163
EDITORIAL
March, 1940]
Indian Medical Gazette MARCH
HOSPITAL ORGANIZATION IN INDIA
Bengal as a whole there are 12 beds per nurse, excluding midwives and male nurses, which had they been included would bring the figure down to 9
or
10.
In Madras there
are
10, and in
Bombay just over 9 beds per nurse. It is the frpquent complaint of the rural civil surgeon vfciiat he dare undertake nothing but emergency or very simple surgical operations because of the total inadequacy of the nursing arrange-
ments. the most serious check to general The hospital is an ancient institution. In uiedical progress in this country is the in- early Greek history there are frequent references aoequacy of hospital organization; the extent to hospitals, both as teaching centres and for this inadequacy may be judged by the the care of the sick, and similarly in India there area that is served by each hospital, are early historical accounts of the founding of by the smallness of the numbers of beds per hospitals, for poor and sick. In Europe, even head of population, and by the extremely poor through the Dark Ages, hospitals, which were Quality of the accommodation and attention mainly refuges for the sick and needy, survived provided in the hospitals. Some relevant figures and there is a hospital in London still occupying are_ given in an interesting review of the position the site which was given to it by Royal Charter Ju India by Colonel Chopra, which will be found in the year 1137. But in India hospitals diselsewhere in this issue, and also in Major- appeared for many centuries until they were general Bradfield's Indian Medical Review reintroduced by the British. Published at the end of 1938. At the beginning of the last century, hospitals The area served by each dispensary varies were not popular and one has only to read the considerably, even if we leave out of considera- accounts by contemporary writers of the ^W0 excePti?nal administrative areas? hospitals that existed in those days to underTVru?Uelhi province with its compact population of stand why. In the pre-Listerian days the total over 1,000 per square mile, and a hospital or mortality of patients entering hospital was for every 24 square miles, and at the appalling; even if the diseases from which they other end of the scale the sparsely populated suffered were easily curable, they usually Baluchistan where each hospital or dispensary managed to acquire some other affection, and a las to provide for an area more than fifty times woman entering a maternity hospital invariably great, 1,327 square miles. In the Central suffered from sepsis. But with a better underr?vinces each hospital or dispensary has to standing of what constituted infectiousness and serve an area of 291 the introduction of antiseptic and aseptic pracsquare miles against 54 in bengal. But whilst Bengal heads the list for tices, hospitals ceased to be the death-traps that tae number of hospitals and dispensaries^ it is they undoubtedly were, and, after the natural obvious that bedless dispensaries predominate, prejudice against them had gradually dis?r the average number of beds in these institu- appeared, they became popular and to-day in i?ns is only 7 against 28 in Bombay, 16 in the most advanced countries the demand for hospital treatment far exceeds the accommodation availand 14 in Madras. In Bengal each nJ.ab, I lQspital bed has to serve a population of 5,000 able. The appreciation of the advantages of Persons and the figure for the whole of India is hospitalization is at its highest in the United States of America (the word itself surely at 0.3 beds per thousand. Un the matter of the on that side of the treatment the of originated Atlantic), and in quality to the occupants of these beds, it is diffithat country few women will choose to be cult to find terms in which this can be measured, confined in their own homes. The hospital habit as there are so many factors concerned; exclud- is developed far more highly in some European continental countries than it is in Great Britain, consideration of the medical personnel, we have the accommodation, the surgical and where incidentally the war has focused a great her equipment, the nursing, and the diet and deal of attention on the present hospital system general medical comforts. Perhaps the easiest with its advantages and disadvantages. But in actor to put into For Britain there are about five beds per the is Great nursing. figures e whole of India the number of beds per nurse thousand of the population and even then many ls 14, or seven nurses per 100 patients; this, patients in need of hospital treatment are alter allowance is made for night and day turned away. The great advantages of hospital Cursing, the administrative and theatre staff, treatment are rapidly being learnt by the people and the leave of India. In the larger cities, there is always a roster, is a ridiculously small figure. In the teaching institutions in the large waiting list for admission for any but emergency cities, the number of nurses per 100 beds is of cases, and it has been said facetiously that it course much larger, 20 or even 30, which is still requires more influence to get a bed for a ?ar below the British and American standards, hydrocele operation in a certain large Calcutta out this hospital than to get a seat in the Legislative larger number in the teaching institutions only means that in other hospitals the Assembly; whenever a hospital is not full one Uumber of nurses is correspondingly low; in
Probably
jmmense
^spensary
pS
caJculated g^en .
