In their book Dissenting Diagnosis, doctors and activists Abhay Shukla and Arun Gadre give us a chilling inside account of widespread malpractices afflicting the healthcare industry. The nexus between corporate hospitals, pharma companies and doctors has increased the risks and costs of healthcare to such an extent that millions of middle -class Indians descend into poverty when they fall sick. "A country which boasts of being a global superpower, of sending a rocket to Mars, and of being among the largest producers of both doctors and medicines in the world, should be able to ensure good quality, rational health care for everyone in the country," they say.
Both doctors have decades of experience in the profession and started working actively with the health NGO Sathi to create awareness and advocate for structural changes to regulate this critical sector. They talk to the Huffington Post:
The book draws a chilling picture of how health services in India have reached a stage where the patient's welfare comes second to commercial considerations. How serious and widespread is this problem?
The problem of gross commercialization leading to distortions in medical practice is very widespread and threatening. As Dr George Mathai, physician from Alibag, Maharashtra states, "Doctors' associations counter the allegation of commercialization by saying that there are always a few black sheep in any profession. But I tell you, nowadays one has to search for a white sheep under [the] microscope."
[A] young super specialist was... warned that unless he convinced 40% of his outpatients to undergo surgical procedures, he would be kicked out of the corporate hospital.
The rot is deepening with the increasing onslaught of big corporate hospitals, growing pressure from the pharmaceutical industry and the massively expanding clout of medical equipment agencies. New entrants in the private healthcare sector have to fall in line and indulge in unethical operations like commission practice.
One of the respondents in the book, a well-qualified pathologist in a megacity who has been in practice for just nine months, testified that out of nearly 150 doctors he met, only three or four agreed to refer patients to him. That's because he didn't offer commissions.
You say, "the greatest rot is to be found in hospital transactions. Distortions of the 'noble profession' that are beyond our imagination are being perpetuated." What types of malpractices have you uncovered that are beyond imagination?
A cardiologist from a megacity narrated a confession by a young colleague in a big corporate hospital. The young super specialist said he was warned that unless he convinced 40% of his outpatients to undergo surgical procedures like angioplasty, he would be kicked out of the corporate hospital.
Another example of malpractice is "sink tests". The referring doctor writes a battery of tests to be done with some predetermined marking system. The blood is collected for all tests prescribed and so is the money. But only the marked tests are actually performed; other samples are thrown in the sink! The results for these 'sink tests' are written within normal limits, without having performed them. The money collected for these 'sink tests' is split and pocketed.
Since the '90s the private medical sector in India has been transformed with the arrival of multinationals, corporate hospitals, private medical colleges et al; they are making enormous profits. At the same time, an estimated 3.5 crore people fall into poverty from illness every year. How did we come to this? Can you give examples of how these entities have inflated the cost of healthcare?
[T]here are not-for-profit hospitals in India that regularly perform a normal delivery for ₹1000, while certain corporate hospitals routinely charge ₹2.5 lakhs for the same thing...
The key transformation from the 1980s and 1990s onwards in India has been a simultaneous weakening of public health services, and a massive expansion of private hospitals and nursing homes. This seems to be part of the larger neo-liberal policy framework adopted by successive governments to "leave it to the market". However, even the most developed capitalist countries do not leave healthcare completely to the market, because it is well known that this is an area that is notoriously prone to "market failure". This market failure is now becoming a market disaster, pushing millions into poverty every year, due to healthcare expenses.
In a scenario where private medical colleges charge colossal donations from each medical aspirant (in the range of ₹50 lakh to a couple of crores), graduate doctors often become profit- oriented and prone to prescribing unnecessary admissions, procedures and investigations. Then the pharma companies and medical equipment companies make medicines and investigations expensive. Finally, the profit-driven corporate hospitals drive up the costs of hospitalization.
The net result of all these "cost multipliers" is massively expensive and often unaffordable healthcare. For example, there are not-for-profit hospitals in India that regularly perform a normal delivery for ₹1000, while certain corporate hospitals routinely charge ₹2.5 lakhs for the same thing; there's no substantial difference in the quality of basic care between the two setups.
Doctors reveal how the pharmaceutical industry corrupts their peers with foreign "study tours", even buying clothes, alcohol and other expensive gifts for them. Can you throw light on the role they play in hospitals too?
The hospitals earn huge profits from the massive differences between the cost they pay for purchasing drugs and other material like stents, and the price at which this is made available to the patient. For example the prominent pharmaceuticals have a hospital line. Their purchase price to the hospital is much lower, but the Maximum Retail Price (MRP) printed on the drug strips/stents is quite high. Many a time, the difference is huge. A cancer drug, for example, might have a cost-MRP difference of four to five times! The medical store earns a huge profit, and most of the time this profit is shared by the referring doctors and the retailer chemists.
