Apollo: myths and myth-making
Despite a wide range of opinions regarding the rise of the corporate hospital, there are many similarities in the manner in which its significance is described both by supporters and critics. An admirer recently wrote:
In 1983, at a time when the government’s commitment to investing in public healthcare appeared to be flagging, Prathap Chandra Reddy did something unthinkable: he launched the country’s first corporate medical system. Three decades on, the argument over the pros and cons of privatised healthcare in a poor country remains unsettled but there is one thing Dr Reddy’s admirers and critics both agree on: the emergence and rise of his company, Apollo Hospitals Enterprises, has altered the health-care landscape of India (7).
Compare this with the sentiment of a critic of Apollo:
I would say that what I noticed during the past thirty years, which is the time I have been practising medicine, the big change is that when we were undergraduates, there were no private hospitals in Chennai. There were private nursing homes which was [a] big difference. Because nursing homes wouldn’t take acutely ill patients. They would only take elective surgical procedures; very mild illnesses. Anything serious was referred to the government teaching hospitals. Obviously the three: Kilpauk Medical College, Stanley Medical College, and the biggest, Government General Hospital. If you had a serious illness, [in] those days it was considered that the place to go to was Government General Hospital. It all changed after Apollo (Chennai Doctor 1).
Yet the claim that “Apollo changed everything” fails to bear the weight of scrutiny. It would be useful to disaggregate the “It all changed after Apollo” myth into its five key elements:
Apollo came up at a time that healthcare for “ordinary Indians” was flagging.
Apollo provided a new model of healthcare delivery in India.
At its heart, Apollo is a patriotic project.
In order to establish Apollo, its chairman, Prathap Reddy, single-handedly changed government policy.
Apollo was an immediate success.
In light of this descriptive convergence among both admirers and critics, the rest of this section attempts to describe and assess these five elements of the “It all changed after Apollo” myth.
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Apollo came up at a time when healthcare for “ordinary Indians” was flagging
Talking about Reddy, a doctor whom I interviewed claimed, “When he set up Apollo Hospitals in Chennai in 1983, private healthcare institutions were virtually unknown to the country”
(8) This aspect of the myth of Apollo is often articulated through three sub-claims: 1a) that there was no reasonable healthcare available in Chennai, 1b) that the government, in particular, had either abdicated or was simply unable to fulfil its responsibility to provide healthcare for ordinary Indians, and that, therefore, 1c) only the very rich had access to high-quality healthcare, for which they travelled abroad.
Let us consider these in turn.
1a. There was no good healthcare available in Chennai for “ordinary” Indians
Although this claim is oft-repeated (that before the establishment of Apollo and other corporate hospitals in Chennai, there was no good quality healthcare in the city for so-called ordinary Indians), it is difficult to find evidence to support this claim. For the sake of simplicity, let us leave aside the vexed question of who an “ordinary Indian” is (as well as the even more vexed question of whether or not she is well served by corporate medical institutions in Chennai today). Whilst historians have yet to fully document the city’s medical past, physicians from Chennai have described in interviews how the city has been the long-standing home of high-quality medical care and medical education in India. Chennai’s reputation as a “healthcare hub” far precedes the opening of Apollo Hospitals in 1983-1984. One of the doctors whom I interviewed, and who was closely associated with the Tamil Nadu branch of the Indian Medical Association, estimated that the city was home to approximately 400 hospitals and 10,000 beds.
The phrase repeatedly used both by physicians in interviews and newspaper journalists to describe the cluster of medical facilities in Chennai is “medical mecca.”The use of this term is based on a detailed consideration of the various aspects of excellence in the medical sphere, including: medical education and large government hospitals; a cluster of private nursing homes run by prominent physicians (particularly along Poonamallee High Road); excellent connections to national transport infrastructure; nodes of specialist expertise; and a reputation for the provision of ethical treatment at reasonable fees.
