By Ruvan Weerasinghe –

Dr. Ruvan Weerasinghe

For some it appears so. For any of them who are rational, it must instead be: can medical education be provided by the private sector? After all, SAITM also awards other degrees as a UGC recognized higher education institution. Many of the arguments for abolishing SAITM are actually calls for reversing some 25 years of private tertiary education in Sri Lanka! The issue has been so politicized, that for the uninitiated, the issue actually is: what is the question?

I’d like to take some space to try to address some of the arguments on both sides with a view to show why, once you’ve taken a side on this issue, your rationality takes a back seat. I also want to take this space to explore what a non-partisan approach to the issues may look like. Of course, I’m open to correction – but only to correction on rational grounds. So, if you are on one of the two sides already, you are either disqualified to respond – or welcome to point out some of the weaknesses of ‘your side’ of the argument only!

First to take on a moot point that both sides seem to be making (obviously to make exactly opposite ‘cases’), that Medicine is somehow NOT to be considered in the same manner as other disciplines (or professions?). This has been a typical elitist stand that the people of this country too appear to have largely accepted, owing to possibly the direct nature of the relationship between one’s physical health and the medical profession. As one of my learned Civil Engineering professor friends pointed out recently, Engineers probably save or in other ways affect the health of populations much more than medical doctors do! A serious look at many of the problems affecting the health of people of this country would cause us to realize that far more counsellors and therapists are probably needed to ‘heal’ our people than medical doctors. No doubt, many other professions including but not limited to law, finance, administration, teaching among others would also feel that their professions are critical to the functioning of a society. Apart from these ‘professions’, it is often the philosophers, scientists, psychologists, sociologists and even politicians that are (or should be) indirectly but much more critically involved in the long-term wellbeing of a nation.

So, what are the arguments surrounding the SAITM issue? Here I attempt to list the ones that have been made in the recent past, not least by the ‘My SAITM Story’ campaign and the state university protest march campaign.

1. The intake to the SAITM degree is deficient
2. SAITM students’ and their parents sacrificed much
3. SAITM charges exorbitant fees
4. State university students come through district quota
5. SAITM students aren’t serious about the medical profession
6. State university students are disruptive
7. SAITM owners represent the elite who get preferential treatment from authorities 8. GMOA is able to influence government
9. SAITM is ‘selling’ medical degrees
10. State university students are jealous of others
11. The clinical training provided at SAITM is inadequate
12. The medical doctors produced by the state system are superior

Even though I’ve mixed up the issues brought up by the two sides, even a novice would be able to figure out that every alternate issue is made by the ‘other side’. How is this possible? The reality is that, apart from a very few, our society has been forced to ‘take sides’ on this issue. In fact, these become issues after one has chosen one’s ‘side’ on it! For those who have not yet taken a side, the issue often is: so, what is the problem?

It would be so refreshing to see a state university medical faculty member making a case for SAITM and private medical education, and similarly a SAITM medical faculty member taking up some of the issues of equity that need to be addressed. But alas, that is too much to expect from a profession to which our society has bestowed so much prestige.

Now to address the issues raised.

Issue #1 above is based around the argument that to get to state medical school one has to have a high z-score. This argument is invalid as the official criterion for passing the A/L is 3 passes and technically, any student who satisfies this, could (at least in theory) enter a state medical faculty. As someone who’s been involved with state university education I am only too aware of the near ‘arbitrary’ nature of A/L results (even less so the decimal points in the z-score) in predicting the success or failure of the graduate produced by a university degree. This is why in some developed countries, professional degrees can only be undertaken after the completion of a ‘general’ degree. This is to ensure both the maturity required to undertake such a degree and to give space for developing a healthy motivation for the same.

Issue #2 appears to be a recurrent theme in the ‘My SAITM Story’ campaign which appeared to be aimed at evoking empathy among readers. While it may have had its (albeit limited) effect, a single ‘My (typical) Pera Story’ written by juxtaposing the lives of 3 state medical undergraduates was an effective counter to this ‘argument’ (if it can be called so). It did however drive the point that SAITM students were not (all) born with a proverbial silver spoon in their mouths.

Issue #3 appears on the surface to be an argument in support of SAITM students! It raises a fundamental question: how much is too much? Would we prefer a lower fee even if it means lower quality? Or is this related to the ill-formed question, why can’t the highest quality education be given at the lowest cost? The reason for this question stems from the fact that the we don’t reveal the cost of undergraduate education to students who enter the state university system. This issue is best addressed by the state giving vouchers valued in real terms to students in order that they select their university knowing how much it costs the state to educate them.

Issue #4 is a question about the fairness of the district quota system. It shows a lack of understanding about the nature of school education in the country. Of the 9000+ schools in the state system, many students are unaware that only some 600 are able to provide A/L science streams. The facilities for science even among those 600 vary so widely that a purely merit based system would in fact be unfair. Having said this, the exact formula used to compute the quotas are completely outdated and yet almost impossible to change owing to the high political charge that they encapsulate. However, it is clear that a student from an underprivileged background would need to put in much more effort to achieve the level required for a given degree programme.

