Hope, Healing & Healthy Nations through Family Medicine: The IMA CGP Golden Jubilee Dr S. Arulrhaj Oration

October 20, 2013

This oration is delivered in recognition of the 50th anniversary of the establishment of the College of General Practitioners of the Indian Medical Association (IMA CGP). It also acknowledges the many contributions of the Chief Patron of the IMA CGP, Dr S Arulrhaj.

Fifty years is a significant milestone in the life of any organization.  It is a time to celebrate and reflect on past achievements and challenges.  But it is also a time to refocus attention on what must be done now to ensure that an organization continues to be relevant, has a vision for the future and plans on how to achieve this.

The IMA CGP has a special place in the history of WONCA, our World Organization of Family Doctors.  WONCA was established in 1972 by 18 national colleges and academies of family medicine.  The IMA CGP was one of those 18 founding organisations.  In the lead up to the creation of WONCA these organisations had hosted four world conferences on general practice.  The third of these world conferences was hosted here in India by the IMA back in 1968.  

Today WONCA has 118 member organisations and represents over 500,000 general practitioners and family doctors in over 130 countries, in all regions of the world.  The 500,000 family doctors represented by WONCA, and including the members of the IMA CGP, each year have over two billion consultations with our patients. Two billion. That’s the scope of our current work and our influence.

WONCA now has three member organisations here in India: the Indian Medical Association College of General Practitioners, the Federation of Family Physicians' Associations of India, and the Academy of Family Physicians of India. I am pleased to see the three organisations working together, alongside the other WONCA member organisations in the nations of South Asia.  In the words of Mahatma Gandhi: “Honest differences are often a healthy sign of progress.”  Each of our organisations is different, but by recognising and respecting and celebrating our differences, we can then achieve wonderful things by working together.

The IMA has one of the largest GP memberships of any professional organisation in the world.  I note on your website that the IMA has 230,000 doctors as members, of whom 60% are GPs.  By my calculation that is around 140,000 GP members of the IMA.  The college itself includes 1000 qualified family physicians as members who have achieved advanced specialist qualifications in our professional discipline.

As I mentioned at the start this oration is named in honour of Dr Arulrhaj.  I expect there is no other doctor on the planet with a CV as impressive as Dr Arulrhaj: President of the Indian Medical Association, President of the Commonwealth Medical Association, Chairman of the Commonwealth Medical Association Trust, Chairman of the Commonwealth Health Professions Alliance, Chief Patron of the IMA-CGP, the list of Dr Arulrhaj’s achievements and honours is seemingly endless.  What is important is that they underpin a life of leadership and service.  A life devoted to making a difference to the lives of other people. 

Dr Arulrhaj is a specialist medical practitioner who has seen the primary care light, and recognized the importance of family medicine and its capacity to bring high quality health care to all people in India and right around the world.

I asked Dr Arulrhaj for some messages to share in this oration.  He said I should stress the need to grow family medicine in India, stress the need for qualified general practitioners to serve the needs of your communities, and stress that the medical students and “young doctors of India must choose family medicine by choice, and not by chance”. So that is what I will do.

The IMA CGP has been providing impressive leadership in family medicine for 50 years and brings together doctors with a passion for the important work of family doctors.

This reminds me of the words of our very first WONCA president, Dr Monty Kent Hughes who said in 1972 when WONCA was founded that: “the future of our professional discipline will depend on our ability to work together in the service of humanity.”

These words have guided us ever since. 

WONCA represents you and your college at a global level.  WONCA advocates for the important work you do every day in meeting the health care needs of your patients and your communities.

But we need to do more. We need to continue to strengthen our global work with the World Health Organization. We need to support the development of GP education and training in those 80 countries where it is not yet present.  And we need to support the next generation of GPs, of family doctors, our recent graduates and trainees in each region of the world.
The paramount responsibility of WONCA, and of each of our member organisations, is to our patients and our communities.  GPs, no matter where we work, ensure that health is affordable, safe, appropriate and equitable.  

