In her book Special Treatment, anthropologistDr Anna Ruddockexamines how social hierarchies and health inequalities are sustained in the way medicine is taught at the much-coveted All India Institute of Medical Sciences (AIIMS) Delhi, which has an acceptance rate of 0.01%. In a conversation with Sunday Times, she talks of the fallout when medicine is used not as a social equaliser but to feed an obsession with meritocracy
What has Covid shown us about the path we have chosen in healthcare and what could AIIMS have done differently?
The pandemic is a moment of reckoning for India with its legacy of neglect of public health and healthcare. What does this moment ask for from medical education, and of AIIMS, mandated to set national standards? I suggest that what is needed is at least an interrogation of prevailing concepts of excellence. And what’s the role of the doctor in society? And how is that imparted to students? A single institution cannot be expected to change the medical culture of an entire country even if the institution was mandated to do just that. But the production and the reaffirmation of narrow norms and conceptions of excellence at AIIMS adds to stifle the potential of the MBBS programme and its students, and with that the transformative impact that some of them could have on Indian health and medicine. A reenvisaging of the purpose of undergraduate education at AIIMS has the potential to make graduating from India’s most prestigious medical college more meaningful. It could become an institution as exceptional in practice as in imagination.
Why do you urge the inclusion of social sciences in AIIMS medical curriculum?

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Section 14 of the AIIMS Act provides for inclusion of humanities in the MBBS curriculum but it has never been introduced. Integrating humanities and social sciences in the broadest possible terms creates a space that doesn’t currently exist for interrogating rather than naturalising social inequalities and crucially for self-reflection among students and faculty on the role of the doctor in society. At present, there is just no space for that.

The book talks of ranks feeding into the meritocracy obsession in AIIMS. How does caste or reservation fit in? Rank is critical. It probably starts in school and by the time they get to AIIMS, everybody is well aware of their ranks — their ranks in school, in the coaching institute, in the entrance exam… I was really struck by what is the function of a number like that on one’s subjectivity, one’s sense of self. In AIIMS or IIT entrance exams, results are calculated to seven decimal places and you have to go through hundreds or thousands of results before you really start seeing a general divergence in terms of score, and tie-breakers are used to do this false differentiation in order to create rank. So, ranks create heterogeneity, they create difference where there is actually sameness. In this scenario, merit is acquainted with upper casteness by virtue of the top ranks being associated with the general category. Often, general category students would say they have no idea of who is in which category. But students in reserved category would say entrance exam results are broadcast and so your identity is attached to you in a way that it isn’t if you were in the general category. It is upper caste privilege to say that I have a casteless worldview or that caste is not important. It is the same as white people saying “I am post racial. I don’t see colour.” This is also what allows for this narrative that affirmative action is regressive. It allows upper caste students to say why are you pulling us back into this caste-based world because we had transcended that, which we know you hadn’t. You just worked around it to be invisible to you.
Why do so few AIIMSonians engage with rural healthcare?
One of the first things that trainee doctors would say is how much they would really like to work in this kind of practice (rural practice) immediately followed by why it’s just not possible. Inevitably, the common narrative is around inadequate infrastructure beyond the city being an impediment to practice. We have to have sympathy because part of that is based on truth. Why should people go to places where they don’t feel safe or where they don’t have equipment? And that goes back to this whole big question of why public healthcare has never been a political priority in India since independence, how the concept of public healthcare never took root and we still see the consequences of that.
You quote a faculty member as saying, “AIIMS killed the GP”. Could you elaborate?
We have people coming to AIIMS, particularly from across north India, in search of what is sometimes primary, sometimes secondary care. When he said AIIMS killed the GP, he meant that despite it being clear every day at AIIMS that people need more access to competent and affordable general care, there has never been an effort in AIIMS to instill in students the value of general practice. These young people are given a clear idea of what is prestigious and what is not. And that is the preoccupation of the AIIMS system, to maintain this aura of prestige.
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