Neurology in India.

In this issue of Annals of Indian Academy of Neurology, there are two interesting articles. The first deals with history of neurology in India and the second addresses the issue of attracting postgraduates to neurology. Mishra brings us up-to-date with how the science of neurology has progressed in India over the last 60 years.[1] While the departments of neurology started getting established as far back as the 1950s, even today, only a handful of neurology training programs exist. Table 1 in Mishra's paper clearly shows this inadequacy. There are still some states in India, which do not have a single center for neurology training in the whole state and students have to travel far to obtain training. Moreover, while the pioneers undoubtedly played their roles in establishing their respective departments and neurology programs, all these have not progressed to keep up with the changing requirements. The theme then was clinical training, still central to all that we do, but the science has long gone in to the laboratories, a lacuna in many of our setups. Expectedly, candidates graduating from Indian institutions embark on clinical careers, competently shouldering the clinical responsibilities whilst only a few choose to continue as professors and teachers in academic institutions. Still, the opportunities in India for research in neurology are scarce and the aspirants have to look westwards for such careers, often at the cost of backtracking their steps. The collaboration between Indian basic scientists and clinical neurologists is only recently beginning to emerge in some centers of excellence and local research is limited to these setups.

The burden of neurological diseases is increasing.[2] As our longevity increases in India, the numbers of patients having dementias, Parkinson's disease, strokes, and other age-linked diseases is expected to increase exponentially. India has still not been able to get rid of road traffic accidents, infectious diseases, and the maternal and child care facilities remain inadequate. These are continuing contributors of mortality and morbidity. This is particularly true for rural India. As Gouri-Devi pointed out,[3] policymakers and administrators perceive neurological problems to be mainly urban, but epidemiological surveys show that rural populations have higher proportions of neurological diseases. Further, the disabilities and economic burden of neurological diseases is staggering. Thus, with limited backup from social organizations, the task of providing neurological care to Indians is daunting for the available work force.

On this background, the limitations of the workforce are very striking, exposing our neurologists to severe clinical workloads. Presently, there are only 1,200 neurologists registered with the Indian Academy of Neurology. Over 400 of them work in the four major metropolitan cities, leaving smaller numbers to cater to rural India. In one study,[4] neurologists situated in district places reported of having to see approximately 80 patients every day. This left them with little time for academics and research, which they regretted. It is obvious that there is an urgent need to increase the number of neurologists working in India. Only when the numbers reach a satisfactory point, there will be growth of interests in clinical and basic research problems faced locally.

It is interesting therefore, to study the perceptions of medical post graduates towards neurology. Gupta and colleagues have elegantly analyzed this issue.[5] Their statewide survey of eligible MD students gives some insights into the students’ thinking. Interestingly, 35% of the students considered neurology as either first or second career option. I have noticed top rank students recently opting for neurology in Maharashtra state and probably the same is true for all regions. Neurology seems to be ‘in demand’ up to a point. Gupta and colleagues state that the analytical and academic nature of the branch and the strong influence of good teachers seemed to bring them to neurology. Such influence of teachers has uniformly been recognized in studies across specialties.[6] But is a poignant issue in these days of “role model crisis”! In their analysis of the deterrents, Gupta, et al., bring out an important point that neurologists are often perceived as diagnosticians, delving in the depths of rarities and complexities, their opinions being important but often not helpful to the patient management. This perhaps is also something to mull over. The transition of the neurologist's image from a high power diagnostician to an effective therapeutician perhaps needs to be actively pursued by all our ranks. We do hope that in the coming years, more students follow their effective teachers and bolster neurology workforce in India.

Gouri-Devi, in her detailed exposition of the subject of neurology workforce,[3] proposed interesting models for delivery of neurological services in India. It is clear that community awareness; coordination between primary, secondary, and tertiary care centers; telemedicine; emphasis on rehabilitation; and development of community day care and inpatient respite centers is the way forward for improved quality of care. The disparity between the demand and supply of clinical neurologists is wide and unlikely to be bridged in the near future. It is therefore imperative that the physician-neurologist interaction needs to be enhanced[7]. This inadequacy was brought out by respondents in Gupta's study. Further, policymakers may also need to consider increasing the numbers of neurology trainees in the country and introduction of a short version of neurology training as in a diploma, in order to increase the neurology workforce.

Futuristically, if we are able to draw more students to neurology, increase the intake of students, entice basic scientists to collaborate with clinicians, have nationwide multicenter registries and programs, pose and answer local research questions, convince the National Health guardians to adopt neurologic diseases, and have wider community participation, we shall perhaps help patients with neurological diseases much more effectively in years to come.