The South Asia Region is very important to WONCA.  After all, 25% of the world’s population lives here.  We have a number of strong member organisations in some of the countries of this region but we need to do much more.  

And, as our first WONCA president reminded us, we need to do this work together.  We need to respect each other’s differences, build on each other’s strengths, and unite in our voice to be advocates for the role that family medicine can play in achieving universal health coverage for every person in this region of the world.

Last month I attended the United Nations General Assembly in New York, representing WONCA and global general practice/family medicine at a summit called to examine progress in meeting the Millennium Development Goals, and to discuss what happens beyond the end of 2015 when the set of Millennium Development Goals concludes.  

You are no doubt aware of the Millennium Development Goals.  They are eight aspirational goals, agreed by all the world’s countries in 2000, which aim to halve extreme poverty rates by 2015, provide primary school education to all children, empower women, reduce infant and maternal mortality, combat HIV, tuberculosis and malaria, and ensure the sustainability of our environment. 

The Millennium Development Goals have galvanized unprecedented efforts across the globe to meet the needs of the world’s poorest people.  And progress has been impressive with rates of extreme poverty halved already ahead of schedule, and significant reductions in infant and maternal mortality and HIV infection rates in many countries, with millions of lives saved through reductions in preventable deaths.  Some of the coordinated partnerships created to achieve these gains have been wonderful.

Examples of successful global programs include the United Nation’s Every Woman Every Child initiative, which has been adopted by governments in many countries and includes ensuring access for women and children to quality health care facilities in the community and skilled community-based health workers. 

Another is the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has led to a decline in new HIV infections in many of the countries most affected by the HIV epidemic.

The United Nations Millennium Development Goals debated actions needed to further diminish global poverty, improve health worldwide, and achieve sustainability of the environment, and provided recommendations for consideration by the leaders of the nations of the world.

Among the key messages that I took away from the summit was how success has occurred when there has been national and local ownership to give the Millennium Development Goals traction, and also the importance of allowing the local adaptation of the Millennium Development Goals to target local conditions.  

And it was no surprise to be reminded that the people of middle- and low-income countries want capacity, not charity – and that building self-reliance is critical.  This is a key role for WONCA in our support through our member organisations for education and training for the members of the primary care workforce in every nation.

High-level statements and commitments are one part of the solution, but they are meaningless without effective in-country action. 
Part of the challenge with the Millennium Development Goals has been in their, sometimes patchy, implementation. Often initiatives to support the Millennium Development Goals in a country have failed to engage with the existing primary care workforce, setting up parallel programs that can diminish, rather than strengthen primary care provision.

The Millennium Development Goals have also come in for some criticism because of what is missing. They don’t tackle the need to strengthen the primary care basis of each country’s health system, or to tackle chronic disease or mental health, or to address the social determinants of health, or to ensure universal health care access for all people in both rural and urban areas.  This is part of the challenge looking beyond 2015.  What should be the focus of the next set of global priorities and targets?

As the world debates what happens next, with the clamour of thousands of interest groups and self-interested industries, WONCA and our member organisations, including the IMA-CGP, need to ensure the clear voice of primary care on behalf of our patients and communities continues to be heard during these debates. 

We need to be clear about our role as GPs in working with our patients and communities to increase life expectancy and achieve equitable health outcomes. 

And we need to support the focus on the social determinants of health and how we ensure marginalized populations, those groups of people in our communities most at risk of poor health, are not excluded from health care. 

One of the leaders in the establishment of WONCA was IMA past president, Dr Prakash Chand (PC) Bhatla.  In 1976, Dr Bhatla became the first recipient ever of WONCA’s most prestigious award, WONCA Fellowship.  At WONCA’s inaugural meeting back in 1972 Dr Bhatla spoke about the need to educate tomorrow’s GPs in providing preventive and curative treatments, in being health educators and counselors, and in motivating and educating people and communities about health.  One line in his speech really speaks to me:

“Every national health program, including the Family Planning Programme, should include the involvement of general practitioners. Education and motivation of the community has to be done on a personal basis.  And who is nearer to the community than the family doctor?”

