, and must teach their students, that the fitting of loops, the supply of pills, and sterilisations, are only half the answer: collaboration with many other disciplines is essential to capitalise on any possible motivations for fewer children. The Indian peasant sees nothing attractive, of itself, in having seven children when he can, with difficulty, support perhaps three. He needs, in the absence of any social security in old age, and in order to fulfil his cultural expectations and obligations, at least one son. Because so many infants and children still die of the preventible water-borne gastrointestinal diseases, mal-
privately
nutrition, tuberculosis, and
so
on
(infant mortality
remains at about 140 per thousand live births), rightly calculates that he will have to produce a
10
he
large
1383 that his needs are met. To demonhim that he could achieve them with fewer children means preventing these diseases, and convincing him, if possible, that the three children he already has will survive. Then, perhaps, he will welcome advice on family planning (though it would take a generation at least, with further very large population increases, for this approach to achieve anything). Once again, India’s urgent need could help to point the way for other countries. To shift, even slightly, the emphasis in medicine and collaborating disciplines away from the fashionable and traditionally attractive therapeutic approach, to that of prevention, could be the most significant social and medical advance of our time. India, if she is to make anything at all of her very large family-planning commitment, has to make this change of emphasis somehow, and India’s doctors have to accept, understand, and demonstrate to others that, while preventive and public-health measures have been the cause they may yet be a possible cure, of overpopulation.
family
to ensure
strate to
ABC of Endocrinology VI—THE THYROID GLAND K.
J. CATT
THE thyroid gland synthesises and releases iodinated thyronine molecules which strongly influence metabolic processes and growth. Unlike other endocrine organs, the thyroid hormones are not stored in the gland cells but in colloid-containing vesicles enclosed by thyroid epithelium as a precursor protein, thyroglobulin. Within the thyroglobulin molecule, tyrosine residues are iodinated to form monoiodotyrosine (M.I.T.) and diiodotyrosine (D.I.T.), which then combine to
form the iodothvronines (fig. 24).
The structural
INTERNATIONAL COLLABORATION
The medical
challenges that India faces, especially in overpopulation, are enormous, but mankind’s future, not just India’s, could depend on how she deals with them. For the crux of the population-control problem is not the progress, welcome though it is, that is made in closed and relatively small communities like Taiwan, Hong Kong, and Singapore; it lies in what happens in countries like India, and the countries of SouthEast Asia and South America, where the immensity of the obstacles is matched by the urgency of overcoming them, and of ensuring rising living standards which, it seems, may be a sine qua non for declining birth-rates. Worldwide collaboration on overpopulation and related topics is now essential,not simply desirable. From outside India, we in Great Britain must pay much more than the familiar lip service to the Indian doctors who are so important for our own Health
Service; we must acknowledge more readily the problems facing Indian doctors coming to work in Britain,
Fig. 24-Structural formulae of the iodotyrosines and iodothyronines.
and in particular the fact that their service here means their absence from a setting where they are far more urgently needed. To offset this, we should look for ways of encouraging more British doctors to spend time in India-especially those with knowledge and skills in public health and preventive medicine. Many will know how difficult it is even to attempt this with a country whose struggle for, and achievement of, independence have left, more than twenty years after the event, a strong political and administrative reluctance to ask for or to accept this kind of aid. But in India’s undergraduate and postgraduate medical colleges and research centres there is a tremendous store of goodwill, and a strong desire for service, teaching, and research links with Britain. From within India, it is very much to be hoped that doctors in these institutions will continue to press their Government to consider and deal more effectively and sympathetically than at present with proposals for exchange of staff and for collaborative research.
similarity of the thyroid to an exocrine gland is due to its evolutionary origin from the endostyle, an organ which secretes iodinated mucoprotein into the pharynx of protochordata.1 During vertebrate evolution, the thyroid has lost its functional and anatomical con-
References
at
foot of next column
The 6th of 7 articles. This series, together with will be published as a book later this year.
some
additional material,
1. Fourth Five Year Plan 1969-74. Planning Commission, Government of India. 2. India 1968. Publications Division, Ministry of Information and Broadcasting, Government of India. 3. National Labour Commission. Cited in Indian Express, May 17,1969. 4. Medical Care in Developing Countries (edited by Maurice King). London, 1966. 5. Technical Manpower. Bulletin of the Division for Scientific and Technical Personnel, Council of Scientific and Industrial Research, vol. x, no. 6, 1968. 6. Royal Commission on Medical Education 1965-68: Report Cmnd. 3569. H.M. Stationery Office, 1968. 7. Report of the Health Survey and Development Committee, India. 1946. 8. All-India Medical Directory and Who’s Who. Madras, 1949. 9. Prasad, B. G. in Epidemiology, Reports on Research and Teaching, 1962 (edited by J. Pemberton). London, 1963. 10. United Nations Demographic Year Book, 1967.
