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?

References

[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)

9 comments:

  1. Nice work, Arpit. May I comment...well, I'm going to anyway! Rs 1500 seems like an extraordinarily small amount of money for saving a patient by sitting at the bedside pretending you are a ventilator, administering antivenom and cleaning up the bite site. Surely the problem is not the fact that the doctor charged as much and enslaved the patient. The problem is that in the grand scheme of things it is truly shocking that Rs 1500 is enough to have a whole family enslaved for life. I think it is a collective failure of every single citizen of our country and our representatives (the government). I would even cast the net wider and call it the collective failure of humanity globally. It seems bizarre that the price of a reasonable steak in one country is the same as the cost of labour of a family for it's entire existence. So, please don't be so harsh on the doctors alone (as guilty as some of us are), I think there are much greater forces of evil in the world. But I'm hopeful that the day of reckoning is not too far away when some of these imbalances will be redressed. Cheers and keep writing

    ReplyDelete
  2. If somebody can sell their daughter's virginity to pay their healthcare bills, they don't deserve any healthcare at all. Whatever happened to principles being absolute? Hah.
    The problem in delivering healthcare is the absurdly huge population in India. The need of the hour is effective contraception and easily accessible abortion facilities; to stop unwanted pregnancies and terminate accidental ones.

    ReplyDelete
  3. Thanks Arvind. You're right - humanity as a whole has to answer for the inequality we face and not just doctors. And I hope I didn't sound too accusatory - after all I am a part of the same system. And as I wrote, the issues are never so simplistic - this was just the tip of the iceberg of the litany of sins man has perpetrated on man. I too await that great day of reckoning. Thanks for bringing in the big picture.

    And Anonymous, in response to the (?harsh) judgement you pronounced on the father, well, I can only say in humility that I am no one to point a finger at the poor man and his decisions. As I said in the comment you are referring to, Absolute Principles are for me and not something I use to accuse anyone. I may even be the first one to fall when put to the test. But I did have a chuckle at your interesting(!!) solution to India's health problems - contraception and abortion!! Thoughts anyone?

    ReplyDelete
  4. Sometimes fingers need to be pointed and people need to take the blame for their actions. His decision to pimp out is daughter is a lot harsher on her than my judgement of his actions.
    Chuckle, hah, that is one of the problems too. We chuckle and giggle at sexual and family planning issues and then go ahead and have unprotected sex and overproduce babies anyway.

    ReplyDelete
  5. Sorry friend. Chuckle was the wrong word given the context and has been misunderstood. I was trying to convey my disbelief that the complete health problems of India could be simplified to such an extent. Sorry for the misunderstanding. As for finger pointing, especially in situations like this, I love the Biblical principle - he who is without sin among you, let him or her cast the first stone. If I was put in a similar situation I hope I will have the courage of conviction to do otherwise. Be that as it may, it is not for me to judge anyone on their actions and their situation.

    ReplyDelete
  6. mercy, compassion, kindness, sympathy and generosity are all intimately connected to human emotion. but also understand, hatred, rage and fury also are major driving forces in the world. over time, these have been potrayed as sinister and evil, but by whom. the self appointed guardians of society who decide for the rest of the world what is kosher or not. in case of the jews, the rest of europe kept silent for a definite purpose. the Jews were holding almost the whole of europe to ransom by controlling the financial jugular of the then world. any chance to break free of the yoke , whether by means of Herr Hitler or someone else was widely welcomed. things dint quite work out as the world desired.
    coming to the issue closer to home, India's needs are many and healthcare being of prime importance among them. However, i dont believe in charity, as charity once given is soon charity demanded. anyone who cannot afford health care should think why he couldnt do so and maybe change the way he lives his life. our country is the only one in the world which holds up its backward classes like a trophy and people try to stay backward to enjoy the welfare endowed by the state. the need of the hour is for a complete shakedown of the system.work and work shall bring you ur salvation instead of living on freebies and help doled out by the so called social sympathisers. get up and get moving.. "arbeit maketh frei."

    ReplyDelete
  7. Dear friend, your comment certainly raises important issues. Thank you for dialogueing - it helps to sharpen the mind and bring out issues I would not have thought about otherwise. I agree with your idea of 'work makes free'. This is the only way in a normal, equal society. And this is how it works in the societies that most of us have grown up in. Any person who has had the advantages and the opportunities that we have had and who is lazy deserves no charity. But our system has been so corrupted that often the 'backward classes' who receive the perks are not so backward after all.

    But there is another group of people which I was never exposed to till I went to Jharkhand. There I worked for 2 years among people who live in bondage with never a hope of getting out due to the unbelievable greed of the landlords. What benefits did they enjoy by being backward? What freebies had they ever received? My friend, the people who receive the benefits and freebies, for the most part are those who do not deserve them - they are the rich people who can buy a caste certificate or whose forefathers escaped the system years ago. Please see the reality - the real poor are not the ones we see. They are the ones who are hidden. There are many such groups throughout our country. There are some in the city slums as well - where a whole days hard labour will bring them Rs. 100 or less. They do not have the advantage of education and except for the few with brilliant minds who will understand the system and make their way forward (usually through underhand means), the poor in the country are travelling on a different track from all of us.

    I had a friend of my own age in Jharkhand. Judging from our discussions and the plans he had made for his life he was probably more intelligent than me. But he had never been to school, as the village school only saw the teacher once a year. With my opportunites, he would have been a different person altogether. But now, his life was bonded to the landlord who had enslaved his father with an unpayable debt. His day started very early with delivering milk and eggs. He would work in the fields during the day (for no money - as all of it was going to pay his debt) and do odd jobs in the evening. He was saving tiny sums of money every month to run away to Bombay, which was for him the escape route from his life. And I realised as I spent time with him that there, but for the grace of God, was I.

    My friend, there is much injustice in the world. It is everywhere. We can get up on our high horse and say the poor remain there because they don't work. Or we can see the reality - that for many of them, even if they do work much harder than us, the odds are so stacked against them that only one or two can beat them. The rest will not only struggle throughout their life, but will pass on the struggle to their children.

    I thank God everyday that he placed me in a family that loved me and provided for all my needs. And I know that what I am today is not just by my hard work - it is by blessing of God and the environment I was placed in. And it is my duty and responsibility to try and fight injustice wherever I find it in any way I can. That is one way I can show my gratitude. I hope I will not fail that responsibility.

    You call for a shakedown of the system. You are right, that's what we need. But the shakedown has to come from us - the educated, rich people who make it our duty to get richer. And so we exploit the system to make it suit our needs. And happily forget those who cannot do this. That work will not make the bonded labourer free. Or the slum dweller with no education. Or the father with no money to pay for the treatment of his dying son. Work will never make them free. So it is our call - do we remain silent and keep working to line our pockets. Or do we speak out against this with our lives and work, in a small way or big.

    ReplyDelete
  8. To do this we have to first recognize the composition of the locks and correlate the correct maintenance and/or design products to shield the client's locks from design or chemical substance process. beverly hills internal medicine

    ReplyDelete
  9. A lot of people usually ask the question, what is Duromine? Duromine is a weight loss pill that is very effective at suppressing the appetite. Resurge scam or not?

    ReplyDelete