Thursday, November 11, 2010

Quo Vadis, Doctor, Quo Vadis?

The young lady was brought to the small hospital in Jharkhand gasping for breath 2 hours after she had been bitten by a snake. She was quickly intubated and given the life-saving Anti-snake venom antitoxin. For the next 2 days, the junior doctor manually ventilated her round the clock as she slowly recovered. Her hand that had received the bite developed fasciitis and required a debridement. But after a week, she was ready to go home. Her bill, after heavy discounting came to Rs. 1500, mainly for the medicines that needed to be replaced. After a day, the husband brought in the money to pay the bill. Out of interest, the doctor asked him how he found the money. He said he had taken a loan from the moneylender. And the interest – Rs.10 for every Rs.100, every month. 120% annual interest. The young doctor was horrified – that was a life sentence. With the enthusiasm and altruism of youth, he offered to pay the money which could be returned to him if and when possible. But the farmer was resolute. He said it was actually a good bargain. He would never be able to repay the loan, but he would be able to work on the moneylender’s farm for the rest of his life and be sure of at least a meal a day. And when his young son was little older, he too could work and this way, his family would be secure…… For the sake of a medical bill he signed away his family into a lifetime of bonded labour.

This is a true story. It is no one-off event. It is repeated nearly every day in the villages of our country, where decades of suppression and government apathy have created a feudal system that would be unthinkable in a modern, educated society. A system that has bled the poor to feed the rich. A system that has sparked the rise of a violent movement that, according to our home minister, is the greatest threat to our national integrity. A system that is due, at least in some degree, to the corruption and avarice of those whose vocation it is to serve – our doctors.

A survey by Transparency International found that after the police, healthcare was the most corrupt service sector in India with a quarter of the respondents having paid bribes to access health services. The key culprits were, not surprisingly, the doctors (77%). We have all read in great detail of the unbelievable corruption that has claimed (for the time being, at least), the head of the chief regulatory body of Indian doctors. But then, he was arrested for corruption in 2001 and came back, winning the MCI election again. The astronomical amounts that buy undergraduate and post-graduate seats in the medical colleges of our country only rise every year. India is the world’s biggest bazaar for human organs. And every new government initiative in health care is quickly and confidently hijacked by our doctors to work for their monetary benefit. In short, our health system has fine-tuned itself to greatly benefit one group of people – the doctors.

And this is no secret. Every patient who goes to a doctor goes with mixed emotions. There is always hope – that the doctor will find the cause of the problem and treat it. But there is also fear – of the possibly unnecessary investigations, procedures and medicines that the doctor will order, knowing that every stroke of his or her pen is directly translated to some personal perk or benefit. The rich have no problem with this system. As with every form of corruption, it is the poor who suffer. Official statistics indicate that about 20,000 farmers have committed suicide since 1997 with poverty being the root cause in most cases. And the World Bank has estimated that one-fourth of all patients admitted to a hospital in India are pushed into poverty by this ‘catastrophic’ medical event. Studies done in random villages of Rajasthan, Gujarat and Andhra Pradesh found health-care expenditure being the cause for falling into poverty in 55%, 85% and 77% of respondents respectively. Health care for the poor in India has become a double-edged sword. Not having it is a denial of one’s rights, but having it is detrimental to the well-being of the household – the ‘medical poverty trap’. And often, health costs are driven steadily upwards by the constant search of health care professionals for higher profits and a better life, a situation that is easily exploited by health care companies and pharmaceuticals. The Hippocratic Oath often becomes a big hypocrisy.

Hippocrates refusing gifts of Artaxerxes the king

In today’s world, there are 2 forces that drive our doctors. The more common one is the monetary drive, where decisions of health practice are driven by the higher salary, cut or perk. The more acceptable one is the drive for excellence, be it professional or academic. But there is a third drive – that is often forgotten. In our dedication to either monetary gain or professional advancement (or both), we often subdue the drive that should be given primary importance by anyone who has sworn the Hippocratic Oath – the drive of service. But service is often pushed to the back of our mind during our medical education and practice. The number of doctors even from Christian medical colleges who serve in ‘areas of need’ are so few and far between.

When Nero was burning the Jews at stake in full view of the whole population, including the distinguished leaders of all the conquered kingdoms, when Hitler was exterminating the Jews with implicit knowledge of the Christian church and the educated population of Germany, it was the silence of those who knew better that allowed them to perpetuate these abominations against humanity. And today, many of us doctors participate in a system that is designed to make us richer and the poor, poorer. When Peter was running away from probable crucifixion in Rome at the height of Nero’s persecution, an apocryphal story tells that just outside the city, he met Jesus walking back to Rome to take Peter’s place. And the question he was asked is the one we are asked today – Quo Vadis, Petros, Quo Vadis? Whither goest thou, Peter?