As GPs we need to be engaged in national health programs.  This is an issue I discussed recently with the Director-General of the World Health Organization, Dr Margaret Chan around the challenges of meeting the polio eradication targets and how our members in those countries where polio is still endemic had commented on a lack of engagement with many of the family doctors and other primary care workers in the remaining endemic areas; doctors with the trust of the local populations who may be able to be part of assisting in the final moves towards global eradication.  “Who is nearer to the community than the family doctor?”

To support our important work we need strong standards for clinical care and standards for education and training. And we need strong government and community support.

Governments need to value our generalist traditions.  What percentage of our medical graduates do we need to train in each country in the specialty of general practice?  If we are to meet the true health needs of our communities, in most of our countries it is likely to be at least 50% and probably more.  

You might like to reflect on the current percentage in this country.  Many nations continue to train large numbers of consultant specialists and sub-specialists and super-specialists, way beyond their nation’s needs. 

There are some big challenges for general practice in India.  I was last in India in April this year attending the National Conference on Family Medicine and Primary Care in New Delhi, along with many of you, and listening to India’s Health Secretary, Shri Keshav Desiraju, and other dignitaries speak about the importance of family medicine to India’s future health care. 

It struck me that there are four big challenges for family medicine in India.  The first is ensuring that every medical school in India has a Department of Family Medicine, teaching medical students and organizing community-based placements.

WONCA’s Singapore Declaration of 2007 states that “every medical school in the world should have an academic department of family medicine / general practice, or an equivalent academic focus.  And every medical student in the world should experience family medicine / general practice as early as possible and as often as possible in their training.”  This is the case in most countries where the adoption of family medicine has been successful.  India is no exception.

Second, every doctor who is going to work as a GP, as a family doctor, requires postgraduate training.  A degree from a medical school does not mean that a graduate is skilled to be surgeon.  And it does not mean that a graduate is skilled to be a family doctor either.  And we need to provide opportunities for existing GPs to upskill and be recognized as specialists.  We cannot afford to leave anyone behind.

Third, we need the support of our colleagues in other specialties.  Some of our greatest advocates for family medicine around the world, including Dr Arulrhaj, originally trained in other specialties.  We need all members of the medical profession to recognise the importance of family medicine and support the advancement of family medicine as a recognized specialty. Our colleagues need to support us in our important work, not block us.

Finally, there must be career opportunities for trained specialist family doctors.  If we are going to attract the brightest and the best of our medical students to train to become GPs, to become family doctors, then we need to support them to practice where they are needed and support their continuing professional development throughout their professional lives.

We also need to consider how we support and encourage GPs to spend part of their career working in rural and remote locations?  How do we support and encourage GPs to spend at least part of their careers working with disadvantaged and vulnerable communities?  

A specific focus of this year’s United Nations General Assembly was on people with disability, and how people with disability are being excluded from a number of the initiatives set in place in many countries to meet the Millennium Development Goals.  

People with disabilities make up an estimated 15 % of the world’s population, around one billion people.  At least 80 % of people with disability live in developing countries and are at greater risk of living in absolute poverty due to their exclusion from equitable access to resources such as education, employment, health care, and social and legal support systems. Think about the challenges that must face a person who is blind or deaf or unable to walk and who is living in a rural village in India.

As GPs we provide care and we are advocates for all our patients, and especially for those who are most marginalized or disadvantaged in our communities.  We have a responsibility to ensure that our services are accessible and available to everybody, including those with disabilities.

The global health policy pendulum swang too far in its focus on high technology tertiary care, but is now swinging back to a focus on primary care and universal coverage.  And for very good reasons. 

Universal health coverage has been part of the charter of the United Nations since 1948.  And universal coverage does not mean meeting the needs of 80% of a nation’s population – it means ensuring that health care is available to everybody. 

