Editorial
Lower price counts little if
purchasing power remains low
WHEN talking to journalists on Thursday, the commerce adviser, Hossain Zillur Rahman, claimed that price of rice on the local market is almost half of what it is on the global market, and that it will come down as the international food market shows signs of cooling down. Hossain Zillur and his colleagues on the council of advisers to the military-controlled interim government seem to have a tendency to draw comparisons between the international and local market whenever the issue of price comes up, be it of essential food items or fuel or fertiliser. More often than not, however, they leave out what should be the key factor in such comparisons – the purchasing power of the people at large. What the commerce adviser and his colleagues do not seem to understand is that no matter how steep the decline, so long as the price remains beyond the affordability of the people at large, it is of little consequence. Simply put, even if the price of rice on the local market comes down to, say, Tk 15 per kilogram, and the people at large cannot afford to spend Tk 15 on food, the decline would be of little solace to them. Therefore, not only does the government need to keep the market prices in check but it should also try to increase the purchasing capacity of the people through employment generation, which it has thus far failed to do by and large.
The commerce adviser also said the government would ‘further strengthen market monitoring’ so that it ‘could glean market information in advance in order to keep the market stable’. That is reassuring, indeed. Even to say the government’s predictive capacity is not up to the mark would be a gross understatement. Weeks, even months, before the recent food crisis, despite repeated warnings from economists, politicians and even the multilateral lending agencies, the government refused to step out of its state of denial. Eventually, as the food prices spiralled beyond the affordability of the majority of the people, one of the advisers admitted in public that the government had failed to foresee the crisis. Later, prior to the boro harvest, the government tried to give the people the impression that rice prices would come down as soon as farmers harvested their boro paddy. Needless to say, its prediction has proved to be wrong; in fact, of late, the rice price on the local market has been on an upward climb.
The government needs to realise that, when the majority of the people are struggling to make their ends meet and when all the avenues to vent their despair and desperation remain closed under a repressive state of emergency, such hollow comparisons and inept market projections appear no less than cruel jokes and could be interpreted as its inherent lack of sympathy for the people at large. Therefore, the least the incumbents can do is show some sensitivity, abandon such futile exercises and make way for elected representatives to take the helms of governance. First up, however, they should withdraw the state of emergency so that the politicians can go back to the people and lend them the sympathetic ears that they need to tell their tales of despair and desperation.
Thumping SSC success is a
challenge for authorities
A RECORD percentage of success in the Secondary School Certificate examination is a cheering bit of news amid the pains and deprivations that characterise present-day Bangladesh. The photograph of joyful young women and young men celebrating the results by exhibiting with their index and middle finger the Churchillian V sign is a welcome relief from the daily viewing of the dismal spectacle of the long queue for rice, water and transport. The success rate of nearly 71 per cent is not only very encouraging in itself, it is a vast improvement over last year’s 57.37. We congratulate the successful candidates, particularly those that secured GPA 5. Of course, one must make allowance for the fact that this year elimination of the weak candidates at the eligibility test was more drastic following a directive of the education ministry that those who fail even in one subject should not be sent up. At any rate, the performance is laudable by all standards. Let us hope the tempo will be maintained in the coming years and those in charge of raising the quality of education will match their efforts with the creditable performance given by students.
By achieving a thumping success without any extra facilities provided to them the students have thrown a challenge to the government, to the education authorities, to the private sector, to society at large. What is the arrangement for fostering their talent from this point on? Many will not get admission in a college of their choice because the number of the most sought-after colleges is as limited as before and nothing has been done to widen opportunities in this regard. Despite performing well many hopes will be dashed for want of opportunities. Although creation of knowledge-based society remains a slogan, little is done to give substance to the slogan.
