Tuesday, 17 March 2015

Choices that Indians abroad and Indian doctors make

Indians fought for their British masters in World War 1

The Indian army personnel who died in World War 1 were commemorated recently. The Indian army during that time numbered 1.5 million soldiers, nearly 1 million fought in the war. About 75000 died and about a similar number injured. 170000 animals came from India 3,700,000 tons of supplies and stores came from India that was worth about £80million. Another £146 million monetary contribution was also provided. £1 in 1917 would be about £340 today (2015) – do the math.

Here is the most fascinating aspect of this:

All the 1.5 million were volunteers. Yes you read that right volunteers.

I heard on BBC Radio that there was even a 70 year old ‘prince’ who went to meet the Viceroy so that he can go to Europe to fight in person on behalf of the empire.

According to most reports India was a relatively rich country at that time. There are some accounts that a Rupee was worth about US $10 around WW1 time. The wealth was not available to an overwhelming majority of Indian people, the wealth was available mainly and overwhelmingly to Britain. Indian people in India were treated quite badly by the British on all accounts. Yet, 1.5 million Indians and their local masters volunteered to fight and sacrifice their lives for their British rulers. Even the great Gandhi asked people to join the armed forces.

This is a remarkable achievement of the British Empire to encourage and motivate people to support them; that ability is truly amazing and deserves congratulations.

The intriguing question is why so many Indian’s volunteered to fight and die for their colonial masters? Why did they allow so many resources to be plundered?

Did the Indians feel that given a choice of their previous muslim rulers or their own local kings and princes versus the British – supporting the Empire was the better option? Did the Indians have genuine loyalty and affection towards the British? Did the Indians have an inkling that this was a long term game and playing with the British was appropriate in 1917? Or is there something in the Indian psyche that makes them support their invaders and colonisers more than their own local people (caste, local rulers’ oppressiveness, lack of local opportunities, personal greed may have all played a part)? Given the long history of these things there seems a certain naivety or gullibility or personal selfishness that becomes apparent.

Make no mistake – I am not talking here about the extraordinarily tragic stories of people who were made indentured labour, oppressed populations and other aspects of cruel history. I am only talking here about volunteers – people who had a choice and chose the colonial British.

My knowledge and analytical ability has to take a pause as I am unable to give more reasons. But, I would like to move to looking at this through a healthcare lens.

Some stats (as though stats convinced anyone!)

The population of India is 1.278 billion

The number of registered doctors in India 885233 as of 2013

India hence has less than 0.69 doctors per 1000 population

The intake into medical colleges in India as of 2013 is 41569

The number of registered doctors in UK is 267146

The UK population is 64.1 million.

This means the UK has 4.6 doctors per 1000 population

If the number of non-practising doctors are removed from the calculation then the UK  has 3.68 per 1000

If we removed the doctors who obtained their primary medical qualification outside UK then the UK would have less than 2.63 per 1000 population

The intake into medical schools in UK is 7900 per year (as of 2013)

36.8% of doctors registered in the UK are from outside UK (their primary medical qualification i.e. MBBS is from outside the UK)

The number of doctors with a primary medical qualification in India registered in UK 24995 (as of 2014)

Stats done, lets move on.

Indian doctors abroad (especially in the UK)

From conventional economics point of view doctors in India are in short supply with great demand and even in a low income situation it should be very attractive for doctors in India to remain in India; potentially and in reality often doctors in India are relative high earners.

Yet about 25000 Indian qualified doctors work in UK. About 125000 doctors of Indian origin working in the western English speaking world, with possibly tens of thousands more working in other countries (eg middle east).

It is also thought and even recognised that Indian doctors are significantly disadvantaged and possibly even discriminated when they work abroad. I have personal knowledge of UK where the statistics and the narrative certainly does not show Indian qualified doctors are equal, there is a strong feeling and growing evidence that they are discriminated against. Examination results, sanctions by the regulators, senior posts, etc all show that International Medical Graduates and Black and Minority Ethnic do not do well in the UK.

Yet, non-UK primary medical qualification holders form 36.8% of the doctors in UK of whom 25.8% are from non-European countries with 9.4% from India. No one forced them to come to UK. They are voluntarily coming to UK.

What is happening here? 