People-centred care is a core component of universal health coverage, and there will be an increasing role for general practice over the coming years in many countries to ensure this happens. We also need to see a rebalance of resources – as GPs we are skilled and dedicated but we can’t continue to do more and more with less and less.  We need to see some rebalance with resources moving from our tertiary services into primary care. 

There are those who say that general practice/family medicine has no real role to play in low and middle-income countries.   Well we have blown that notion out of the water.  In June this year, the director-general of the World Health Organization, Dr Margaret Chan, launched the new edition of the WONCA WHO publication on the contribution of family medicine to improving health systems. 

The guidebook includes contributions from the WHO showcasing the research into the impact family medicine is having in improving health outcomes in many middle-income nations including Brazil, China, Thailand and countries in the Middle East.  And there is a chapter outlining the remarkable work that is underway across Africa to strengthen family medicine, especially involving WONCA member organisations within Africa supporting developments in neighbouring nations.  

What these developments demonstrate is the need to strengthen the whole health care workforce, including GPs, community nurses, community health workers, and traditional birthing assistants, and support the primary care team working together to deliver appropriate care to all people.  People in low income countries still want and deserve access to health care, access to caring clinicians, access to life saving medications for themselves and their children.

The digital world also provides a lot of challenges.  In our asynchronous world, how do we achieve continuity of care?  

We need to embrace the opportunities provided by new technology.  And this is nothing to be afraid of as many GPs in India have shown the world.  As GPs we are experts at adopting innovations into our practice and acting as translation agents for new technology. We are used to working quickly. We are used to change. We can accommodate innovation quickly when we see a direct benefit to the care of our patients.

At a time of rapid change and social unrest and conflict in many parts of our world, general practice provides some comfort to our patients, our communities and our nations.  

We can provide comfort because we are used to dealing with complexity and uncertainty.  

We provide comfort at a time when uncertainty is increasing for our patients who are faced with a barrage of choices and options and a wealth of misinformation thanks to the Internet.  

We provide comfort to our nations, which are facing uncertainty about their capacity to provide health care to all people and know that they should be keeping people out of expensive hospitals, but are not sure how to do this.  

At this time of uncertainty about the future of health care, the role of the GP continues to grow around the world.  And this need for comfort moves our global organization into an increasingly strategic role with the World Health Organization and other global health organisations.

Something Dr Iona Heath, past president of the Royal College of General Practitioners in the United Kingdom, said a few years ago really struck a chord with me, “I believe that general practice/family medicine is a force for good throughout the world.”

I am impressed with the commitment of GPs to human rights issues.  I am convinced that as GPs we care about human rights.  The basic expectations we all have about how we and our families and all people should be treated.  

As GPs we have social responsibilities. Each of us needs to be an advocate for social justice and human rights.

We need to stand up for freedom and justice and peace.  1.5 billion people live in countries affected by violent conflict with the associated terrible immediate and longer-term health consequences.

We need to speak out for what is right, to say “this is not OK”, and in so doing contribute to social change, both locally and globally.

And we need to contribute towards ensuring equity of access to health care – “a fair go for everyone”.  Are you familiar with the term “a fair go”?  It is an Australian expression meaning that we treat everyone equally.  

And we need to care for the health of our planet as well as the health of our patients.  What is good for the climate is also good for our patient’s health – reducing obesity, increasing physical activity and healthy improvements in diet. 

And why do I say that we should focus on these social issues.  It is because if we, as GPs, with our privileged position in society, and our access to pretty much the entire population in our communities, don’t stand up for these things, who will?

I would like to finish by saying thank you.  Thank you to the IMA CGP, to your members and your staff, for 50 years of contributions towards progressing primary care medicine across India and around the world.

I congratulate you all on the great commitments and achievements of your college, and on your personal commitment to making a difference to the lives of the people of your nation and our world.  I look forward to our work together during my time as WONCA president. 

Michael Kidd
World Organization of Family Doctors (WONCA)
Hyderabad, India
October 18, 2013