There are three factors responsible for good showing in the exams: innate talent, labour and facilities. As for creation of facilities, this is in the hands of those who control education, and much else besides. Students have done their job, others must rise to the occasion. Every year it is seen that one or two obscure institutions steal the limelight. This year it is the little known Manipur School and Kadomtola School in Dhaka. In such cases talent and labour were able to overcome lack of facilities. These are private schools which owed their success to sincere involvement of the local communities. Cadet colleges do well every year because all the conditions for nurturing talent are met in these institutions. This year in Mirzapur Cadet College 44 out of 46 candidates achieved GPA 5. If good teachers are recruited and given incentives, good facilities for curricular and extra-curricular activities are created, management is efficient and discipline is enforced, and distribution of resources is made more even, more schools can be made to attain the quality of education of cadet schools. We trust this year’s result will force a rethinking by the authorities on the entire gamut of school education.
Reflection and reminiscence
on medical education
Teaching career is more than marking time on the post and getting promotion automatically. A system that fails to ensure performance, monitor and evaluate with rigour, and give recognition and reward when and where earned could not be expected to protect the interest of the academic community’s real goal, writes Dr Zakir Husain
THERE comes a time to reflect and to reminisce over the past with hindsight acquired from the present. The writer looks back to the early 1950s; his student years spanned 1949-1954 at the Dhaka Medical College, then a fledgling yet premier college. Nostalgia clouds his reminiscences but reflections are vivid and poignant.
Medical education and practice have evolved through past many centuries. The dynamics of that evolution embraced changes in response to new advances of knowledge and practice. Change has been a constant companion. Some traditions became redundant and obsolete. Yet, some remained. Both education and practice of medicine inherited some abiding old traditions.
One tradition comes instantly to mind. I have in mind the system of ‘clinical apprenticeship’ – an attachment of new graduates to their tutor clinicians often seen as role models. That has not fallen by the wayside. Or has it?
Some traditions have gone. I have in mind those old fashioned but time tested ‘clinical methods and procedures’. In those days, these were taught and practised with great flair by clinical professors of medical college.
Those classic clinical methods of history taking and physical examination seem to be followed today more by exception than by rule. Times and methods might have changed in the past 50 years but in my judgement the value and validity of good clinical methods remain undiminished.
Indeed, much new knowledge has been generated by scientific research and technology development, particularly during the past two centuries. Changes in physical environment and social and cultural beliefs and practices in places and populations have influenced medical education and practice.
Medicine is not entirely based upon physical science nor is it restricted to clinical or laboratory technology. Medicine is also a social and behavioural science. Subjective and non-quantifiable factors play important role; these influence the state of health and delivery of care to the patient or protection of health of a population. Medical science is not neutral nor totally value free.
But a technology dominated world of quantitative methods has pushed aside the scope of subjective and qualitative judgements. That to my mind is a loss to the science and art of medicine and its practice.
Theory and practice of medicine is an academic discipline wherein didactic instruction and close clinical observations reinforce textbook learning.
Again I recall my student years in the 1950s. Teachers were fewer than today; most of them appeared rather cold, stern and aloof. There was a cultivated barrier to informal or easy teacher-student communication.
Mercifully, there were remarkable and redeeming exceptions to this rule. Three foreign teachers on contract and two local teachers provided some welcome relief. They made evening rounds and gave bedside instructions. They demonstrated cases live in the lecture hall. They took questions as much as asked questions.
The limitations of teaching resources were compensated by the amount of time and effort given by at least some of the teachers; they never failed to come on time, be at work most of the day, and return in the evening to make ward rounds.
True, they had little facilities to carry out serious clinical or basic research. Yet they did keep and scrutinise patient care records meticulously enough to the point of medical audit.
They did scrupulously follow detailed ward rounds as part of clinical teaching, and invariably made evening visits to wards on admission days.
On a training study to North America, the writer had seen teachers stay fulltime in hospital preparing lesson plans, making and using audio-visual teaching materials, embrace educational technology to enhance the learning process of students.
In doing all these, they did justice to all three functions of a medical college and hospital: patient care, teaching and research.
Teachers taught and took care of patients. They did some commissioned research with small or large grants. Some of them did some private practice but within the hospital and within working hours; and received a part of the fees charged.
They had ample time for students, for their own study, and for periodic interactive clinical seminars.
I hesitate to pass an objective judgement on how the situation is today or what the quality and content of teacher-student interface and interaction in our medical colleges today.
On principle, a medical educator is, or should be, judged by how much time and effort the educator is willing or able to spend on teaching the theory and practice of medicine or how well educational technology and other resources available or improvised are used to enhance the teaching content and process. Are teachers in public or private medical colleges fulltime?