The Wider World MEDICINE IN INDIA T. W. MEADE Public Health Department, London School of Tropical Medicine, London W.C.1
No
Hygiene and
democracy faces greater problems in providing
and medical education than India. Its population (520 million)-second only to that of China -makes it the largest free society in the world. Poverty and illiteracy are wide-spread. The Fourth Plan1 (1969-74) has allocated an annual 10s. to be spent on the health of each man, woman, and childone of the world’s lowest figures, and a stark comparison with the C35 allocated in Great Britain. Distances are enormous; road and rail journeys are slow and often difficult, and most people travel by bullock-cart or on foot. Languages present another communications difficulty: 14 languages are spoken by 87% of the people, while the remaining 13% speak no fewer than 812.2 Agricultural progress is still too often offset by the vagaries of the monsoon-and looming over every actual or potential achievement is India’s (and the world’s) greatest problem, overpopulation. The country’s annual rate of natural increase, at 2’5%, means 13 million more mouths to feed in 1970 than in 1969. By the end of the century, India may well have overtaken China with the world’s largest population. Every social and economic advance has to be measured against this crucial index of population growth; too frequently, still, the latter is the greater. India must," in many spheres, run simply to stay in the same place. Individual family planning and the more general concept of population control have barely scratched the surface of the problem. The country’s youthful population, poised to double India’s numbers by the year 2000, finds itself competing in a labour market where 10 million are officially unemployed, to say nothing of the 16 million only partially employed.3 Both of India’s principal neighbours, China and Pakistan, have invaded within the past 8 years. Few, inside or outside India, would seriously contest the existence or size of any of these problems. A free Press, and widespread domestic interest in the (currently swiftly altering) political scene, have ensured that these vital issues are not glossed over or ignored. With a background of this kind it is almost impossible (and difficult even in a developed country) to pick out one topic, and to discuss it in vacuo. To consider the provision of medical care and education, in particular, at once raises questions of policy and priorities in virtually every other area of the country’s economy and planning. There are, however, two basic facts which
medical
provide
care
a
starting point. THE VILLAGES
The first is that India is,
principally,
a
country of
500,000-600,000 villages (mostly of one or two thousand people) scattered over the countryside; 80% of the population lives in these villages. Many villages some
from the nearest centre where even the basic medical facilities might be expected-with
are remote
most
the well-known consequences that distance exerts on attendance.4 The second fact, however, is that some 40% of India’s registered doctors live (and practise) in the 19 or so largest towns and cities, serving only 4% In fact, India, or so of the country’s population.5 with 170 doctors per million population, compares very favourably with 25 per million in Nigeria, and 20 in Malawibut a majority of these doctors provide care mainly for the (usually affluent) few. There is consequently a vast undermanning of the medical services just where they are most needed-in the country and among the villagers. It is intended that there should be a primary health centre (recommended in the Bhore report)with a doctor as the doctor of first contact, in each development block of 60,000 to 100,000. There are in fact just over 4900 such centres ("the base of the integrated structure of medical services in the rural areas") 1-a remarkable advance over the figure of 725 in 1956.2 But these centres mean little when so many are closed, or only partly functioning, because they have no staff; at least 8% have no doctors, many " lack buildings, residential quarters and equipment ", and 350 development blocks have no primary health centre at all. The situation is partially alleviated by paramedical teams. These are expanding, and, in addition to some trained auxiliary staff, are often composed of young men and women who trained and qualified in non-medical subjects and cannot find work in their own fields (engineering is the outstanding example). These people receive further training which enables them to give some elementary medical care, promote health education, and carry out surveys of disease. (This is, incidentally, a situation from which we in this country could learn much in terms of what the non-medically trained can do, and do to a very high standard.) But, encouraging though the para-medical movement is, it lacks what it needs most-direction, supervision, advice, and continuing support from medical staff. India’s most urgent administrative medical need, therefore, as in so much of the world, is somehow to divert doctors (and increasing numbers of auxiliaries) into the rural areas. The most attractive theroretical approach is, of course, to encourage young doctors to spend a year or two in the primary health centres after registration. But even with some kind of financial incentive (which is constantly under review) this is likely to involve the young doctor in considerable isolation, particularly from more senior professional colleagues, at a time when he will especially want their support. He may well not have electricity or piped water in his house; if he is married and has children, there will almost certainly be domestic and educational difficulties. It is not an easy life, or an inviting proposition. Financial incentives so far have not worked: proposals for a system of conscription, or of bondserving (whereby the costs of training are paid in return for an undertaking to serve for a spell in a nominated area), are widely criticised as infringing freedom of choice. A partial solution may be evolving, however. As the number of newly qualified doctors increases, the much-sought city jobs are becoming more and more difficult to secure, and it is hoped that this force of circumstance will make the staffing of rural hospitals and centres easier.
