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 of two principal reasons: (a) quality of medical care offered by Indian hospitals is on par with that of the so-called ‘advanced’ Western nations. (b) The vastly improved and credible health care dispensation comes at substantially cheaper rates than those in developed nations.
However, two incidents happened quite recently in Kerala, the Indian state that captains India’s march towards excellence in the healthcare front (which the Chief Minister of Uttar Pradesh, Yogi Adityanath prefers to disagree with!). Kerala is known for having acquired health standards even better than Scandinavian nations-considered to be the healthiest in the world, going by measurable health indices. This, concomitant with near cent percent education in the state has been recognized by the WHO as the famed and much-acclaimed ‘Kerala Model of Development’. The two unfortunate incidents leave a bad taste, leaving one wonder if this ‘vastly improved’ healthcare dispensation in India has become a curse to the country’s own citizens, who ought to be eating the fruits of this remarkable advancement than just visiting ‘medical tourists’!
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 infection within the abdomen, as is quite common, caused other organs like the kidneys, lung and the heart to fail one after the other-a condition called Multi-Organ Dysfunction Syndrome (MODS). The lady who hung on to precious life by a thread had to undergo multiple surgical procedures, as the condition she was diagnosed with, warrants. Multiple surgical procedures, high-end antibiotics, other costly drugs, dialysis, mechanical ventilation and prolonged stay in the ICU caused her medical bills to swell. The family was not at all well to do financially. They ran from pillar to post to somehow manage money that was hard to come by, to meet the mounting hospital bills. They somehow paid part of the bills with the help of medical insurance the patient had obtained in her healthier days. Soon the bills vastly exceeded the amount of money she was insured for. Land and valuables like gold were sold to pay the hospital bills, which welled up to gargantuan proportions. The family was in doldrums. Later, good Samaritans chipped in with help. The patient, in the mean time found the disease she was up against beyond her to handle. Infection and its ravages had the last laugh. She ultimately succumbed. The family could only manage to pay a fraction of the bill that had piled up way beyond their capability. When she died, the family still owed Rupees 10 lakhs to the hospital. The hospital authorities refused to release the dead body to the family, broken at heart and financially. They contended that they would release the body to the family only after they paid the bill in its entirety. The body was ultimately 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 said 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 throw open the flood gates to a few pertinent questions- has Indian medical care come to be a curse for the country’s own citizens, especially the poor among them paradoxically, while the rest of the world makes a beeline to India seeking it’s ‘vastly improved and cheaper’ medical care by way of expertise and availability of skilled and well-trained medical personnel?, 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 searched for, two uncomfortable realities stare hard on our faces: (1) as of today, quality medical care and dedication required to treat complicated diseases exist predominantly in hospitals in the private sector. (2) Hospitals in the government sector, on which the poor depend for their health needs lack facilities to treat life-threatening diseases, and complications they meet with, during the course of treatment. Such diseases demand dedication and long hours of focused attention by the patients’ bed side. There is glaring paucity of a work culture and ethics that demand long and often extra hours by the patients’ bed side among the personnel manning public hospitals, including doctors. More significantly, facilities to treat such diseases and to handle complications are glaringly non-existent in hospitals in the public sector. The poor, whose health needs are supposed to be addressed by these hospitals fail to meet that demand. The poor are thus forced to seek services of hospitals in the private sector, albeit reluctantly. To add to the complexity, hospitals in the private sector in India have heartlessly degenerated into money-laundering ‘business centers’. Thanks to over-corporatization. The attendant of one of the patients I was involved in treating long ago described doctors working in private hospitals in the country as ‘highway burglars’, while I hung my head in shame! Profit at the expense of the ailing poor is unfortunately a glaring reality in India’s health facilities in the private sector these days. Detaining bodies of patients who were being treated by them, for inability of the dead person’s families to pay the entire bill does not augur well for civility and humanity of a country such as India.
Why have things come to such an unfortunate passing in the healthcare sector?
