Published online: May 22, 2019
DOI: https://doi.org/10.20529/IJME.2019.028The book Healers or Predators? Healthcare Corruption in India, edited by Samiran Nandi, Keshav Desiraju and Sanjay Nagral (1) hit the headlines, both for its content and its provocative title. The dissatisfaction regarding healthcare services in India is at its peak and a new mega healthcare project has been launched. The authors should be congratulated on choosing to write about a subject which has been discussed– sometimes in hushed tones– but rarely covered in depth. Not surprisingly, the book received its share of accolades as well as opprobrium.
In his Introduction to the book, Amartya Sen rightly points out “The entire organization of Indian health care has become deeply flawed in nearly every respect”. He observes at the outset that “India spends little over 1% of its gross domestic product on public healthcare”. Cautioning that “corruption is a charge that must not be made lightly”, he ends his introduction to what he calls “this splendid but depressing book”
I agree with Amartya Sen’s comments – in particular with his description of the book being “splendid but depressing”. What makes it splendid? Its intention and effort! The book rightly identifies several key areas in the healthcare scenario that have become rooted in corruption: medical education, its regulatory agency: the Medical Council of India; drug control policy and its administration by the Drugs Controller General of India (DGCI); medical research; the pharma industry, the bureaucracy and the political system; the neglect of primary healthcare, increasing privatisation and the tilt towards tertiary care, among others. The book also lists major scandals in healthcare, education and research. Some success stories titled “Beacons of hope” that have beaten the corruption malaise have also been included. It takes both commitment and courage to talk about corruption in healthcare and the medical profession, especially when writing about your own colleagues and peers. For all these “splendid” parts of the book, the authors must be appreciated and congratulated.
In fact, this could have been an extraordinary book, given that the authors are experts in the field, with the best of intentions, and a wide and relevant range of topics. But the flaw is that it is indeed depressing. Partly, this is because the content naturally makes for unhappy reading, focusing on the misdeeds of those dealing with disease and suffering. Beyond this, it is depressing because it is repetitive, often clichéd, and in most places targets doctors excessively. The authors seem to view doctors as the root cause of everything that is wrong with Indian healthcare; but fail to offer any solutions or hope of improvement to offset the gloom. The supposed corruption of doctors is discussed repeatedly, ad nauseum, in chapter after chapter, even in those whose primary focus is a completely different issue. In the end, people will remember the provocative title above all else, and will come away with the feeling that most healers are indeed predators.
Some issues are worth debating in detail:
The book faults the doctor‒ the healer– for not preventing corruption. The book wants and wishes the doctor, as indeed, our society seems to do, to be a knight in shining armour, a whistle blower and an activist, fighting not just diseases, but all ills of the profession of health. Finding that he or she fails in these expectations, they are blamed for all the problems in healthcare, failing to recognise that a doctor is only a frog in the pond. A doctor’s decade long medical training focuses entirely on medicine and leaves him unprepared for anything other than his profession. The passion for the profession leaves little time even for the family, let alone society. He/she gets insulated in the cocoon of the practice, burdened by the workload which is heavy and exacting. So, it is no wonder that the doctor usually fails as an administrator and leader. This conveys an impression of indifference to the other administrative and societal ills in healthcare – the doctor may even appear to be money-minded, insensitive, or unconcerned about anything other than his profession. The public fails to recognise that he may be just a pawn, subject to pulls and pressures, manipulations and exploitation.
In several small towns and villages, single-doctor clinics and small nursing homes run by doctors render yeoman service. These small establishments, often run by doctor couples, struggle throughout the year, without a break, against several odds including lack of electricity and infrastructure, lack of trained staff, and of access to a second opinion and referral; frequently facing corruption in every attempt to secure a licence, pressure from local politicians and at times violence too. They most often provide the only healthcare facility available in the vicinity, delivering service at a low cost (2). These doctors are not funded by the industry nor are they being sponsored for foreign tours. Their life begins and ends with their patients. Yet, the book hardly recognises this group and fails to discuss either their a contribution or the problems faced by them.
These hospitals and clinics deliver most of the available healthcare in tier 2 and 3 cities and towns, and in villages, and without them healthcare would collapse (3). It is surprising and disappointing that the authors did not write a single sentence about the yeoman service rendered by these clinics and hospitals, even in the section on “Beacons of hope”. Even the Indian government has a hypocritical approach towards them, considering the profession as a commercial activity, and charging commercial rates for electricity and water, while at the same time expecting them to serve the people. These hospitals are facing several challenges as outlined in a recent publication (3):
This lack of recognition of the contribution of this sector is indeed symptomatic of not just this book, but of every other narrative about healthcare in India, which assesses Indian healthcare with only corporate hospitals in mind.
