About five years ago, a patient who underwent a trans-abdominal tubectomy at the Cuddalore district headquarters hospital died due to complications. It turned out that the surgeon had injured her intestines and failed to recognise this after she developed abdominal distension and vomiting in the post-operative period. By the time he called for help and another operation was performed, the patient was in poor shape. The patient’s husband approached the courts, which recently ruled that the doctor was criminally negligent and ordered his arrest. The Tamil Nadu Government Doctors’ Association threatened a strike if the government did not appeal the ruling and provide them with security and insurance against legal proceedings by patients. The government has promised to help.

I do not want to make any comment on the ruling in this particular case, but one point, which does not seem to have been brought out in this controversy, is the extremely poor conditions in the government hospitals today. In fact, the conditions in hospitals in general and operation theatres in particular are so bad that it is sheer good fortune that such disasters do not occur more often.

The point I am making was emphasised in a gruesome fashion when, on August 20, a part of the floor of the thoracic ward in the Government General Hospital, located on the first floor, caved into the ward below. One patient was killed and nine people including two doctors were injured. Fortunately, the ward below had been evacuated for renovation. The government’s response was to order compensation, and, in an extraordinary act of callousness to state that the patient was critically ill anyway! Nobody explained how this was relevant to the fact that he had fallen to his death in an institute where he had come for treatment.

One must remember that till as recently as fifteen years ago, the Government General Hospital was the premier institution in south India. This was the place where many chief ministers of the state were treated. Today even minor political flunkeys do not use government health services.

A combination of events brought about this situation. Beginning in the 1970s and continuing till today, a large number of doctors returned from abroad and the large corporate hospital came into being. Most of these were given substantial concessions – in short they were given subsidies from public money. In return, they look after the political class – a neat quid pro quo. From the late ’60s, appointments to the government services in general, and the teaching hospitals in particular, have been done more on political considerations than on merit. Perhaps knowing the quality of the people they have put into important positions, the politicians prefer to utilise the services of other doctors! The poor, sadly, have no choice. It appears that since they have no personal benefit from the government hospitals any more, the politicians now do not care what happens there.

This is reflected in the budgetary allocations, and also in the way whatever money is available is spent. The 1993 World Bank Report, Investing in Health (1), which suggested that governments in third world countries like India should not attempt to provide comprehensive medical care, but focus only on a few areas, seems to have become official policy. But even this is being done in a typically bureaucratically opaque fashion. Thus the government does not officially state that it will provide only limited medical services. But, in effect, this is what it does by starving the hospitals of essential supplies.

This style of functioning has a terrible effect on morale, because the patient cannot be told that the facilities for his/her investigations and treatment are not available. Many patients spend a considerable amount of time in the hospital before it dawns on them that they will be getting no treatment and then choose to leave, which in officialese is called “discharged at request” or, “discharged against medical advice”. There are no “mission statements” which say how soon a person with a particular should be investigated and treated. There is no audit of waiting lists.

It is disturbing that the association of government doctors does not protest this state of affairs. It is patently demeaning and demoralising for a group of highly trained professionals to participate in this huge hoax being perpetuated on the patients. Yet, except for mild protests about the supply of materials, which are added on almost as an afterthought whenever government doctors go on strike, there has been no sustained effort to improve the working conditions in the government hospitals. It is also remarkable that whenever the strikes are settled, even these minimal demands for improvement of the hospitals are forgotten.

The employees of the medical services, from sanitary cleaner up to the director of medical services, by and large, seem to forget that the patients are the only reason that they are there. The users of hospitals are seen as supplicants, and anything done for them a favour. The concept that patients and medical service providers are part of the same society, and that the services are paid for out of taxes that everyone pays, does not seem to have been understood by most of the medical staff. One can hear absolute absurdities being purveyed as wonderful insights. For example, health is a ‘spending’ department and therefore should not expect much attention from the governments and the bureaucracy. The elementary fact that governments should garner revenue in the form of taxes only to spend on welfare seems to have escaped them completely. It appears that the government is seen as some form of huge corporation whose purpose is to make profits!

Perhaps the most important factor that will change the sorry state of the public medical system is pressure from the public. It would be wonderful, however, if doctors were a part of the move for change.