Issue #5 is a gross generalization which also seems to imply that all state university students are highly motivated to help the suffering. In fact, a contemporary of mine had not too long ago asked each A/L biology stream student he met, why they wanted to be a doctor. Most of the responses (often from a parent standing nearby) centered around being able to have a ‘decent quality of life’ for themselves – with none responding that their reason was to do with being appalled by suffering or wanting to ease the pain of suffering people. In fact, very few students actually do what they are passionate about, and are more concerned about not ‘wasting their z-score’ even if it means doing something they are not interested in.

Issue #6 is one of the most common perceptions of university students among the general public: that state university students concern themselves with ‘irrelevant’ issues – those outside their own education. To be sure, the present issue is different, as the problem actually is that it is very much to do with their own future! For this reason, in this particular issue their ‘disruptive’ action is less justified. In general, however, it is university students who often awaken the ‘conscience’ of the rest of society to issues, which may be ‘disruptive’ in the short term, but possibly critical to society in the long term. Many a disaster has been averted in our history owing to the protest action led by university students.

Issue #7 is a lingering concern ‘fertilized’ by successive regimes that have governed the country owing to the dependence of the election system on big money that is only accessible to big business. The issue then becomes how to change the election system rather than how to stop the education ‘business’. Even if successful in stopping medical education becoming an ‘industry’, many other industries, not least the lucrative health industry that is patronized by those making these arguments, would continue to be abused in this unethical way to influence regimes even in the future.

Issue #8 is a reality to be faced. There is a need for strong unions especially in the contexts of corrupt regimes. Unfortunately though, this particular ‘strong union’ was mostly absent in the days when the regime was most corrupt! That should call to question their legitimacy in taking such an overly strong stance on this arguably much less ‘corrupt’ issue. However, that particular experience (in 2014) also taught us that a strong civil society can overrule not just strong unions, but even strong governments.

Issue #9 is old outdated rhetoric. In a society which ‘has a price for everything’, it is strange that education cannot have a ‘price’. Over 25 years ago tertiary education was already privatized and today most degrees in most disciplines can be gained through that system. Apart from IT and Business/Management, students can earn degrees in Law, Engineering and Science in the private sector today. Isn’t the present phenomenon of ‘selling healthcare’ a much more dangerous trend to be combated? Or will that be detrimental to those who are liberal with this rhetoric?

Issue #10 is a gross generalization again. I personally know many state medical undergraduates who are uncomfortable with the present situation. However, they also realize that there is a matter of equity that cannot be ignored. While they themselves may not find it difficult to compete and succeed in the ‘market’, they are very aware that some of their colleagues will not be able to do so, often owing to the handicap they bring with them in terms of their level of English proficiency and general ‘family’ background. Ignoring this issue without addressing it will only make those who feel disadvantaged fight all the more to keep private medical education at bay.

Issue #11 has probably been put as the major argument against granting SAITM recognition. A recent article by a former Dean of a Dental Faculty in the Island amply illustrates the irony of this assertion. Many state university faculties and departments would then have to cease granting the degrees they currently offer. Some hurriedly setup medical faculties in the past (e.g. Rajarata University) are other cases in point. Sri Lanka also recognizes medical degrees of several other countries but there is no evidence that the SLMC or the GMOA has scrutinized each of those degrees to the same extent as they have, SAITM. Even if this is a valid concern, that is no reason to scrap the degree surely? Rather, ways to address that situation should be the major concern of organizations such as the SLMC and the GMOA. Again, I wish these organizations pay much more attention than they currently do, to monitor and control the proliferation of sub-standard private health practices and hospitals in this country!

Issue #12 is a moot point. Since no medical graduates have come out from SAITM, we only have the example of the North Colombo Medical College (NCMC) that was subsequently made the Kelaniya University Medical Faculty. My own personal experience has been that some of the doctors produced by that institution while it was private are arguably among the best I’ve encountered and today serve in leading positions within the state health system. There may be many reasons for this including the fact that they had to ‘prove themselves’ as ‘underdogs’. Whatever the reasons, it suggests that private medical education could just as well produce the kind of doctors that would be on par with the best that the state system can produce. This is not to deny the fact that the state system does produce some excellent practitioners, but this does not preclude the private sector doing so too.

Overall then, it is clear that our side on the matter, largely determined by personal preference rather, prescribes our reasoning in matters such as this. We are either firstly on the SAITM side owing to being there or having a sibling, child or relation studying or teaching there; or with the state university system owing to having a similar connection to it. What we do need are serious individuals from each side who concede to rational arguments from the other side too. This alone will allow us to see beyond our own self- interest and seek the best for the country going forward.

The above is my attempt to do precisely this, however deficient it maybe. I invite others to point out weaknesses in my arguments on purely rational grounds, and not to argue based on their prior stand on the issue. After all, isn’t it highly unlikely that all arguments of one side are rational while those of the other side are all irrational?