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Binayak Sen: redefining health care in an unjust society

EDITORIAL IN INDIAN JOURNAL OF MEDICAL ETHICS (JULY – SEPT 2007)

C Sathyamala

On May 14, 2007, Binayak Sen was arrested by the Chattisgarh police under sections of the Chhatisgarh Special Public Security Act, 2005, and Unlawful Activities (Prevention) Act, 1967 (2004) for alleged links with the banned Maoist groups (1). His arrest was the upshot of his attempts to raise issues of human rights violation in government-sponsored violence, both within and outside Chattisgarh, in his capacity as the General Secretary, Chattisgarh People’s Union for Civil Liberties (PUCL).

What makes this event of particular interest to the readers of IJME is that Binayak Sen is a practising doctor who sees his activism as intrinsic to his work as a health professional.

Binayak is a graduate of Christian Medical College (CMC), Vellore, an elite institution known for its exceptional teaching. One of the top students of his batch, Binayak completed his post graduation in paediatrics in the early 1970s. For most of the years since then, he has devoted his life to health care in poor communities. For this, in 2004, he was conferred the college’s prestigious Paul Harrison award “in recognition of his outstanding contribution to society”, as stated on the citation presented with the award. His contribution was not seen so much in his capacity as a physician, but (as the citation notes), for having “… redefined the possible role of the doctor in a broken and unjust society, holding the cause much more precious than personal safety”.

Why would a doctor of Binayak’s calibre choose a life far removed from the career path followed by the run-of-the-mill medical graduate? The answer to this question may be found within the debates of the Medico Friend Circle (MFC), in response to problems potentially faced by all health professionals. I believe that while Binayak’s training at CMC gave him excellent clinical skills and reinforced an already present empathy with the patient, it was his close association with MFC that contributed to his understanding and growth as a public health professional with a difference.

The birth of MFC, in the mid 1970s, followed the coming together of a group of individuals, who were trained or interested in health care but who were dissatisfied with the health care system in the country. They felt that it did not match the health needs of the vast majority of the people who lived a life of poverty and deprivation. Those who had received training as doctors felt that their training had failed to equip them to respond to the challenges even as medicos.

Though MFC drew inspiration from the Jayaprakash Narayan movement during the Emergency imposed in 1975, it evolved as a pluralistic “thought current” drawing individuals subscribing to ideologies of differing shades, extending from Gandhian to Marxist philosophy. Binayak, who was in search of a meaningful role as befit a “socially conscious” doctor, became part of this loose group.

One of the first major debates within MFC arose three years after its formalisation. There was a general consensus that the maladies of the health system were a part of the malady that affects the socio-economic structure as a whole, that unless society changes fundamentally, the health system cannot, and that health reforms alone cannot markedly improve the health status of the population unless the fundamental problem of poverty was solved. However, there was a divergence of opinion on what the alternatives could be that would make a health care system responsive to people’s needs (2).

Is it possible to have a scientific understanding of the health system without understanding its social basis, which requires discussions on economics and politics? And if health professionals formulate a scientific critique of the medical education and health system, should they not go one step further and get involved in political activity to change the system? Should they strive for reform within the system that might provide some relief to people or should they use health work for bringing about socio-economic change?

This debate, which continued over some time, led to frustration among the members. On the one hand, it appeared that health work alone would not lead to changes in the socio-economic situation. This left the health worker with no role to play in bringing about social change. On the other hand, there was a feeling that an insightful analysis of the present system did not automatically lead to concrete programmes on how to remedy the situation.

Finally, it was decided that while MFC would continue to critically analyse the health care system, it was up to the individual members to decide on how they wished to operationalise their role as health workers.

The next decade saw the divergent paths that the MFC members took in their search for context and alternatives. Many preferred to develop alternatives in the form of community health projects with efforts at demystifying medical technology, rational and low cost therapeutics, and training of non-literate village level workers to provide primary level health care. Most members contented themselves with what came to be known as “people’s participation”, which ranged from encouraging the community to contribute towards the services provided, to getting them to select village level workers.

Binayak’s search took him in a different direction. Working in a rural development programme in Madhya Pradesh as a medical doctor, treating patients with tuberculosis was both a frustrating and a heart wrenching experience. The community’s circumstances were such that the highly qualified professional who had learnt from the best could do little to get patients to not “default” from completing the course of treatment or prevent the onset of a disease in others.

Around this time Shankar Guha Niyogi, the then little-known leader of the Chattisgarh Mines Shramik Sangatan (CMSS), an independent union of workers in the iron ore mining belt of Madhya Pradesh, in Dalli Rajhara (now in Chattisgarh), wanted to build a hospital that would provide good quality secondary level health care (personal communication). Niyogi and his colleague were catapulted into the national limelight when they were arrested for their union activities. Binayak, his wife Ilina, and I were returning from the PUCL meeting to protest their arrests when Binayak began discussing the idea of working with the CMSS.

Health care is political

Binayak and Ilina elaborate their perspective in working in the Shaheed hospital of the CMSS and how they saw the relevance and significance of health care within a Left paradigm (3). They state that any health care is by its nature political. By providing health care within a working class movement, every activity (from clinical work to training a health worker) that might otherwise be considered reformist (merely tinkering with the system) assumes a revolutionary potential, and the capacity for bringing about fundamental changes. Work in such contexts creates a culture counter to that perpetuated by present-day medical institutions and enables the empowerment of the working class.

It is as part of this thought process that Binayak and Ilina continued with their work among the workers (he conducts a weekly clinic in the workers’ settlements) and among tribal communities who were displaced by construction of dams many years ago.

To get involved with the issue of human rights then became a natural extension of a perspective that saw health work not merely as the provision of health care services but as any effort that counters the suppression of the socio-economic and political rights of the marginalised. This, Binayak found, was particularly inescapable in a state like Chattisgarh that is witnessing large-scale government-sponsored terrorism in the name of Salwa Judum, an operation whose stated objective is to combat Maoist insurgency but which in reality is to wrest ancestral land from the tribal communities, for the use of private industrial houses.

By arresting Binayak, the government is sending a clear message: in today’s globalised world, the government functions as a law and order keeping machinery in the interests of the corporate sector. No one who poses a threat to such interests or comes in the way of “growth”-driven development will be tolerated. “Waging war against the state”, and “unlawful activities”, sections under which Binayak is being held, then get interpreted to mean any activity that opposes the immoral and unjust activities of the government and the capitalists who are under the protection of the benevolent eye of the law.

In this context, working towards the improvement of people’s health requires that such laws be repudiated. Health work means to take the side of the people. Less than this would make it of questionable worth.

References:

1. Human Rights Forum, People’s Democratic Forum, People’s Union for Democratic Rights, Andhra Pradesh Civil Liberties Committee, Association for the Protection of Democratic Rights. Condemn arrest of Dr Binayak Sen. Joint press statement condemning arrest of Binayak Sen. 2007 May 14. [cited 2007 June 5]. Available from: http://www.pudr.org/index.php?option=com_content&task=view&id=119&Itemid=60

2. No authors listed. Medico Friend Circle: which way to go? A debate. In: Bang A, Patel A, editors. Health care: which way to go? Examination of issues and alternatives. Pune: MFC; undated. p. 219-30

3. Sen B, Sen I. Health care in a revolutionary framework: possibilities for an alternative praxis. Socialist Health Review 1984; 1 (1): 24-8.