Increasing privatisation and growth of high-tech corporate hospitals have been blamed for being causes of the corruption in healthcare. However, we need to note some other factors responsible for the increasingly higher cost of medical care, and thereby contributing to privatisation and corporatisation; With changing attitudes, increasing affluence and awareness in society, the expectations and needs of patients and their attendants have gone up. The need for hospitality and comfort have been added to hospital care and treatment, which have pushed up costs, well beyond the capacity of the small hospitals mentioned above, pushing the patients into the arms of the large corporate hospitals.
A comprehensive analysis must focus adequately on how government policies have impacted costs; how National Accreditation Board for Hospitals & Healthcare Providers (NABH) accreditation requires more man power, more space and inevitably leads to higher costs; how drug control policies, or the lack thereof, lead to increasing costs, particularly in the field of cancer therapy, where costs of different brands of the same drug vary hugely. Very high customs duties are charged on imported essential equipment. One fact that is entirely missed is the fact that the government which should have beenp> delivering healthcare free to citizens, fails to spend even 2% on health; worse, it actually tried to levy service tax on the patient fees and thereby tried to earn money from patients (4),(5). It was only after protests that this tax was withdrawn, even though some parts of healthcare are still subject to GST, such as cosmetic surgery, insurance premiums, etc. Oxygen cylinders were, till recently, subject to GST of 12%. Operation theatre lights, chairs, are still subject to 18% GST. These aspects don’t get adequate attention in the book.
The biggest disappointment in this book comes when one looks for solutions for the many ills mentioned. Admittedly, solutions are not easy to come by. But a book of this nature is expected to search for answers. There is no significant solution provided for alternatives for the much-maligned Medical Council of India (MCI), itself the focus of much controversy. A single statement, that the new National Medical Council (NMC) may serve to take care of the issues is all that one finds. This lack of analysis of NMC, at a time when it has been subjected to so much criticism, is glaring. Nor can one find an analysis of different health establishment acts including the draconian Act of West Bengal (6). Likewise, only a broad statement about the recent Ayushman Bharat scheme that “it is hoped—“ is made without any analysis of its many shortcomings. Being senior health professionals, it would not have been difficult for the authors to suggest solutions such as; increasing government budget share, enhancing primary care, increasing the number of medical personnel , improving governance in government colleges, lessening interference by politicians, streamlining admissions in medical colleges, avoidance of capitation, transparent drug policy, and so on. The book would then have looked more positive in its outlook and, more splendid and less depressing.
It is indeed unfortunate that the authors fail to take in to account, how the so called ‘healers turned predators’ have been subjected to violence – in other words healers are victims too. There has been a spate of violent incidents against medical personnel (7), across the country. Resident doctors are often the target, at a time when they are ill equipped to handle the violence. A number of promising careers have been destroyed by such violence. Though several states have passed laws against violent attacks on the medical profession, implementation is tardy. Courts, media and society in general have been singularly insensitive, often antagonistic to doctors even when they were attacked, and condoning the assailants. The book is largely silent on this issue, except for one passing sentence: “Why is that so many distinguished professor practitioners feel that the heart of their profession has been lost?” The book says “there is no answer”. There should have been a chapter on where the medical profession is headed in this situation and the authors, should have searched for an answer to give a more balanced perspective of the subject.
This is not to say that there are no pluses in the book– the book rightly rues the lack of leadership from the profession, particularly from senior doctors. Many share this concern about doctors that the book espouses. The professional voice has been lacking in every major debate – be it college education, the medical syllabus, drug policy, or research. The image of the profession would have been far better if more senior doctors had shown greater courage in taking a stand in favour of society and patients, and spoken about the ills that plague the healthcare sector. Society has regarded doctors as healers and placed them on a high pedestal, not just to treat patients, but also to help manage the healthcare of its sick and diseased. It is time to recognise, as this book does, that doctors need to do more to justify this high pedestal.
The chapter on global corruption is indeed very well written, with instances provided from different countries. For instance, the chapter on Bangladesh deals systematically with corruption at different levels. However, this section is limited to just a few countries such as the UK, Australia, the US and a couple of neighbouring countries. Chapters on corruption in China, other south east Asian nations and the former communist countries would have been interesting and made the discourse more inclusive. The chapter on corruption in clinical research and publications is also very pertinent. The chapter on success stories also makes for very interesting reading. The section on scams, in particular, the VYAPAM scam is dealt with comprehensively.
In summary, I feel that a book on the subject was needed and is timely;but the title should have been more sober and the approach more balanced. The vast majority of doctors who are indeed healers may feel offended and saddened, and the small minority, who are perhaps predators, may not be bothered– if they choose to read it at all. It is also doubtful if it does any good as far as patients are concerned– as they may now regard all healers as predators, and more worrying, as the only predators.
These authors, themselves healers, have boldly embarked on an ambitious and noble task; but it has to be said with a touch of disappointment, that, much like its title, the book could do with more nuance and context.