1382 MEDICAL EDUCATION
In medical education, therefore, the most pressing question is whether there is a better, if more radical, method of producing doctors willing to practise in the villages. This and other needs have led to a situation in medicine in India that mimics, in miniature, the population explosion-the enormous proliferation of medical colleges. In 1937 there were 10 colleges and 27 schools (these gave licentiate training, and no longer exist as such). By 1949, 29 colleges and 3 schools were training 2000 doctors a year. In 1968 there were 91 colleges, and by 1974 the number will be 103, with a capacity of 13,000 admissions annually.! But another acute shortage is teachers of medicine, especially in pre-clinical subjects. Some of the new medical colleges have admitted students with very little provision for later access to clinical material and teaching. Unrest among medical students recently has largely sprung from a not unreasonable concern that full recognition of their courses may be withheld or withdrawn on these grounds. There are by now real fears that quality has been sacrificed too much to quantity, and many people feel that the number of colleges and students should not increase any further until adequate facilities are assured. As a corollary, pressure for fuller recognition to the country’s thousands of indigenous practitioners is mounting. There is, however, an even more fundamental barrier to the provision of medical care to the villagesthe interests of those selected for a medical education,
and their consequent reaction to the needs and demands of their society. Many, probably most, of those who receive medical training come from the cities 9; their families (and family ties are, of course, exceptionally strong) live in cities, and their way of life and their expectations are based in the cities. While they may well understand the needs of the countryside, they are not attracted to practise there, and no-one can really blame them for this. (A substantial number of places in medical colleges are reserved for members of Scheduled Castes and Tribes. The main object of this is social equality, but presumably it may also encourage those who may have some positive motivation for rural
practice.) There are two broad ways in which the problem of rural practice in India could be tackled at the undergraduate level. The first would be to identify and select students whose interests and backgrounds apparently make them more likely than others to spend time in the villages. This would be a difficult job of eliciting and assessing attitudes, motivation for choosing medicine, and so on. Britain’s Todd Report6 made it quite clear, in the little more than one page it devoted to aims and methods of selection, how little is known in this area. But, conversely, no-one has demonstrated that the job is impossible, and Indian medical educators, with the very clear distinction that can be made between the needs and different motivations for rural and urban practice, may be in a unique position for experiments in the selection of medical students which could be of the greatest importance throughout the world. For the health of a developing country, there could be very few more valuable assets than the ability to spot the candidate whose interests
likely to be the rather impersonal prevention of typhoid in fifty healthy people than the much more dramatic and personal treatment of one case. This example points the way to the second method. If one cannot influence the choice of students, one can influence what they are exposed to during their training. Social and preventive medicine (and prevention, whether it be of the water-borne gastrointestinal infections, or of overpopulation, is the key to medical practice in rural India) are compulsory subjects for all medical students, and each college must have a department. But, here again, the gap in our knowledge is general; we have no idea whether exposing medical students to a particular subject makes them any more, or less, interested in it-though no exposure must virtually preclude interest of any kind. As with the question of student selection, the opportunity, as well as the urgent need, exist in Indian medical education for studies that could have far-reaching implications there and in other countries. are more
POPULATION CONTROL
Greater
emphasis on rural practice and preventive is, therefore, of fundamental importance in medical service and medical education in India; its necessity reaches a peak, of course, in the area of family planning and population control. Government and
measures
financed programmes are much in evidence but, apart from a very small number of local and exceptional efforts, there is no evidence that they have had any important effect. This, again, is not disputed by many politicians and others interested in the problem. Since most births and deaths have not hitherto been registered,2,IO it is difficult to be sure of these basic rates. A census is due in 1971, which will provide important data, but the latest estimates suggest little change in the birth-rate, which remains about 42 per thousand living. The crude death-rate, however, has fallen steadily since the war, and is currently between 8 and 13 per thousand living.1O The increasing control of mass killers such as cholera and smallpox, superimposed on the control of malaria and other less specific improvements, has ensured that simple and inexpensive public-health measures have had a relatively enormous effect in making all the difference between dying, on the one hand, and just living (and being able to reproduce), on the other. Medicine in its broadest sense, together with sociology and demography, must be involved in the attack on overpopulation in such a large and diverse a country as India. Doctors must increasingly see, and must teach their students, that the fitting of loops, the supply of pills, and sterilisations, are only half the answer: collaboration with many other disciplines is essential to capitalise on any possible motivations for fewer children. The Indian peasant sees nothing attractive, of itself, in having seven children when he can, with difficulty, support perhaps three. He needs, in the absence of any social security in old age, and in order to fulfil his cultural expectations and obligations, at least one son. Because so many infants and children still die of the preventible water-borne gastrointestinal diseases, mal-
privately
nutrition, tuberculosis, and
so
on
(infant mortality
remains at about 140 per thousand live births), rightly calculates that he will have to produce a
10
he
large
1383 that his needs are met. To demonhim that he could achieve them with fewer children means preventing these diseases, and convincing him, if possible, that the three children he already has will survive. Then, perhaps, he will welcome advice on family planning (though it would take a generation at least, with further very large population increases, for this approach to achieve anything). Once again, India’s urgent need could help to point the way for other countries. To shift, even slightly, the emphasis in medicine and collaborating disciplines away from the fashionable and traditionally attractive therapeutic approach, to that of prevention, could be the most significant social and medical advance of our time. India, if she is to make anything at all of her very large family-planning commitment, has to make this change of emphasis somehow, and India’s doctors have to accept, understand, and demonstrate to others that, while preventive and public-health measures have been the cause they may yet be a possible cure, of overpopulation.