That the medical education provided in and around Chennai is of a high quality is common knowledge. Three medical colleges in the region are consistently ranked in the top ten nationally. These are the Christian Medical College in Vellore (established in 1902 and affiliated to Madras University in 1942), Jawaharlal Institute of Postgraduate Medical Education and Research in Pondicherry (established in 1823 and re-developed in 1956), and Madras Medical College in Chennai (established in 1850).The students graduating from these institutions not only staff large teaching hospitals, but also go onto to staff and manage the small, medium and large hospitals across Chennai.
Further, Chennai is famous for the high quality of treatment and research carried out in a number of its government hospitals. Special mention may be made of the Government General Hospital (established in 1664), and Stanley Hospital (established in1792). Other hospitals of note included the Southern Railway Headquarters Hospital in Perambur (date of establishment not available),Vijaya Hospital (established in 1972), KJ Hospital and MV Diabetes Hospital
(9). The same high standards of quality are maintained by several high-profile voluntary and charitable trust hospitals as well. These include the Voluntary Health Society (established in 1958), the Cancer Institute (established in1954), and Sankara Nethralaya (established in 1978). Speaking of the high standards of government hospitals, one physician said:
When I went to medical school [1970s], MMC was still the place you went to if you had complicated illnesses. Even private doctors would do hernias and gall bladders outside. But if you needed cancer surgery… they’d say: “Hey, listen come to the government hospitals. They are better equipped to do all those. We are academic centres” (Chennai doctor 2).
Another physician echoed these sentiments:
“…I think more and more people joined medical college in Madras. It was considered to be, you know, the place to go to. So it had that reputation of being something, even right from the first days…” (Chennai doctor 7).
Apart from the extensive medical infrastructure in and around Chennai in terms of medical education and large government hospitals, over the 20th century, the city also became famous for its large number of private nursing homes, run by prominent physicians. These private nursing homes included the Pandalai Nursing Home, Sundaravadanam Nursing Home and Kumaran Nursing Home. Nearly every doctor I interviewed mentioned that, particularly from the 1960s onwards, Chennai’s Poonamallee High Road came to be India’s “Harley Street” among doctors and patients across India. Nevertheless, none of this is apparent in the awestruck assessment of Reddy and Apollo Hospitals cited below (an assessment which is very common).
[Reddy’s] plan for the creation of a nationwide hospital system in the corporate sector may not seem extraordinary today when private medicine has made major inroads across the country but it was dramatic 30 years ago… When he set up Apollo Hospitals in Chennai in 1983, private healthcare institutions were virtually unknown in the country (7).
Yet, rather than being “virtually unknown”, Chennai’s private hospitals and nursing homes were part of a larger regional and national trend of an expanding private medical sector, a trend which emerged around 1960. As Bhat observes, “Private healthcare expenditure in India has grown at 12.5% per annum since 1960-70”
(10). In rural India, the number of small private treatment facilities increased threefold between 1984 and 1992
(11). Similarly, in the small city of Mangalore in south-west India, the number of moderate-sized nursing homes jumped from six in 1986 to 20 in 1994, and to 32
(12) in 1998 . Further, as Nicher and Van Sickle point out, “In the 1980s, small private labs began springing up in towns and cities…”
(12).
As home to a good number of highly-trained physicians, whether practising privately or in government institutions, Chennai became well known as a centre of excellence in particular specialist areas. One doctor summed up what many others noted:
Historically, Chennai is the healthcare capital of India… for whatever reason the primary centre is always started in and around Chennai. Cardiac units, neurosurgical units, orthopaedic units; anything that starts in India and healthcare first seems to be able to kick off in Chennai and then to somewhere else. Dr B Ramamurthy was the legend of his time -a first world-class neurosurgical centre that he put up in the seventies (Incomplete)… Like that, the Cancer Institute in Adyar still has a reputation for being a good oncology centre… In ophthalmology, [Sankara] Nethralaya is a world-class centre (Chennai doctor 2).
