Rajkumar and Mary Ramasamy: ‘I’m not just a GP. I’m a specialist in life’
Dr MARY & Dr RAJKUMAR | KC Patty CF Health Centre
Civil Society News
RAJKUMAR Ramasamy and his wife, Mary, have spent the past 20 years of their lives running a model primary healthcare centre at KC Patty (short for Kilakkuchettipatti), a village 50 km from Kodaikanal in Tamil Nadu. As villages go in these parts, KC Patty is a big one because it has 800 people. The other villages are smaller with just 200 people living in each of them. Many of them are surrounded by reserve forests and the only way to get to them is on foot.
The centre is simply called the KC Patty CF Primary Health Centre and they run it through the Palani Hills Health Development Trust. Rajkumar, 66, has a degree in internal medicine from Cambridge and is a Fellow of the Royal College of Physicians (FRCP). He also has a specialization in family medicine. Mary, 65, is a gynaecologist who qualified from the Christian Medical College (CMC), Vellore.
Before they moved to KC Patty, they worked from 1986 in the Christian Fellowship Hospital in Oddanchatram and made trips to KC Patty and nearby areas two or three times a week to be available to patients. Then they came to stay and now their health centre, with locally trained staff, serves a target population of 15,000 in a radius of 50 km or so.
Q What led you to live here and set up your primary health centre in this remote location?
Rajkumar: We used to come here from the hospital when we were in Oddanchatram but it wasn’t enough because links would be broken and we would lose the continuity in treatment. We realized that primary healthcare is what you needed to do because it’s not just those who come to a health facility that matter — the people who don’t come matter equally.
So, we moved here to the Lower Kodaikanal Hills, which is an area about 50 km east of Kodaikanal where there are about 15,000 people of whom about 6,500 are tribals. In them we have a target population. One aspect of primary healthcare is that you need to have a target population.
We provide acute care services in the morning and about 90 percent of patients are treated and managed totally here. If they need referral, they are first stabilized and then referred to secondary care hospitals about 40 to 50 km from here. It takes a minimum of three hours to get there if they need acute urgent care.
But the most important thing we do is that in the afternoons we usually go out into the field. The reason we go out is to see those who are, for whatever reasons, afraid to use our facilities. For the elderly it may be for physical reasons or it may be for cultural reasons or maybe because of socio-economic reasons. We need to make sure they’re also cared for and not just those who come to the facility.
We also go out there because of those who come to the health centre with acute illnesses 80 percent need ongoing care. For example, if the disease is tuberculosis. Or if the condition is heart failure. The initial treatment has to be kept going if it’s to be made worthwhile. We go out and we have a robust recall system. Those who need ongoing care who do not attend health facilities are recalled and an effort made to engage them as to why they couldn’t come or if they could come, what are the things that make it possible for them to go and carry on with ongoing care. There may be an agreement on costs. There may be an agreement on families coming and collecting medications rather than they themselves having to come to the health facility and so on.
We also integrate preventive care with acute care at every level. In the field, we see children who are under five and make sure they are nutritionally okay and so on. And if they do come to the health facility, we make sure they are screened. A young person who comes with knee pain will not just have that ailment dealt with, they will also be checked for smoking and alcohol history.
If you are going to do all this you need a target population and a good strong team because, obviously, we two can’t do it alone. We have 12 health workers who are drawn and trained from the local community, especially the vulnerable sections. The reason why that matters is that that itself is a statement that our target group is the vulnerable group. And when that section of the community comes to use our health facilities, they feel at home, so teamwork is a crucial aspect of healthcare.
Q What needs to be done to provide better primary healthcare to people?
Rajkumar: You need more doctors trained in primary healthcare, which I equate with family medicine. If you look at countries where there are well-developed healthcare systems, primary healthcare is the driving force of the whole healthcare service.
What we need in India is an opening up of training in family medicine so that anyone who wants to practise general medicine or primary healthcare must go through the family medicine degree. It is already available in India.
I think this is key because right now anyone who does an MBBS can become a primary care physician, which is absurd because in all other countries you have to have specialty training in primary healthcare or family medicine. I think that’s the most important thing.
It is also important to not just have a degree but also to train in general practice. There should be postings in all districts and in government and
mission hospitals so that you can do six months of paediatric, six months of medicine, six months of surgery and smaller postings like ENT. A modern and robust final examination should follow.
Primary care needs resources. I think the current system of the chief minister’s fund or the government health insurance scheme mainly supports secondary or tertiary care. It has very little for a family doctor, who, for example, may see patients with hypertension and the goals are that 70 percent of those patients take regular treatment and at least 50 percent of them achieve target blood pressure. There should be a reward system for people who practise family medicine for achieving those targets.
Also, you need patients to go through a primary care physician to access secondary level care. This will ensure that there is no odd investigation of people and that the right specialist can be seen. Someone with chest pain may have a cardiac disorder, a gastrointestinal disorder or an anxiety disorder. A family physician is well equipped to make sure they go and see the relevant specialist.
Q All that you say is true. But we do have a healthcare system modelled on Britain’s and it doesn’t function. What is lacking? Is it the chemistry? Is it that family medicine is not attractive enough?
Rajkumar: If you have trained people, you’ll attract people. If you look at our health centre, the majority of patients will come to us before they go to a specialist and they’ll be much happier. Actually, they often bring reports of other places and make sure that we verify them and that we sanction them. I’m not trying to boast about our care or anything. But I think (it makes a difference) that we are qualified primary care physicians. And we have a team trained to ensure that when a person comes here they are welcomed and all their health issues are addressed.
