Is medical care in India a curse to Indians?

Dr. George Jacob.

Kochi: Over the years health ‘care’ in India has made rapid strides. This is, thanks to coordinated and concerted efforts by, and advances made in Allopathy (modern medicine) and indigenous medical systems like Ayurveda,Yoga, Unani Siddha and Homeopathy (AYUSH).

As the result, India has emerged as a favorite ‘health-tourism’ destination. This is due to: (a) quality of medical care offered by Indian hospitals being on par with that of ‘advanced’ Western nations. (b) Availability of vastly improved and effective health care dispensation being substantially cheaper than in developed nations.

However, two incidents happened recently in Kerala, the southern Indian state that captains India’s march towards excellence in healthcare through its WHO-acclaimed ‘Kerala model of Development.’

A middle-aged woman was being treated in a private corporate multispecialty hospital in one of Kerala’s cities for peritonitis (infection within the abdomen). She was diagnosed with a life-threatening condition in which one of the main blood vessels supplying purified blood to the intestines was abruptly blocked off by a thrombus (blood clot).

This resulted in gangrene (death and putrefaction) of a long segment of her intestine. The resultant peritonitis, as is common, caused other organs like the kidneys, lung and the heart to fail one after the other. The patient who hung on to precious life underwent multiple surgical procedures, as the condition she was diagnosed with warranted.

Surgery, costly drugs like antibiotics, dialysis, mechanical ventilation and prolonged stay in the ICU caused her medical bills to swell. Her family which was extremely poor ran from pillar to post to manage money to meet the mounting hospital expenses. Part of the bills was paid with the help of medical insurance. Soon the bills exceeded the amount of money she was insured for. Land, house and valuables like gold were sold to pay the mounting hospital bills.

However, Infection had the last laugh, and the patient succumbed. The family could only manage to pay part of a hefty bill. When she died, the family still owed 1 million rupees to the hospital. The hospital authorities refused to release the dead body to the family. They contended that they would release the body to the family only after they paid the entire bill. The body was handed over to the family following intervention of well-meaning private citizens and the police.

This is not an isolated incident in India. Four days after the above incident unfolded shamelessly and shockingly in this part of the country, report of a similar nature appeared in the print media. The body of a man who had died in a private hospital in another town in Kerala was detained as the family could not cough up Rupees 2.5 lakhs to pay the hospital. The body was handed over to the relatives on the orders of the District Police Chief.

The above incidents raise a few pertinent questions- has Indian medical care degraded into a curse for Indians, especially the poor among them paradoxically, when the rest of the world makes a beeline to India seeking it’s ‘vastly improved and cheaper’ medical care? Or, is ‘quality medical care’ available in India meant only for the rich? Are the poor condemned to succumb to diseases for lack of money?

While answers are being fished for, two uncomfortable realities emerge: (1) as of today, quality medical care and dedication required to treat complicated diseases exist predominantly in private hospitals. (2) Government hospitals, on which the poor depend for their health needs lack facilities to treat life-threatening diseases, emergencies and complications they meet with, during the course of treatment.

Such eventualities demand dedication and long hours of focused attention by the patients’ bed side. This is glaringly absent among personnel manning government hospitals, including doctors. More significantly, facilities to treat such diseases and to handle complications are non-existent in government hospitals.

These hospitals fail to meet the demands of the poor, who approach them for high-end health needs. They have no option but to seek services of private hospitals, albeit reluctantly. To add to the complexity, private hospitals in India have heartlessly degenerated into money-laundering ‘business centers’.

Thanks to over-corporatization. An attendant of one of the patients I was involved in treating long ago described doctors working in private hospitals in the country as ‘wayside burglars’. I hung my head in shame! Profit at the expense of the ailing poor is unfortunately a stark reality etched to healthcare facilities offered by private hospitals these days.

Why have things come to such an unfortunate passing in the healthcare sector?