Reasons are myriad:
- Hospitals in the public sector are grossly inadequate to provide quality health care required to treat life threatening diseases. This is because of (1) inadequate ‘facilities’ in terms of gadgets and investigative machinery that help to diagnose and treat diseases. (2) In addition to this, there is the much talked-about ‘inferior work ethics’ in government hospitals. There is a glaring reluctance on the part of personnel in government hospitals to walk that extra mile, which modern medical care demands. Strict ‘work-to-rule’ ethics have come in the way of willingness of personnel in government hospitals to work for longer hours outside their duty hours, which their counterparts in the private sector willingly do. Poor pay in government hospitals, besides understaffing are cited by the staff in those hospitals to stick solely to work demanded of them by the book. Other reasons for reluctance among staff in government hospitals including doctors to work with willing earnestness, and for that undesirable tendency to work ‘with the eye on the clock’ besides poor pay and poor job satisfaction are: understaffing, and resultant overwork, dearth of facilities existing 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( as a large segment of public hospitals are located in rural India). Overall, India has 35,416 government hospitals which provide 13, 76,013 beds. But unfortunately, only 2% of the doctors serve in rural India, which comprises 68% of Indian population. With more than 740,000 active doctors at the end of 2014, the doctor: patient population ratio was 1:1674, worse than Vietnam, Algeria and Pakistan. Shortage of doctors was one of the health management failures cited in a report of a Parliamentary Committee on Health and Family Welfare, which presented its findings to both houses of Parliament on March 8, 2016.Other issues investigated by the committee along with the medical Council of India (MCI) – the 82-year old organization responsible for medical education standards in India were (a) Illegal capitation ‘fees’ demanded by private medical colleges. These ‘colleges’ ultimately churn out money-avaricious doctors, whose priority once they begin practicing after graduation is to reclaim the capitation fees through ‘practicing medicine’, (b) the questionable standard of ‘medical education’ imparted in these so-called ‘medical colleges’. Often, these colleges lack patients for students to study medicine, and prescribed staff pattern. It is common knowledge that, during inspection by medical education regulatory bodies, some of these colleges fill up required teaching faculty with qualified doctors from other hospitals, (c) health-services inequality between urban and rural India and (d) disconnect between public-health and medical-education systems. India’s poorer states have health indicators worse than many poorer nations. In fact, India’s healthcare spending is the lowest among the BRICS nations. Every year 55,000 doctors complete their MBBS and 25,000, post graduation nationwide. If this is true, India ought to have 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.
- Medical education shortages manifest themselves in understaffed public-health services nationwide. There is 83% specialist medical professionals in 25,308 Community health Centres(CHCs) in 29 states and 7 Union Territories, which falls short by more than 3,000 doctors, with the scarcity rising by 200%(or tripling) over 10 years. Apart from Allopathic doctors, shortage of dental surgeons, nurses, pharmacists and AYUSH doctors has also been on an increasing trend.
- Reluctance by the government to fund healthcare has also been an undoing of significance 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.
- Doctors do come across many occasions 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 patients who are brain-dead, consequent to severe brain injury sustained in road traffic accidents, or following diseases such as stroke, heart attacks associated with shock, wherein the brain suffers cessation of, or gross reduction in its blood supply. The other instance being patients with advanced cancer, where the disease has spread to areas far away from primary malignancy. Brain dead patients need to be resuscitated and stabilized, if their families have consented for organ donation. Treatment here is meant to sustain life and clinical stability till organs are harvested. This is to ensure that quality of organs harvested is not compromised, so that recipients of organs are benefitted to the best possible extent. Treatment of such patients is withdrawn logically, once organs are harvested. 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 and briefed about the futility of treating them. Reasons for which continuation of treatment is requested for are predominantly social: when arrival of a dear and near one beside the deathbed is awaited, or simply to ‘satisfy the family’s conscience’ that ‘everything possible was done for the patient’, or because the family needs the patient to remain alive and conscious as long as possible in instances of conflicts over inheritance of the patient’s worldly possessions. Here, doctors are forced to comply with the family’s request to ‘go all out’, albeit reluctantly. Futile Treatment continues and hospital bills swell. Bad blood is 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 like pancreatitis, and vascular pathology of bowel like the above mentioned first patient, seek treatment. These patients are in a unique situation where, should they survive the long- drawn and often eventful (read costly) hospital course, possibly go on to live their entire lifespan with reasonable quality. Because of this reason, treating such patients is worth it, unlike patients harboring advanced malignant diseases, whose longevity is anyway curtailed by the disease. For that matter, any disease, however seemingly ‘benign’ or ‘commonplace’ can run into attendant and well-described complications, inflicting unaffordable financial burden on the patients and their families out of the blue. Even common flu, also called H1N1 is known to go through serious life threatening complications like ARDS (Acute Respiratory Distress Syndrome), necessitating many days on the ventilator, and even 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, often beyond expectation. Families of such patients are thrown into a calamity most abruptly. 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, patients being treated for the so-called ‘benign diseases’ require prohibitively expensive treatment, with infection, primary and secondary, playing the villain. Often surgical procedures and repeated costly investigations become necessary to treat such patients. Multiple, and cost-heavy treatment modalities like dialysis, ventilation, high-end antibiotics and other costly drugs form part of the armamentarium employed 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? Many such patients linger in ICUs for many days. Some make it. Others do not. Doctors and other medical personnel involved in treating this subgroup of patients being treated for ‘benign’ conditions ‘are caught between the devil and the deep blue sea’, in today’s healthcare scenario. 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 should these patients be treated?’ ought to be considered, simply because of the huge costs involved. But, won’t that amount to prematurely withdrawing treatment to patients who stand a high chance of survival? 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. It is high time the country’s judiciary lays down clear-cut legal policy and guidelines on euthanasia. Euthanasia (mercy killing) must be considered in patients with advanced malignancies, where treatment is futile, and in patients who are brain-dead and unwilling to donate organs, and in patients leading a vegetative existence, dependant on costly equipment and drugs to sustain life for nothing.