Indians (especially Indians abroad even more especially Indian doctors abroad) need to think about how they make their choices

Is discrimination the reason? Like the rest of the world, India has discrimination too, worse in some areas than others. If discrimination was the reason, why have Indian doctors working in the UK chosen to be subject to UK style discrimination than Indian style of discrimination?

Is it the ability to contribute to the health of the population? Why do Indian doctors want to contribute to the health of the British population when the need for the Indian population is much higher?

We can talk about many aspects such as opportunities, economics, corruption, ethics, etc. The point is that the evidence shows that BME population in white societies do get the wrong end of the stick. My main question is why do Indians and in the context of this writing Indian doctors choose the wrong end of the British stick (and choose not to subject themselves to the wrong end of the Indian stick)?

A lesson for India is perhaps that the Indian stick is much harsher in day to day terms and India needs to do something about that.

But for individuals, is there a different explanation? Are Indian doctors in the UK and in the rest of the western world the equivalent of the WW1 Indian volunteers? Remember the aged prince who went to the viceroy demanding he personally fight on behalf of the British empire?

There will always be mobility of labour. The mobility of labour that the western citizen generally seem to choose is one where he/she will be treated well, the western person does not seem to volunteer to work for or sacrifice his/her life for populations who treat them badly (that is why the British people left India along with their imperial government, as they did in many other countries).

The more I think about this topic the more I am convinced that there is something about seeing oneself as a winner (which is slightly different from actually being the winner), or siding with whom we think as the winners. Power is a great influencer of cultural values, especially conventional power (money and military).  Conventional power has a certain vicious attraction where even those who suffer its negative effects begin to support it. Might propagates culture and might is often very harmful.

This makes very uncomfortable reading but those of us who have chosen to leave families behind voluntarily, who have chosen to benefit an even more an already advantaged population, those of us who have chosen to submit ourselves to disadvantage and discrimination by the west, do have to wonder whether we are naïve, whether we are gullible and whether we are selfish. Indians abroad often see themselves as winners, Indians in India often see their compatriots abroad as winners.This illusion of feeling as though you are winning while losing can be addictive and almost permanently disorienting.

If we are the new era equivalents of the Indians who volunteered to fight for the British imperial masters in WW1, our development needs are so profound that it will not be a surprise if takes generations to address.  If we really want to be winners (not just seen as winners) there needs to be a different mind set where volunteering into a generally negative situation is not a trade off for personal benefits or for some vague notions of future benefits (which will mostly remain unrealised).

If we willingly subject ourselves to abuse, there will always be someone who will willingly abuse us.


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I am a doctor with a primary medical qualification from India and every word above is applicable to me.

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Dr praveen sarda said...

Dear Hemadri
I have always admired your emails on indigo, but First time I read your blog, and very impressed with the maturity and clarity of your thoughts.

Whilst India is progressing in leaps and bounds, day to day life is still very challenging due to all the issues you have already mentioned. There are various reasons people want to migrate, some of which you have already mentioned.

I am also intrigued as to why so many of us come to the UK, when other places offer potentially more money or better work environment? For example US offers much better chances of equality and merit based progress(logically, its a country of immigrants, although I do not have any figures to substantiate this) and places like US, gulf or Australia that are more rewarding financially.

I guess it is down to well laid pathways over the years that make it easier to migrate to the UK, plus perhaps an element of mental slavery still exists? While many would contest this, I feel that NHS is the archetypal 'sarkari' system like in India that rewards mediocrity. there is no incentive for anyone to push the boundries, indeed that can be detrimental! It therefore offers a great escape for people who do not want the cut and thrust of private practice in India/US where you are judged by your results everyday!

Doctors in India today earn more than counterparts in the UK, but the type of practice and environment there is not everyone's cup of tea and therefore many people come back after relocating. Part of the problem is that everything in India has personalised contacts based approach, not robust systems. Daily utilities, healthcare, business or police, nothing moves unless you 'know' someone relevant. In India, as opposed to the west, the person is powerful than the system. Whilst this has its advantages, it benefits select few, and not the masses. unless the systems are improved (development as you have written), where an average joe bloggs does not have to struggle to find contacts for everyday work, there will always be a flight of professionals out of the country.

M HEMADRI said...

Hi Praveen

Thank you for your comments.

You are absolutely spot on.

Tolerating corruption and injustice - is it a matter of scale or a matter of principle? I feel that Indians working abroad seem to think its a matter of magnitude