In addition, many physicians noted that the practice of medicine in Chennai was marked by a high level of professional ethics, combined with relatively low costs. One doctor observed: “A kind of good temperament is there in most of the senior doctors in Chennai, they want to be helpful not necessarily just make money” (Chennai doctor 3) Another doctor elaborated on this theme: “Medicine really exploded during the post-war years. And Madras had the reputation that it tended to be a little bit more conservative. The Bombay person is always a little bit more of an entrepreneur”(Chennai doctor 12).In this conversation, the doctor equated a broader cultural conservatism with a higher level of professional probity.
1b. Apollo came up at a time when government support for healthcare for ordinary Indians was flagging
Just as with the claim that good-quality healthcare was virtually unavailable for ordinary Indians before Apollo, the claim that Apollo “filled a gap” in the provision of healthcare due to the lack of government support is difficult to sustain. This is particularly the case when one considers the overwhelming evidence to the contrary. There was a substantial government health infrastructure in Tamil Nadu before the establishment of either Apollo or any other corporate hospital in Chennai.
As part of a larger project of widening and strengthening the health infrastructure in India, primary health centres and sub-centres were introduced as the “rural health” component of the Minimum Needs Programme during the Fifth Five-Year Plan (1974-1978). As Duggal explains: “During the 1980s, the public health spending peaked and this was reflected in major health infrastructure expansion in rural India via the Minimum Needs Programme”
(13). Tamil Nadu was particularly successful in its attempts to implement the programme for building health infrastructure. As Muraleedharan et al narrate: “Tamil Nadu embraced the concept whole-heartedly and built the facilities much faster than almost all other states”
(14).
However, there is also a possibility that Tamil Nadu was able to capitalise on the rural health agenda of the Minimum Needs Programme, at least in part, because it had already launched a robust programme of health planning
prior to the implementation of the Minimum Needs Programme. KS Sanjivi (doyen of Chennai’s voluntary health sector, b. 1903-d. 1994) claimed in 1973 that Tamil Nadu was one of the few states which had the requisite number of primary health centres, complete with the medical and paramedical personnel needed
(15). In 1973, Sanjivi explained:
The government of Tamil Nadu was the first to constitute a state planning commission with a task force on health … presided over by Malcolm Adiseshiah… [It] divided itself into working parties to consider in depth the problems of health services, medical education, family planning, nutrition, sanitation, the role of voluntary organisations and indigenous medicines, including homeopathy. It handed over its report to the Chief Minister of Tamil Nadu, M Karunanidhi, in 1972 (15).
Taken together, the pre-existing government health infrastructure and the policies prioritising planning for the provision of primary and tertiary healthcare did much to contribute to the growth of
all healthcare in Chennai, well in advance of the establishment of Apollo.
Whereas the role of Apollo may constitute a part of these larger trends, it would be erroneous to claim that it could have served as a catalyst for them. Many of the doctors interviewed pointed out that it was, in fact, the long-standing healthcare infrastructure in and around Chennai that created a client base for private medicine. Several doctors drew attention to the fact that, particularly by the 1980s, the region’s population had been sensitised to the importance of good healthcare “habits”, such as visiting doctors to address their health concerns. It is also to be noted that the relatively higher levels of development in Chennai and across Tamil Nadu over a long period meant that even before liberalisation, the state was home to a comparatively large middle class population which could afford specialist care in Chennai.
1c. Apollo triumphed because it provided what was up till then unavailable in India or for Indians
This aspect of the Apollo myth claims that good-quality healthcare was out of the reach of Indians, except those who were very, very rich. The corollary claim is that those who could afford international travel went either to the UK or to the USA for specialist, life-saving treatment. The following is an excerpt from an interview with a doctor from Chennai, and what he says is typical of what many physicians reported:
Chennai doctor7
… I mean, they were doing excellent work. But there was always this thing that if you were a VIP you got good treatment,whereas if you were a common man you didn’t get such good treatment. And the hospital could have been a lot cleaner. So that was one thing that did put people off. Now suddenly here was a place where everybody could go to. I mean not everybody – people who could afford it, and who did not want to go to a GH [General Hospital] could come here.