- Patients being treated for ‘benign’ diseases continue to linger in ICUs receiving prohibitively expensive treatment. Such treatment often run to multiples of ten or twenty thousand per day, as fighting for them, with ‘no holds barred’ is worth it because life of reasonable quality can be expected, should they survive. It is in these situations that doctors must be helped by well-prescribed regulations and laws, as to ‘how far treatment must be offered’, as chances of survival are real. It is when huge amounts of money are spent by patients’ families, and favorable results of the same are not forthcoming in terms of patients’ clinical improvement and survival, that a lot of bad blood is shed on the doctor-patient family relationship. Sometimes even the sacrosanct doctor- patient relationship becomes a casualty. These are situations which ultimately result in physical attack on hospitals and treating personnel, sullying medical profession.
- 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. This issue has to be settled once and for all by the collective effort of the government, the MCI, and people’s representatives through NGOs, and the judiciary. This delicate and sensitive issue is not taught in medical colleges, nor are they included in the medical curriculum. Medical students must be made aware of this stark reality, which they’ll be called to face aplenty after graduation.
- On many occasions, 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. Instances where healthcare facilities have been ransacked and treating personnel manhandled and physically attacked by irate family of patients, who die or fail to improve, are rampant. On numerous occasions, even mere onlookers or uninvolved public are found to jump into the fray!
- The press, during such instances find pleasure in adding fuel to the fire by reporting incidents of ‘medical negligence’. On many instances unsubstantiated, and churned out of rumor mills. 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. These winds of change infuse hope into healthcare dispensation in the country, which has clearly taken on dangerous portends for the personnel involved by way of threat to life and property, and mental anguish suffered.
- 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. This unfortunate turn for the worse starts from the hallowed halls of medical schools in the private sector. The words of legendary physician William Osler (1849-1919) ‘medicine is learnt by the bedside and not in the classroom. Let not your perceptions of disease come from words heard in the lecture room, or read from the book. See and then reason and compare and control. But, see first’, have been forgotten to be relegated to medical history books. 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 true, 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 medicine in India is the mushrooming of ‘medical colleges’ in private sector. Entrusting private players 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, 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 crores for super specialty courses. Some of these medical colleges even lack patients, who are clinically examined by medical students, and diagnosis arrived at, again tearing into pieces words of William Osler, 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. Their sole intention as doctors is to somehow reclaim huge money spent by their parents for their medical ‘education’. 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 money and private money-spinners who have seen convenient ‘geese that lay golden eggs’ by setting up medical, nursing and dental colleges ought to be checked in the interest of the health of medical education that, currently attracts suspicion, loss of credibility and 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 public hospitals. Facilities existing in these hospitals must be escalated at least to basic levels where thousands with simple diseases form long queues seeking their services. High-end investigation facilities can wait till public hospitals are equipped with simple things like cotton, dressing materials and simple medicines like Paracetamol. Results of simple blood tests must be issued without delay to help in treatment. More patient beds are called for in the wards, as many patients are found to 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. Before equipping public hospitals, especially teaching ones with high-end gadgets and machines for investigations, stress should be made to equip operating theatres, emergency departments and outpatient departments with more facilities, especially basic ones.
- 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. Often it is the glaring failure on the part of doctors to communicate honestly, and openheartedly, that is the starting point of breakdown of a positive relationship with the patients’ attendants. No facts, however unfavorable must be kept under wraps.
- Having said this, there is a huge responsibility on doctors to take into confidence the families of patients by briefing them daily honestly, and without hiding facts about progress or deterioration of patients being treated.
- This sensitive issue of patient-doctor, and patients’ family-doctor relationship and it’s nurturing must be inculcated into medical curriculum, and even be included in qualifying examinations
- The government must spare no effort to put in place a comprehensive medical insurance for every Indian. This will undoubtedly entail an extremely huge amount of money considering the nation’s population. The medical insurance must be based on a premium, though menial, paid by citizens. The insurance must cover substantial part of the bills incurred during hospitalization, most importantly, in emergencies. These days patients sadly 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 now, the snaillike pace and red-tapism involved makes it as good as nonexistent. This facility must be expedited.
- The country, by collective brains of the government, judiciary, MCI and NGOs must put in place clear-cut policy and guidelines on euthanasia. The practice of treating patients who will not respond to treatment, and for whom treatment is futile and even unethical must be stopped. Money must not be allowed to be wasted on lost causes. Such patients’ families must not be allowed to plunge head-on into penury.
- As important as a framework on euthanasia. 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. A close scrutiny of bills reveal numerous ‘hidden’ categories viz; ‘miscellaneous’, nursing charges, rounds fees, medication charges that add up cruelly to the bills rolling out of billing machines in private hospitals making them money-spinning behemoths, than revered centers of healing. The government must put in place strict billing patterns 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. When legislators themselves run medical, dental and nursing ‘colleges’, one cannot see this happening!
- 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.