There have been developments in educational technology. Modern teaching tools and aids are abundant and affordable. Teaching aides are effectively used to enhance the teachers’ ability and the trainees’ learning process.
Are modern educational tools and technologies used and used effectively in medical colleges? Have we produced indigenous audio-visual materials to improve the relevance of teaching materials?
And what about evaluation of efficiency and effectiveness? These are better evaluated by a kind of self-audit and peer review through an academic council or similar body. But is this happening?
Teaching career is more than marking time on the post and getting promotion automatically. A system that fails to ensure performance, monitor and evaluate with rigour, and give recognition and reward when and where earned could not be expected to protect the interest of the academic community’s real goal.
Additionally, medical profession demands high moral integrity and ethical conduct of the practitioner. Such high standards are also expected to be ensured by internal self-discipline and self-auditing rather than solely by external regulatory instruments.
For this and other reasons, medical profession has always been judged not only by the technical knowledge and skills of the practitioner but also by the manner in which those are applied. Today, the consumerist society is addicted to gadgets with electronic speed; craves for instant gratification of desires. Therefore, in some quarters at least, it might sound old fashioned and out of sync to talk of subjective things like morals, compassion and empathy. Yet, the same consumerist society members who seek instant cures also crave for things intangible like ethical, moral and compassionate treatment.
Perception matters much; sometimes it matters more than objective reality. Survey after survey shows how perceived behaviour and attitude of a caregiver make a huge difference in level of patient satisfaction and acceptability, even the outcome of care given and received.
But do all members of the health workforce shoulder that responsibility equally and well? Not so according to surveys.
There is severe net shortage of doctors in the country. The huge disparity of distribution between urban and rural locations aggravates the gross inequity. Shortage of professional nurses and medical technologists is even more severe. Add to these, poor working conditions in rural facilities you have a huge problem.
Like it or not, as leadership falls upon the doctor in health facilities, medical education and training matter more than it perhaps should.
The need for a balanced production and deployment of health workforce is so critical and urgent it deserves the highest political commitment supported by investment of greater resources.
Deep reforms in medical education will not happen quickly. But given the current situation in health workforce in Bangladesh, medical education has to take a lead.
Let me focus upon one particular possibility that could bring great benefits by way of stopping primary care health facilities from being abused for benefit of individual doctors who remain absent and on deputation to postgraduate study.
The upazila health complex is the key first referral centre for primary health care. These are non-performing and doing little to inspire the confidence of patients who are obliged to seek care elsewhere. This waste of public resources is not acceptable. Yet it has continued for years and an indifferent management has ignored this. The upazila health complex could be restructured and brought to life as the pivotal centre for essential healthcare to the entire population. But the present state of things would never deliver that.
If medical colleges trained certified family physicians in sufficient numbers; if they were assigned to the upazila health complexes; if they were given preferential selection for a second specialty in due course; the return in health outcomes of people would be multiplied. This single step would enhance the performance of the upazila health complexes and their utilisation to a large extent. The state has the power but does it have the will?
Working conditions could be improved by providing four nurses to each medical officer; four medical officers (family doctors) majoring in internal medicine, general surgery, paediatrics, and obstetrics and gynaecology. Add medical technologists and you have a far better staffed upazila health complex. By providing needed equipment and supplies you make each upazila health complex function to its highest potential. You create a good team; you give high satisfaction to the people. You get a high return on investment. But investments you have to make. Even at current level of expenditure the state has the capacity to find resources if it has the will.
The above is not a suggestion utopian. Countries who have gone to the extreme specialisation and overuse of technology at high cost are craving for all round primary care by family physicians. I have no doubt Bangladesh could learn from lessons of the past and experience of those countries with strong commitment to primary healthcare, commitment to rationalise health systems through balanced development of health workforce.
Why now? Because the mushrooming of uneducated, untrained or half-trained, unregulated or ignored informal health workers constitutes a serious present and future threat to public health outcome.
There are other key issues to be addressed. But for now I would leave it at that. Hopefully, I shall return on this subject.
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