^g
sjul
.
THE INDIAN MEDICAL GAZETTE
164
may be sure that there is something wrong inside the hospital walls. New ideas in medical treatment rapidly seep through to the illiterate ryot who forms the bulk of India's population. A good example is the parenteral injection; 25 years ago the sight of a syringe frightened a patient into absconding from hospital, to-day the same patient thinks he is being unfairly treated if he is only given medicines by the mouth. The hospital idea is firmly implanted in the Indian mind and it will continue to grow. The problem is to meet the increasing demand for hospital accommodation. The tendency is to attribute the lack of hospital accommodation to India's poverty, or alternatively to the failure of the government to do something about it, but the trouble is deeper and goes back further than this. We will not attempt here to trace the growth of the hospital system in other countries, except to note that in practically all European countries, the first hospitals were founded by religious bodies and were charitable institutions. They were often given the blessings of the government of the day but no more and sometimes less, in that their funds were frequently confiscated. It is from such beginnings that the ' voluntary' hospital system, which until recently was the mainstay of British medicine, evolved. No counterparts, either of these early religious institutions, or of the present voluntary hospitals, exist in India. The first hospitals in this country (within the last millennium) were founded by the British Government or by Christian missionary bodies, and it is only within very recent times that other religious bodies have followed this example. The government hospitals, in particular, were modelled on the British system, modified to suit Indian conditions, so that they have never had the advantage of natural growth through which The case process British hospitals have passed. of the missionary hospitals is somewhat different; most of these have developed from small beginnings, and though poorer and not so well equipped they are often quite as well suited to the requirements of the people as are the more pretentious government hospitals. Another big group is formed by the municipal and district board hospitals. Nearly all the hospitals in India can be placed in these three groups, and in the country as a whole they each provide about one-third of the beds. The proportion of hospital beds already provided by the central and provincial governments is far in excess of those provided by the governments in most other countries, and they cannot be expected to provide more, except for special purposes as for example in connection with medical education. It is not really desirable that they should, even if they could afford the money, which in these days they obviously can not. Nor will the problem be solved by Indian
philanthropists
building
large
hospitals,
on
[March,
1940
which their names may be inscribed but which, lack of endowment and of any local remain half empty and even then have to be maintained by government. In other countries the hospital system has been built up by the people themselves; in this country the beginnings have been made by the government and foreign missionary bodies, the interest has been created, and it is for local enterprise with the aid of local philanthropists to carry on the work. There are many missionary hospitals in India which though started and still helped by funds collected in other countries are now almost self-supporting; by charging fees to those who can afford to pay, they have been enabled to provide free treatment for the really poor and it is on this principle that hospitals of the future will have to be built up. Colonel Chopra, in the paper to which we have already referred, has suggested that the almoner system should be introduced into government hospitals. Something of the kind will have to be done, but it will be difficult to put into effect, for the government is always looked upon as fair game and many, who will conspire to defraud the government by concealing the truth, will hesitate to cheat the local community, and, further, their fellow citizens will see that they do not do so. Finally, the idea of personal service must be further developed in India. The shortage of nurses is a serious handicap to progress in hospital provision. For many years only Europeans and Anglo-Indians came forward for training as nurses and even now the profession of nursing does not appeal to the educated Indian, but if there is to be any marked improvement in hospital provision a very large body of nurses will be required; these cannot be provided by one community, and the leaders of all communities must endeavour to change the present attitude and encourage their educated young women to take up nursing. That the facilities for training nurses are not ideal is perfectly true, but recently, though efforts have been made to improve these and induce more better-class Indians to take up this profession, the response has been disappointing. Perhaps the most serious obstacle to progress is the poor provision that is made for nurses, both in the matter of pay and of accommodation; it is not a good sign that recently the funds raised for building a new hospital in Calcutta were expended on the provision of an up-to-date hospital building without any balance being left for the nurses' quarters, more particularly in view of the fact that this was a women's hospital and that women were mainly concerned in the organization and management of the fund. The problem of hospital accommodation in India is not simply an economic one; it will not be solved until the civic conscience is more fully developed, and the people begin to realize that an impressive facade does not compensate for poor medical treatment behind it, that a good
through support,
March, 1940]
HEMATOLOGICAL TECHNIQUE
nursing staff is more important than an rr-ray apparatus, and above all that the provision of
:
NAPIER & DAS GUPTA
hospital treatment responsibility.
for the sick is their
165 own
local
EDITORIAL
March, 1940]
Indian Medical Gazette MARCH
HOSPITAL ORGANIZATION IN INDIA
Bengal as a whole there are 12 beds per nurse, excluding midwives and male nurses, which had they been included would bring the figure down to 9
or
10.