Quo Vadis, doctor? Our country desperately needs more health professionals who will respond to the need and heed the cry of the millions of Indians who suffer under the yoke that the medical system places on them. Men and women of character, who have the courage of conviction to stand against the tide and make a difference like Dr. AK Tharien, Drs. Raj and Mabel Arole, Drs. Abhay and Rani Bang and so many others. The issues are not always so simplistic, but we need to make a start somewhere. Individual decisions need to be made until, over time, we reach the ‘tipping point’ when the flow of health care service will turn from being doctor-centric to patient-centric. It sounds impossible given the present situation, but that day will surely come. And it could start with you and me.

A young doctor stood at the bedside of a patient. This man had survived a major emergency operation in spite of a host of complications. He and his young daughter were extremely grateful to the doctor, but were pleading for a reduction in his bill. The young man took the plea to his boss, but was refused. The next day, the patient was gone, bill paid. Nine months later, the doctor saw his patient again. He had come for the birth of his daughter’s first child. The doctor was confused, remembering the beautiful young girl who had begged for a bill reduction. ‘But I thought she was unmarried,’ he said. ‘She is,’ replied the man, with a bowed head. ‘I sold her virginity to pay my bill.’

This is a true story. Quo Vadis, doctor? Quo Vadis?


[1] Sanjay Kumar. ‘Healthcare is among the most corrupt services in India.’ BMJ 2003; 326 : 10 doi: 10.1136/bmj.326.7379.10/c (Published 4 January 2003)
[2] Peters , DH, Yazbeck , AS , Sharma, RR, Ramana, GNV, Pritchett, LH and Wagstaff, A (2002), 'Better Health Systems for India 's Poor. Findings, Analysis and Options', Washington DC, The World Bank
[3] Krishna , A (2003a), 'Falling into Poverty: Other Side of Poverty Reduction', Economic and Political Weekly , February
[4] Krishna, A, Kapila, M, Porwal, M, and Singh, V (2003b), 'Falling into Poverty in a High-Growth State: Escaping Poverty and Becoming Poor in Gujarat Villages',Economic and Political Weekly , December 6, pp 5171-5179
[5] Krishna , A, Kapila, M, Pathak, S, Porwal, M, Singh, K, and Singh, V (2004), 'Falling into Poverty in Villages of Andhra Pradesh: Why Poverty Avoidance Policies are Needed', Economic and Political Weekly , July 17, pp 3249-3256
[6] Whitehead , M, Dahlgren, G, and Evans T (2001), 'Equity and Health Sector Reforms: Can Low-income Countries Escape the Medical Poverty Trap?', The Lancet , Vol 358, September, 833-36
[7] Malcolm Gladwell. ‘The Tipping Point’. Abacus, 2000.

(The edited version of this article was published in Current Medical Issues (hence the references!), the journal of the Continuing Medical Education department at CME, Vellore this month - my mother's farewell issue. She has done a wonderful job of revamping and editing the journal since 2003 and has begun the process to get it indexed)

Saturday, November 6, 2010

Is India rich or poor?

UN HUMAN DEVELOPMENT REPORT 2010: The UNHDR 2010 was released on the 4th of November. Where does India stand? On the Human Development Index, we occupy the 119th spot (out of 169). There has been an improvement of one solitary position (!!) over the last 5 years. We rank below our neighbours, Pakistan and Bangladesh in education (average time spent in school is 4.4 years compared to Pakistan - 4.9) and health (life expectancy 64 versus 67 in Pakistan and Bangladesh). But India has secured the 10th position in the area of improvement of the income index!! In a nation where there are 421 poor people in just eight states, more than the 26 poorest African nations combined - 410 million. We also score 122nd among 138 countries in gender inequality. Generally not a good report card......

2 HINDUSTANS: So how can our income, GDP and economy be going up when there are so many poor people? The mystery man of Indian politics, Rahul Gandhi (or as Lalloo and Sharad Yadav call him - baccha/babua!!), made an interesting observation in an impromptu speech to the AICC meet. 'There are two Hindustans -- one is growing very fast and the other is for the poor (which is in crisis).... We have to connect and unite the two.' He has been doing some interesting things over the last few years, like riding a local train in Mumbai, regularly breaking his security cordon to meet poor people, secretly riding a second-class compartment from Gorakhpur to Maharashtra (with a visit to the unreserved compartment on the way) and meeting students in colleges over the country encouraging them to join politics. It seems he has done some research before making this observation.

WHERE THE MONEY IS GOING: The 2008 Swiss Bank Association report had an interesting finding. The country which has 1/3rd of the global poor also has the maximum amount of money stashed in Swiss bank accounts!! Nearly 2 trillion dollars of it! A large percentage of which must be black...The top 5 stashers are
India ---- $1891 billion
Russia----- $610 billion
China ----- $213 billion
UK ----- $210 billion
Ukraine---- $140 billion
Rest of the world ----$300 billion

AND WHAT'S LEFT GOES TO...: Certainly not the poor!! It seems that a lot of money goes to the world's superpower - Obamaland!! India is now the second fastest growing investor in the United States after the United Arab Emirates!! As for the 42% of Indians below the international poverty line, let's just forget about them for the moment, shall we......