Reasons are myriad:
• Government hospitals have fallen short to provide quality health care required to treat life-threatening diseases and emergencies. This is because of (1) inadequate ‘facilities’ in terms of state-of-the-art gadgets and investigative machinery that help to diagnose and treat diseases. (2) There is the much talked-about ‘laidback work ethics’ even among doctors. There is an evident reluctance on the part of personnel in government hospitals to walk that extra mile, which dedicated modern medical care demands.
• ‘work-to-rule’ mentality among the workforce in government hospitals not to work longer than their duty hours, which their counterparts in the private sector willingly do. What led to such a mindset? (a)Poor pay in government hospitals compared to private hospitals, especially for doctors (b) poor job satisfaction (c) understaffing, and resultant overwork (d) dearth of facilities in Indian hinterlands such as schooling opportunity for their children and employment opportunity for spouses and rest of the family, and other comforts in terms of standard of living existing in larger towns and cities.
• Reluctance by the government to fund healthcare has also been a significant undoing that adversely affects healthcare dispensation in the public sector. India spends merely 1% of her GDP on health, far less than some of the world’s poorest nations.

• Illegal and mindboggling capitation ‘fees and donations’ demanded by private medical colleges. So what? These ‘colleges’ which leave a huge hole in the parents’ pockets, ultimately churn out money-avaricious doctors, whose priority once they begin practicing after graduation is to reclaim the hefty capitation fees by ‘practicing medicine’ on their terms in the so-called corporate tertiary healthcare behemoths in the private sector. To serve in government hospitals situated in urban India is never even considered. This has resulted in Gross disparity between numbers of doctors qualifying and those actually available to work in government hospitals. Every year 55,000 doctors complete their MBBS and 25,000, post graduation nationwide. If this is true, India ought to have had an allopathic doctor for every 1,250 people for a population of 1.3 billion by 2020, and one for every 1075 by 2022. But the reality falls far short of this by many a mile.