We practise patient-centred care which is holistic medicine. When that is practised you will find people coming to primary health centres first and they might even question what a specialist has advised them and ask the family physician to give an opinion on it.
Mary: I think when you asked why is there no chemistry, you meant why are doctors not moving to primary health, right?
Q Yes, but this is interesting, too, so please continue.
Rajkumar: I think many of the trainees who have come to us leave saying they understand what primary healthcare is and the self-respect they should have as family physicians and what the potential is. So, when you have that training you really have people who are enthusiastic about family medicine and who realize they are specialists in their own right. I think the Australian College of General Practitioners has a very good slogan, which says, ‘I’m not just a GP, I’m a specialist in life’.
When you say that, I think there are doctors who want to join. I don’t have any doubt about it because, as I said, there are many people who come here unmotivated about primary care and wondering why they chose it and often they chose it because they didn’t have any other choice. And they leave with their heads held high and wanting to practise.
Q What you are saying is to give this the respect it deserves. Give it the status it deserves and make it attractive.
Mary: I think having an enthusiastic and committed family physician training as a junior doctor makes a lot of difference. Inevitably, the departments where we have a good time are the ones we tend to take on for postgraduate studies. When you have a very enthusiastic committed primary family physician passing on that enthusiasm to the trainees it makes a lot of difference and makes it attractive for the people posted there.
The other thing is that doctors feel that this is not economically viable, that the remuneration that they may get is not equivalent to what they would get in a hospital set-up. That is quite an important factor for many people. We usually say primary care in itself is difficult to be self-sustaining. The importance is that the community receives a lot and their expenses go down. But for the personnel who are taking it up, they may need to have other resources. It may not be possible for them to manage totally on what they collect from the patients.
Rajkumar: Of course, that’s very sad. Half our activities are income-generating. In the morning, when we see patients, they pay a cost which they feel they can afford. But the rest of the activity, like field visits to recall patients, or home visits too, and trying to understand what needs to be done to help them take treatment — that’s not income generating. And neither is health screening or checking the blood pressure of everyone over the age of 18 every year.
So primary care cannot meet its own expenses, even if it is done properly, but it saves a community enormous costs. In that sense, it’s an essential part. It’s not an option. It’s not a project. It’s an essential part of the healthcare system that will make the health budget of this nation sustainable.
Q What do you charge a patient in your rural setting who comes to you? And how do you make your kind of health centre sustainable?
Rajkumar: We meet about 70 percent of our own expenditure that includes medication, staff salaries, vehicle charges and all the other running expenses. But about 30 percent we are unable to meet. The doctors here, for example, work on a voluntary basis. We don’t draw a salary equivalent to our qualifications.
But I think the point you’re raising is important. I think in the end it is only the government primary healthcare system that is going to be replicable all over India. I don’t think the private sector will be able to take over the role of primary healthcare as much as they would do at, say, the secondary or tertiary care level because of these cost constraints.
Q How do you live without a salary?
Rajkumar: We work more or less voluntarily. I sometimes take three months a year away and do locum work elsewhere. In that sense, we meet our own expenses. Our expenses here are very little.
Q So, at the end of 20 years, you have no regrets at all?
Rajkumar: I wouldn’t be honest if I agreed. Because obviously there are times when things become frustrating. I think working here does require its sacrifices. There are times when I would rather run away and be in a place where I can take my wife for a cup of coffee or take her out somewhere and have a meal. Those are things we do miss. Those are little things. But you gain so much more.
Q It’s always interesting to meet people who make choices they are not forced to make. But you can also get fed up.
Mary: Yeah, so in places like this, it is important that we take our breaks. It’s important. Sometimes you can keep going in the same direction without looking on the side or feeling any change or something. So, getting away and then being able to look in from an outside perspective is important. It’s not always possible because if you don’t have a second hand here it is not possible to just up and out. So often it’s not possible for us to take leave at the same time or get away at the same time. Those are things that are not easy.
Q What kind of illnesses do people come to the centre with?
Rajkumar: We cater to about 15,000 people but of them, 7,000 are the most vulnerable sections of that community. We get, on average, 1,000 to 500 patients per month. Our health workers are ordinary folk from villages who come for training every month. They treat basic illnesses at village level itself and send those who have more complicated problems to us. During the coronavirus pandemic the number of people turning up at our health centre increased to about 2,000 a month because there were people trying to escape the coronavirus by coming here.
The disease profile has changed in our village. When we started we had some of the highest incidences of tuberculosis in Tamil Nadu. Communicable diseases were common. But now tuberculosis has come down to about 10 percent and communicable diseases have reduced, like everywhere else. Instead there are more non-communicable diseases. Hypertension is probably the most important of them and afflicts even hard-working, lean members of the population.
Also, alcohol addiction. Tribal people hardly ever drank alcohol when I first came here. Now it’s a common problem along with smoking-related diseases.
Mental health takes up about 10 percent of our workload. It’s one of the most rewarding things you can treat. There is a lot of misconception that family physicians can't treat mental illness. In fact, I think family physicians are in the best position to treat mental illness because it is a tragedy when it is not treated.
Q If you have to refer your patients to a psychiatrist, what happens?
Rajkumar: We manage nearly 95 percent of mental health patients ourselves. If a psychiatrist is needed we phone one and ask for advice. About five percent of patients will have to go to the Christian Fellowship Hospital in Oddanchatram, where they will find a specialist psychiatrist. Mental health needs not just a diagnosis but also an understanding of the patient’s social context. What is the individual factor that is precipitating such illness? With some people it is a biological factor, or genetic. With others it is an environmental factor. If you understand where a person is coming from, as a family physician you are in a better place to treat mental illness.