SH (author):
Instead of going abroad.
Chennai doctor 7:
Yes. Now let’s talk about the heart. Everybody who needed a bypass would go to the US. Now suddenly here was a place that one could go to. You didn’t have to go there.
This claim, however, fails to take into account some basic developments in India’s economic history. In the mid-1980s, the cost of international travel rose astronomically for Indians. This was because of changes in the exchange rate and, in particular, radical devaluing of the rupee, particularly by the late 1980s. It was at precisely the same time as overseas medical travel became prohibitively expensive that Apollo began to announce dividends via newspaper articles. In other words, it is worth considering that Apollo did not create a market, but stumbled into one.
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The emergence and rise of Apollo was a catalyst for a new model of healthcare delivery in India
This claim is predicated on the corollary claim that Apollo was quickly emulated by many others in the private healthcare sector. Certainly, the story of Apollo can be described as that of the emergence and rise of
one corporate hospital chain in India. To be fair, from the very beginning, Apollo’s promoters planned Apollo not as a single institution, but as a
chain of large private hospitals
(16). This was, indeed, a new concept in India in terms of the scale, organisation and delivery of private healthcare. What is less clear, however, is the degree to which Apollo served as a
catalyst for the successful emergence of other large private hospitals and hospital chains across India.
In claiming that Apollo served as a catalyst for other private hospitals and chains to emerge, many assume that Apollo was an
immediate success. However, Apollo took at least five years (and most likely, many more) before it made any dividends. Further, there was a substantial gap (at least 15 years) between the inauguration of Apollo in 1983 and the establishment of other large, successful Indian hospital chains that continue to be in existence today. Nevertheless, Apollo did make waves in the early years. As early as 1991, Chennai was hailed as the”corporate healthcare” city of India, though it had only a total of
four large private hospitals (compared to the approximately 20 that we have today). In 1995, one journalist celebrated Chennai’s achievement thus:
Madras is the new “mecca of medicine”… In the last five years the hospital services sector has boomed in this city, though “for profit” hospitals exist elsewhere in the country, Madras is the only city with four corporate hospitals (17).
Indeed the 1990s was a time of relative early growth, and, soon after this article was published, Chennai had six corporate hospitals: Tamilnad Hospital, Devaki Hospital, Malar Hospital, Dr Agarwal’s Eye Hospital (which went public in 1994), and Chennai Kaliappa Hospital, in addition to Apollo. One of the obvious factors to reckon with was, and still is, that starting a corporate hospital requires immense funds. One of the doctors interviewed observed that “the gestation period for a hospital is five to seven years, minimum, before it can make a profit,” (Chennai doctor 6). As one physician explained:
When you borrow money [for a hospital], you’re asked to repay like an industry in like five years. [But] you cannot pay back in healthcare in the five years. Absolutely impossible. So what then happens is that people take the massive amount of money. [But] modern medical technology depreciates in four years. At the end of the fifth year, you have junk, it’s scrap…(Chennai doctor 2).
The following tale of Tamilnad Hospital illustrates how, while it was one thing to open a corporate hospital, it was quite another to keep it going or to turn a profit.