• Doctors do come across many situations where they are required to treat patients in whom treatment is futile. Situations where precious money is wasted on lost cause. Some such instances include (a) patients who are brain-dead, following severe brain injury sustained in road traffic accidents, or following diseases such as stroke and heart attack (b) patients with advanced cancer, where the disease has spread to areas far away from primary malignancy. Patients who are diagnosed with advanced cancers, where costly treatment is futile must be offered only palliative care in cheaper health facilities with basic facilities than in prohibitively expensive facilities like the ICU. This has to be legally formalized into law. Having said that, situations are aplenty where families of such patients demand continuation of futile high-end treatment despite being advised against and briefed about the futility of treating them. Here, doctors are forced to comply with the family’s request to ‘go all out’, albeit reluctantly. Futile Treatment continues. Hospital bills swell. Bad blood is ultimately spilt between doctors reluctantly treating such patients and families who arm-twist doctors to treat them for their own reasons. Avoidable Physical and verbal skirmishes result within hospitals between treating personnel and confused and embittered families of patients being treated unnecessarily.
• Families and doctors often find themselves in delicate situations, wherein patients with apparently ‘benign’ diseases seek treatment. ‘Benign diseases’ referred to are diseases which are not cancers, and if treated by ‘giving it the best shot’, bestow patients with long years of life with treasonable quality. Because of this reason, treating such patients is worth it, unlike patients harboring advanced malignancies, whose longevity is anyway curtailed by the disease. However, any disease, seemingly ‘benign’ or ‘commonplace’ can also very well run into attendant and well-described complications, inflicting unaffordable financial burden on the patients and their families out of the blue. Even common flu, caused by H1N1 virus is known to go through serious life threatening complications like ARDS (Acute Respiratory Distress Syndrome), necessitating many days on the ventilator, and often expensive treatment modality like ECMO (Extra Corporeal Membrane Oxygenator), as Kerala witnessed in the first half of 2018, when the state was in the grip of fevers of various kinds. Treating so-called ‘simple diseases’ which run into complications entails huge financial burden on patients, unexpectedly. This poses a great ethical dilemma. It is the duty of doctors to treat these patients, sparing no effort, giving it ‘their best shot’. Unfortunately, not uncommonly, patients being treated for the so-called ‘benign diseases’ require prohibitively expensive treatment. Infection, primary and secondary, play the villain. Often repeated surgical procedures and costly investigations become necessary to treat such patients. Cost-intensive treatment modalities like dialysis, ventilation, high-end antibiotics and other costly drugs are required to treat such patients. It is here that noble and well-meant intentions of doctors to ‘get the patients well somehow’, come to be misconstrued by patients’ families as “‘doctors and hospitals trying to make big money by employing ‘unnecessary costly treatment’”. These patients form a unique subgroup, where to treat them by going ‘all-out’, is worthwhile on one hand, but is prohibitively expensive, with hospital bills mounting to lakhs of rupees, sometimes a crore or two, on the other. How many in this country can afford this?
It is the question of raising finances, by no means menial to treat these patients that form the crux of a great dilemma. Ethical questions such as: ‘How far these patients should be treated?’ ought to be considered, simply because of the huge costs involved. But, won’t prematurely withdrawing treatment to patients who stand a high chance of survival amount to murder of sorts? This dilemma and ethical issues involved cannot easily be brushed aside. Answers to these questions have to be found in the interest of the health of Indian ‘health care’.
• India lacks a comprehensive policy on euthanasia. At the time of writing, the Indian Supreme Court has legalized passive Euthanasia (mercy killing by withdrawal of life supports) and ‘living will’ (where people can legally opt not to be placed on life supports, should need arises later in their lives) this is indeed a much-awaited move in the right direction.
• Lack of Consistent and honest communication and briefing of patients’ families by doctors add to the former’s suspicion about the latter when bills swell. Charges of ‘doctors spending money for nothing’, and ‘doctors are pulling fast ones about patients’ chances of leading a quality life after survival’ fly thick and thin as hospital bills mount on a daily basis.
• families of patients who are seriously ill are reluctant to see the writing on the wall. They simply refuse and are not in a frame of mind to accept lack of improvement of the patient, worsening of the patient’s clinical condition, or worse, death. Social workers, psychologists and counselors have a lot of room for their services in this sensitive situation.
• The press contribute negatively to dispensation of medical care in the country by adding fuel to the fire by reporting incidents of ‘medical negligence’, when none exists. On many instances unsubstantiated rumors and speculations are banked on. This causes a great disservice to medical profession.
• India lacks a credible insurance policy or state support for its sick, in line with the West, where citizens are covered by medical insurance. The Indian government needs to ensure that citizens have something to fall back on, in times of medical crisis, especially during emergencies. The recent budget for the years 2018-2019 has proposed health insurance cover of Rs. 5 lakhs/year for secondary and tertiary care hospitalization for 10 crore poor families. One hopes that this heralds the beginning of a healthy policy to insure India’s citizens. Similarly, the Kerala government also plans to pay for initial treatment in emergencies, where the money will be later claimed from insurance companies. It remains to be seen how far the country’s insurance companies would cooperate with these path-breaking populist measures.
• The other glaring cause for the unfortunate turn for the worse medical care in India has taken is overdependence of doctors and other personnel on costly gadgets, machinery and investigations. Costly Invasive monitoring systems have rapidly replaced cheaper noninvasive systems, especially in the corporate tertiary care hospitals, which can afford to have them. Despite the so-called ‘giant advances’ in medicine, nothing, till date has replaced dedicated bedside practice of medicine, where patients are treated by doctors and nurses who station themselves beside sickbeds. There is an increasing trend among Young and ‘fresh medical graduates’ to rely on costly gadgets, machinery and investigations (sometimes repeated ad nauseum), citing ease of diagnosis and treatment. While this might be deemed ‘necessary’ by some, bedside medicine cannot be replaced by flashy gadgets. Absolutely cheap and basic simple steps of clinical medicine viz: inspection, palpation and auscultation still hold good, and serve well to diagnose diseases even today. The MCI has a duty to reinforce basics in medical curriculum and education.
• Finally, the most vicious curse to have befallen medicare in India is the mushrooming of ‘medical colleges’ in private sector. Entrusting private sector with medical education is akin to arming a bank looter with an AK-47! Gross commercialization of medical education has come to stay as the worst bane to have robbed medical education in India of credibility, reasonable standards and nobility. Admission to such ‘medical colleges’ created out of every wayside kiosk are available in the ‘market’ at exorbitant rates running to lakhs and even millions for super specialty courses. Some of these medical colleges even lack patients to be clinically examined by medical students, and diagnosis arrived at, caring two hoots for the words of legendary physician William Osler (1849-1919), who famously quoted; ‘he who studies medicine without textbooks sails an unchartered sea, but he who studies medicines without patients, do not go to sea at all’ Students who have absolutely no aptitude and attitude to take up responsibilities of doctors, graduate by hook or by crook. They come to represent ‘dream come true’ of their filthy-rich parents, and to satisfy their rich parents’ ‘social standing’ by having their wards graduate as doctors. Merit has been shown the backdoor by this pitiable state of affairs in medical education, as it is, in India of today. Admission to medical courses ought to be solely on the basis of merit measured through credible entrance exams and nothing else. Big-time private money-spinners who have seen convenient ‘geese that lay golden eggs’ by setting up medical, nursing and dental colleges ought to be shown the door in the interest of the health of ‘medical education’ that currently attracts suspicion of malicious intentions by Medical Boards worldwide.