family
to ensure
strate to
ABC of Endocrinology VI—THE THYROID GLAND K.
J. CATT
THE thyroid gland synthesises and releases iodinated thyronine molecules which strongly influence metabolic processes and growth. Unlike other endocrine organs, the thyroid hormones are not stored in the gland cells but in colloid-containing vesicles enclosed by thyroid epithelium as a precursor protein, thyroglobulin. Within the thyroglobulin molecule, tyrosine residues are iodinated to form monoiodotyrosine (M.I.T.) and diiodotyrosine (D.I.T.), which then combine to
form the iodothvronines (fig. 24).
The structural
INTERNATIONAL COLLABORATION
The medical
challenges that India faces, especially in overpopulation, are enormous, but mankind’s future, not just India’s, could depend on how she deals with them. For the crux of the population-control problem is not the progress, welcome though it is, that is made in closed and relatively small communities like Taiwan, Hong Kong, and Singapore; it lies in what happens in countries like India, and the countries of SouthEast Asia and South America, where the immensity of the obstacles is matched by the urgency of overcoming them, and of ensuring rising living standards which, it seems, may be a sine qua non for declining birth-rates. Worldwide collaboration on overpopulation and related topics is now essential,not simply desirable. From outside India, we in Great Britain must pay much more than the familiar lip service to the Indian doctors who are so important for our own Health
Service; we must acknowledge more readily the problems facing Indian doctors coming to work in Britain,
Fig. 24-Structural formulae of the iodotyrosines and iodothyronines.
and in particular the fact that their service here means their absence from a setting where they are far more urgently needed. To offset this, we should look for ways of encouraging more British doctors to spend time in India-especially those with knowledge and skills in public health and preventive medicine. Many will know how difficult it is even to attempt this with a country whose struggle for, and achievement of, independence have left, more than twenty years after the event, a strong political and administrative reluctance to ask for or to accept this kind of aid. But in India’s undergraduate and postgraduate medical colleges and research centres there is a tremendous store of goodwill, and a strong desire for service, teaching, and research links with Britain. From within India, it is very much to be hoped that doctors in these institutions will continue to press their Government to consider and deal more effectively and sympathetically than at present with proposals for exchange of staff and for collaborative research.
similarity of the thyroid to an exocrine gland is due to its evolutionary origin from the endostyle, an organ which secretes iodinated mucoprotein into the pharynx of protochordata.1 During vertebrate evolution, the thyroid has lost its functional and anatomical con-
References
at
foot of next column
The 6th of 7 articles. This series, together with will be published as a book later this year.
some
additional material,
1. Fourth Five Year Plan 1969-74. Planning Commission, Government of India. 2. India 1968. Publications Division, Ministry of Information and Broadcasting, Government of India. 3. National Labour Commission. Cited in Indian Express, May 17,1969. 4. Medical Care in Developing Countries (edited by Maurice King). London, 1966. 5. Technical Manpower. Bulletin of the Division for Scientific and Technical Personnel, Council of Scientific and Industrial Research, vol. x, no. 6, 1968. 6. Royal Commission on Medical Education 1965-68: Report Cmnd. 3569. H.M. Stationery Office, 1968. 7. Report of the Health Survey and Development Committee, India. 1946. 8. All-India Medical Directory and Who’s Who. Madras, 1949. 9. Prasad, B. G. in Epidemiology, Reports on Research and Teaching, 1962 (edited by J. Pemberton). London, 1963. 10. United Nations Demographic Year Book, 1967.