From Tamilnad to Global
Tamilnad Hospital was incorporated in 1984 by a US-based non-resident Indian, Dr CP Velusamy. In 1985, it became a public limited company. In 1991, Tamilnad Hospital issued public shares in order to finance the cost of setting up what was at that time described as “the first phase” -a 250-bed hospital in Perumbakkam, which was in south suburban Chennai and quite remote in those days
(18). In 2000, after a protracted labour dispute, Tamilnad Hospital faced a mass walk-out of physicians
(19). Following the labour unrest, as well as a lengthy delay in the hospital’s plans to start a medical college jointly with the Kanchi
math nearby, Tamilnad Hospitals folded up. In 2003, the Kanchi
math took over the hospital through its deemed university at Kancheepuram. The hospital was rechristened the Sri Kanchi Kamakoti Sankara Medical Hospital
(20). However, in 2006, Sankara Hospital admitted defeat in being able to make the venture profitable and applied to sell the hospital, explaining that in its expansion to 450 beds on the 46 acre site, it had become untenable financially. In 2007 in an all-cash deal worth Rs 257crore, Sankara Hospital was bought by Global Hospitals and was renamed Global Health City, which is what it is known as today as well
(21).
In short, whilst Apollo was the first, it is far from clear whether it paved the way for other large, private hospitals in Chennai, or whether other large, private hospitals found it easy to succeed. If anything, time has shown that the largest organisations tend to survive, given that they can do business (and spread losses) across economies of scale.
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At its heart, Apollo is a patriotic project
The assertion that Apollo is a symbol and an institution representative of the greatness of the Indian nation is a truism. Statements on this aspect of the Apollo myth are often repeated and it is this angle that the Apollo Hospitals Group promotes the most vigorously in its publicity material and media appearances. As Prathap Reddy regularly emphasises in his many interviews to the media, “…bringing the best healthcare within the reach of every patient is our mission and [at Apollo] we are determined to make it a reality”
(22). However, this claim addresses an implicit criticism. That is, one often hears worried murmurings, even among physicians employed by Apollo, of how for-profit medicine may be profit-driven. The anxiety is that profits in medicine make for bad medicine and a deterioration in morals, which would be particularly deleterious to patients in India, a nation still wracked by dire poverty. In framing the business of Apollo as a service to the nation, this criticism is neutralised.
Apollo Hospital not only neutralises the criticism of for-profit medicine, but also often presents Prathap Reddy’s very pursuit of profit (whether in healthcare or other ventures) as patriotic. Mostly, this claim of patriotism is paired with praise for the service Apollo Hospital provides to middle-class consumers. One of Reddy’s recent interviewers wrote, “[Reddy’s] is the story of one man who set out to revolutionise the unaddressed healthcare needs of a section of India’s growing middle class. It is a tale of manoeuvring through difficult bureaucratic and complex medical systems”
(7).
Indeed, much of the retrospective publicity concerning Reddy and the establishment of the first Apollo highlights a series of meetings he had with Indira Gandhi, and later, Rajiv Gandhi. The accounts of these meetings portray Reddy as one who aimed to help save the nation from what was seen as stifling regulation and bureaucracy. These accounts regularly include a version of the following story: “I told Mrs Gandhi only the rich and powerful get access to healthcare and she really gave the first impetus by telling everybody, ‘Here’s a man who wants to reverse the brain drain'”
(8). However, no one mentions the fact that Indira Gandhi, who is regularly credited with evaluating the overall effect of the first Apollo, died within the first year of its establishment. Of Mrs Gandhi’s endorsement of Apollo Hospitals, another of Reddy’s interviewers wrote:
The new hospital attracted the best medical talent, including eminent non-resident Indian doctors who returned to India from hospitals in the US and UK. This prompted then Prime Minister Indira Gandhi to remark, “Dr Reddy you have brought talent back to India and reversed the brain drain” (23).
Reddy regularly remarked that “…the man who really changed the face of healthcare in this country with his vision and clarity was none other than Rajiv Gandhi – by opening up hospitals to funding and other opportunities”
(8).
However, when Reddy was preparing to open Apollo in 1982, his statements regarding the national role that the hospital was expected to play were substantially different from the stories we hear today. In 1982, a newspaper reported that Apollo was an institution primarily intended to serve foreigners travelling to India from the Gulf for medical treatment:
A hospital being built under the corporate sector here expects a steady flow of rich Arab clients and a huge inflow of foreign exchange, since the Arabs are not satisfied with the facilities offered in the Bombay hospitals. Dr Prathap Reddy, chairman of the company behind the venture, told newsmen here yesterday that many rich Arabs had told him that they wanted to be picked up from the airport to the hospital and all investigations and treatment should be done under one roof, regardless of cost (24).