In Madras there
are
10, and in
Bombay just over 9 beds per nurse. It is the frpquent complaint of the rural civil surgeon vfciiat he dare undertake nothing but emergency or very simple surgical operations because of the total inadequacy of the nursing arrange-
ments. the most serious check to general The hospital is an ancient institution. In uiedical progress in this country is the in- early Greek history there are frequent references aoequacy of hospital organization; the extent to hospitals, both as teaching centres and for this inadequacy may be judged by the the care of the sick, and similarly in India there area that is served by each hospital, are early historical accounts of the founding of by the smallness of the numbers of beds per hospitals, for poor and sick. In Europe, even head of population, and by the extremely poor through the Dark Ages, hospitals, which were Quality of the accommodation and attention mainly refuges for the sick and needy, survived provided in the hospitals. Some relevant figures and there is a hospital in London still occupying are_ given in an interesting review of the position the site which was given to it by Royal Charter Ju India by Colonel Chopra, which will be found in the year 1137. But in India hospitals diselsewhere in this issue, and also in Major- appeared for many centuries until they were general Bradfield's Indian Medical Review reintroduced by the British. Published at the end of 1938. At the beginning of the last century, hospitals The area served by each dispensary varies were not popular and one has only to read the considerably, even if we leave out of considera- accounts by contemporary writers of the ^W0 excePti?nal administrative areas? hospitals that existed in those days to underTVru?Uelhi province with its compact population of stand why. In the pre-Listerian days the total over 1,000 per square mile, and a hospital or mortality of patients entering hospital was for every 24 square miles, and at the appalling; even if the diseases from which they other end of the scale the sparsely populated suffered were easily curable, they usually Baluchistan where each hospital or dispensary managed to acquire some other affection, and a las to provide for an area more than fifty times woman entering a maternity hospital invariably great, 1,327 square miles. In the Central suffered from sepsis. But with a better underr?vinces each hospital or dispensary has to standing of what constituted infectiousness and serve an area of 291 the introduction of antiseptic and aseptic pracsquare miles against 54 in bengal. But whilst Bengal heads the list for tices, hospitals ceased to be the death-traps that tae number of hospitals and dispensaries^ it is they undoubtedly were, and, after the natural obvious that bedless dispensaries predominate, prejudice against them had gradually dis?r the average number of beds in these institu- appeared, they became popular and to-day in i?ns is only 7 against 28 in Bombay, 16 in the most advanced countries the demand for hospital treatment far exceeds the accommodation availand 14 in Madras. In Bengal each nJ.ab, I lQspital bed has to serve a population of 5,000 able. The appreciation of the advantages of Persons and the figure for the whole of India is hospitalization is at its highest in the United States of America (the word itself surely at 0.3 beds per thousand. Un the matter of the on that side of the treatment the of originated Atlantic), and in quality to the occupants of these beds, it is diffithat country few women will choose to be cult to find terms in which this can be measured, confined in their own homes. The hospital habit as there are so many factors concerned; exclud- is developed far more highly in some European continental countries than it is in Great Britain, consideration of the medical personnel, we have the accommodation, the surgical and where incidentally the war has focused a great her equipment, the nursing, and the diet and deal of attention on the present hospital system general medical comforts. Perhaps the easiest with its advantages and disadvantages. But in actor to put into For Britain there are about five beds per the is Great nursing. figures e whole of India the number of beds per nurse thousand of the population and even then many ls 14, or seven nurses per 100 patients; this, patients in need of hospital treatment are alter allowance is made for night and day turned away. The great advantages of hospital Cursing, the administrative and theatre staff, treatment are rapidly being learnt by the people and the leave of India. In the larger cities, there is always a roster, is a ridiculously small figure. In the teaching institutions in the large waiting list for admission for any but emergency cities, the number of nurses per 100 beds is of cases, and it has been said facetiously that it course much larger, 20 or even 30, which is still requires more influence to get a bed for a ?ar below the British and American standards, hydrocele operation in a certain large Calcutta out this hospital than to get a seat in the Legislative larger number in the teaching institutions only means that in other hospitals the Assembly; whenever a hospital is not full one Uumber of nurses is correspondingly low; in
Probably
jmmense
^spensary
pS
caJculated g^en .