• Is there treatment for these maladies?
‘Treatment’ there is, if those concerned like the government, judiciary and MCI are ready to apply balm, mend broken bones, and remove cancers that have come to infiltrate the ‘art of healing’ in India, lest that art becomes a curse for India, and her citizens, as it is now.
• The place to begin would be government hospitals. Facilities existing in these hospitals where thousands with commonplace diseases queue up seeking their services must be escalated at least to basic levels. High-end investigation facilities can wait till public hospitals are first equipped with simple things like cotton, dressing materials and simple medicines like Paracetamol and common antibiotics. Results of simple blood tests must be expedited to help in diagnosis and treatment. More patient beds are called for in the wards, as patients languish on the floors of the wards seeking treatment. The government must be willing to spend more to spruce up health care, even at the cost of other money-intensive national priorities like defense.
• Doctors in India must master the delicate art of communicating patient’s response to treatment, even if it is bad news of failure to improve, and impending death, to the patients’ families. Nothing is more appreciated by patients’ families than honest health providers.
• The government must spare no effort to put in place a comprehensive medical insurance for every Indian. The medical insurance must be based on a premium, though menial, paid by citizens themselves. The insurance must cover substantial part of the bills incurred during hospitalization, and more importantly, in emergencies. These days, patients chose to walk away from hospitals, unable to cough up money when emergencies strike out of the blue. This must stop.

• Another important aspect of governmental support to the country’s sick is reimbursement of medical bills accrued by government servants. Though such facilities exist, the snaillike pace and red-tapism involved makes it as good as nonexistent. This process must be expedited.
Legal guidelines must be laid down in situations where treatment of so-called ‘benign’ diseases, especially when treatment tends to be long-drawn process due to complications that often set in. How far should doctors go about treating such patients? Should a ceiling on money that needs to be spent to cure patients be laid down? Should treatment of such diseases be limited to a particular limit monetarily? Such difficult ethical questions must be addressed. It is time they are. Should Doctors be allowed to play God when the patients’ families are being decimated beyond redemption financially? When they are being bled by rising medical bills?
• Runaway billing practices so rampant among hospitals in the corporate sector must be strictly regulated. The government must put in place more humane billing practices by private hospitals that they cease to arm-twist the poor sick Indian.
• Medical education in India must be uncompromisingly made out of bounds for private players. Admission into medical, dental and nursing courses must be based on merit measured by tenable entrance examinations and nothing else.
• Involvement of good Samaritans, well-meaning individuals, corporate houses and clubs which are socially conscious and who nurture humanitarian causes must be encouraged to shoulder at least a part, if not the entire expense incurred, especially by the poor, who seek medical treatment in India as charity. After all there is nothing wrong for the haves to help the have-nots, as there is nothing wrong for the government to cut defense expenditure, and to siphon money thus saved to bolster dispensation of medical treatment in India, so that medical treatment ceases to be a curse to Indians within India.

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