In this early iteration, Apollo would serve the Indian nation – not by ministering to Indians -but by ministering to India’s foreign exchange reserves. The avowal of such objectives echoed a statement Reddy had made slightly earlier, in which he had disclosed that the government recognised the Apollo venture as a “core economic activity” because it (the government) was aware of the potential of healthcare to attract foreign exchange
(25). It should be evident that this quote is at odds with the avowed aim of Reddy and Apollo that has been commemorated subsequently. Reddy and Apollo Hospitals have been honoured with the highest accolades that the Indian nation can bestow. Reddy received a Padma Bhushan in 1991 (India’s third highest civilian honour) and a Padma Vibhushan in 2010 (India’s second highest civilian honour).The Indian Postal Service issued a commemorative stamp in honour of Apollo Hospitals in 2009.
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In order to establish Apollo, Reddy changed state practices single-handedly
Many go on from the assertion that Apollo was a trailblazer, that too the only one, in crafting a new future for medicine in India, to claim that Reddy effected these changes by dint of his personal charisma. According to these accounts, Reddy charmed the “Delhi Durbar” under successive prime ministers during the 1980s with the sheer persuasiveness of his argument that his was a national/populist project.
Indira Gandhi and Rajiv Gandhi figure prominently in these accounts. One newspaper reported: “Banks were not willing to fund hospitals. Apollo approached the Centre and found a patient listener in the then Prime Minister, Indira Gandhi. The healthcare sector gained industry status, and access to financial markets”
(26). Referring to 1989 when Rajiv Gandhi was the Prime Minister, another interviewer made the following claims:
…On Reddy’s representation, the former (Rajiv Gandhi)amended in three days in the Parliament and removed all hardships leading to liberal funding And so the costliest medical equipments made inroads[sic] into Indian hospitals and were equipped on par with the western. Rajiv Gandhi also gave a tax exemption of Rs 10,000 [on medical equipment] (27).
Finally, another interviewer risks over-egging the pudding, exceeding even Reddy’s and Apollo’s own claims: “Often referred to as the father of modern healthcare in India – after all, he revolutionised healthcare in India when the country was mired in babudom”
(8). Reddy himself was quoted as having said the following of the first Apollo:
…securing licences to import 370-odd medical equipment for the hospital itself took two years. Meanwhile, lowering of import duty on life-saving medical equipment also helped private healthcare during the pre-reform era. The duties came down from 100% to 5-6% over the years (26).
The claims regarding the transformation brought about by Reddy ignore and obscure the fact that the pre-existing economic climate had already been in the process of changing. Reddy takes credit for these changes, in particular, liberalisation, first under Indira Gandhi in the early 1980s and then under Rajiv Gandhi in the late 1980s. This aspect of the myth also underplays the increasingly active role of associations such as the Federation of Indian Chambers of Commerce and Industry (FICCI) and the Confederation of Indian Industry (CII).
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Apollo was an immediate success
The popular perception is that upon its establishment in 1983, Apollo was an immediate success in terms of therapeutic outcomes and profit margins. The publicity circulated by Apollo Hospitals gives one to believe the same. As one of the doctors who was interviewed emphasised, “[Apollo] was a place where you could be confident you get every kind of treatment under one roof. And it was available for a price, but it was there. The quality was there. That was right from the beginning. It was a foregone thing. It just took off” (Chennai doctor 7). Many attribute the success to Reddy’s visionary nature. Another doctor declared, “Apollo succeeded because Reddy could see what was coming”(Chennai doctor 8). However, this was not the case, as is clear both from Apollo’s own attempts to secure funding through further public share issues to underwrite further expansion, as well as the struggle of other hospitals to thrive within the same market (Chennai).