^g
sjul
.
THE INDIAN MEDICAL GAZETTE
164
may be sure that there is something wrong inside the hospital walls. New ideas in medical treatment rapidly seep through to the illiterate ryot who forms the bulk of India's population. A good example is the parenteral injection; 25 years ago the sight of a syringe frightened a patient into absconding from hospital, to-day the same patient thinks he is being unfairly treated if he is only given medicines by the mouth. The hospital idea is firmly implanted in the Indian mind and it will continue to grow. The problem is to meet the increasing demand for hospital accommodation. The tendency is to attribute the lack of hospital accommodation to India's poverty, or alternatively to the failure of the government to do something about it, but the trouble is deeper and goes back further than this. We will not attempt here to trace the growth of the hospital system in other countries, except to note that in practically all European countries, the first hospitals were founded by religious bodies and were charitable institutions. They were often given the blessings of the government of the day but no more and sometimes less, in that their funds were frequently confiscated. It is from such beginnings that the ' voluntary' hospital system, which until recently was the mainstay of British medicine, evolved. No counterparts, either of these early religious institutions, or of the present voluntary hospitals, exist in India. The first hospitals in this country (within the last millennium) were founded by the British Government or by Christian missionary bodies, and it is only within very recent times that other religious bodies have followed this example. The government hospitals, in particular, were modelled on the British system, modified to suit Indian conditions, so that they have never had the advantage of natural growth through which The case process British hospitals have passed. of the missionary hospitals is somewhat different; most of these have developed from small beginnings, and though poorer and not so well equipped they are often quite as well suited to the requirements of the people as are the more pretentious government hospitals. Another big group is formed by the municipal and district board hospitals. Nearly all the hospitals in India can be placed in these three groups, and in the country as a whole they each provide about one-third of the beds. The proportion of hospital beds already provided by the central and provincial governments is far in excess of those provided by the governments in most other countries, and they cannot be expected to provide more, except for special purposes as for example in connection with medical education. It is not really desirable that they should, even if they could afford the money, which in these days they obviously can not. Nor will the problem be solved by Indian
philanthropists
building
large
hospitals,
on
[March,
1940
which their names may be inscribed but which, lack of endowment and of any local remain half empty and even then have to be maintained by government. In other countries the hospital system has been built up by the people themselves; in this country the beginnings have been made by the government and foreign missionary bodies, the interest has been created, and it is for local enterprise with the aid of local philanthropists to carry on the work. There are many missionary hospitals in India which though started and still helped by funds collected in other countries are now almost self-supporting; by charging fees to those who can afford to pay, they have been enabled to provide free treatment for the really poor and it is on this principle that hospitals of the future will have to be built up. Colonel Chopra, in the paper to which we have already referred, has suggested that the almoner system should be introduced into government hospitals. Something of the kind will have to be done, but it will be difficult to put into effect, for the government is always looked upon as fair game and many, who will conspire to defraud the government by concealing the truth, will hesitate to cheat the local community, and, further, their fellow citizens will see that they do not do so. Finally, the idea of personal service must be further developed in India. The shortage of nurses is a serious handicap to progress in hospital provision. For many years only Europeans and Anglo-Indians came forward for training as nurses and even now the profession of nursing does not appeal to the educated Indian, but if there is to be any marked improvement in hospital provision a very large body of nurses will be required; these cannot be provided by one community, and the leaders of all communities must endeavour to change the present attitude and encourage their educated young women to take up nursing. That the facilities for training nurses are not ideal is perfectly true, but recently, though efforts have been made to improve these and induce more better-class Indians to take up this profession, the response has been disappointing. Perhaps the most serious obstacle to progress is the poor provision that is made for nurses, both in the matter of pay and of accommodation; it is not a good sign that recently the funds raised for building a new hospital in Calcutta were expended on the provision of an up-to-date hospital building without any balance being left for the nurses' quarters, more particularly in view of the fact that this was a women's hospital and that women were mainly concerned in the organization and management of the fund. The problem of hospital accommodation in India is not simply an economic one; it will not be solved until the civic conscience is more fully developed, and the people begin to realize that an impressive facade does not compensate for poor medical treatment behind it, that a good
through support,
March, 1940]
HEMATOLOGICAL TECHNIQUE
nursing staff is more important than an rr-ray apparatus, and above all that the provision of
:
NAPIER & DAS GUPTA
hospital treatment responsibility.
for the sick is their
165 own
local