Hospitals have 'marketing managers' who arrange alcohol parties, organize supposedly educational lectures sponsored by pharmaceutical companies...
Hospitals too have 'marketing managers' who arrange alcohol parties, organize supposedly educational lectures sponsored by pharmaceutical companies, and take doctors to foreign countries for tours.
This book gets credibility from the fact that 78 doctors--you call them "whistleblowers"--from different disciplines, practicing in urban and rural settings across India speak out on the malpractices they have personally witnessed and the price they have paid professionally to remain honest...
Yes, most of the doctors who gave the interviews are still practicing. Some are at the pinnacle of their careers with more than 30 years of ethical practice. Others have paid a huge price. For example, one cardiologist from a metro city was forced to leave a corporate hospital, since he [couldn't keep up] with the unrealistic targets to perform angioplasties. One uro-surgeon had to leave a corporate hospital because he was admonished by a young non-medical administrator for deciding not to operate a small, insignificant kidney stone shown in an ultrasonography.
You give instances where critically ill patients have died because they didn't have the deposit money on arrival for emergency treatment. Or cases where bodies are not released because bills are not paid. Are these practices legal? What are the rights of the patient?
An ethical doctor explains issues in detail, gives more time (at least in the first visit), is transparent in rates... he does not investigate just because the patient demands it.
As we have mentioned in the book, the Supreme Court has clearly ruled that any patient, irrespective of their capacity to pay, must be provided emergency medical care by a hospital without insisting on payment or deposit. Similarly, detaining either a live patient or a dead body on the grounds that hospital dues have not been paid, amounts to illegal detention. We have described legal cases related to both these situations, where courts and consumer redressal forums have clearly upheld the rights of patients in this regard. However, in the absence of patient-friendly and accessible grievance redressal forums, as well as fully operationalized legal mechanisms, these unethical practices remain rampant in private hospitals.
How can a patient find an ethical doctor today? What are the warning signs that a doctor/hospital is trying to squeeze a patient with unnecessary medical procedures and medications?
It's a difficult task to find an ethical doctor in most parts of India today. As Dr Thomas George from Chennai comments, in India the patient needs to choose his doctor, and selection is generally based on what they hear from acquaintances. This does not really give any guarantee that the doctor chosen is ethical. There are a few clues though. An ethical doctor explains issues in detail, gives more time (at least in the first visit), is transparent in rates, and allows the patient to take a second opinion. He does not investigate just because the patient demands it.
What can be done to improve the situation at the citizens' level and at the national level? Have our medical councils failed to regulate the industry?
In the final chapter of our book, "Joining hands for healing the health sector", we have suggested how ordinary citizens now need to get organized for legal and operational protection of patients' rights, along with demanding effective social regulation of the private medical sector.
[M]edical councils have failed to ensure ethical conduct by doctors, and have been ineffective in dealing with complaints regarding medical malpractices.
We have also clearly described how medical councils have failed to ensure ethical conduct by doctors, and have been ineffective in dealing with complaints regarding medical malpractices. The recently released report of the Parliamentary Committee on Health, related to Medical Council of India, has very strikingly brought forth the massive distortions in this body. It has suggested a range of long overdue and much-needed reforms in the MCI, including a dedicated body to regulate conduct by doctors. This report should be widely read, and people should ask their MPs to ensure action is taken.
Are there citizens and doctors forums where alarmed readers can add their voice for transformation of the healthcare system?
The very idea of a citizen-doctor forum is still emerging in India. In the city of Pune where we are situated, a Pune Doctor Patient Forum is now being formed. If successful, this forum could become a guiding light for needy patients, would support ethical doctors, and could offer services such as a second opinion. It might even function as a non-official grievance redressal forum.
At present, we seem to be on track to become like America where even well-off middle-class families have to sell their homes once they fall sick because there was no social support before Obamacare. How can India develop a universal healthcare system?
We are today seeing the results of market failure in healthcare. While effective and accountable regulation of the private medical sector is an urgent first step, we also need to dedicate serious efforts towards developing a universal healthcare (UHC) system in India. Other middle-income countries like Thailand and Brazil have set up reasonably effective UHC systems with levels of financing that are achievable in the Indian context also, provided there is adequate political will. We should ask political parties to make this a major item on their agenda.
A country which boasts of being a global superpower, of sending a rocket to Mars, and of being among the largest producers of both doctors and medicines in the world, should be able to ensure good quality, rational health care for everyone in the country.
Dissenting Diagnosis by Dr Arun Gadre and Dr Abhay Shukla , Random House/ Vintage 288 Pages | ₹399
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