Arun Gadre, Abhay Shukla. Dissenting diagnosis. Voices of conscience from the medical profession. Gurgaon, Haryana: Random House India. 2016. Paperback. 190 pages. ISBN 9788184007015. Rs 399.00.

In his foreword, Mr Keshav Desiraju describes this book as remarkable, on the basis of the fact that the authors have interviewed 78 physicians, recorded their thoughts about their profession, and got them to describe their cynicism and the bad faith prevailing among doctors. He concludes that all doctors, those influencing policies on health and everyone interested in the future of public health in India must read this book.

Mr Desiraju is an acclaimed and respected officer of the Indian Administrative Service. His efforts to improve the functioning of the Medical Council of India were frustrated by the order summarily transferring him from the post of Secretary in the Union Ministry of Health in February 2014 – a post which he held for less than a year. He has since retired, and lives in Chennai.

Jan Swasthya Abhiyan, the Indian circle of the worldwide People’s Health Movement, was founded in 2001. It had publicly protested against Mr Desiraju’s transfer in 2014, but to no avail. Dr Abhay Shukla is one of the national conveners of the Abhiyan (campaign). He studied Community Medicine at the All India Institute of Medical Sciences (AIIMS), New Delhi. He has, to his credit, books on such subjects as the inequities of healthcare in Maharashtra and crises in the healthcare system in the country.

Dr Gadre, too, has impeccable credentials. Inspired by Baba Amte, he and his wife moved to Lasalgaon, a village in Maharashtra, where he has since served as a gynaecologist for the rural poor. Before he gave up the comforts of life in a metropolis to settle there, pregnant local villagers had to travel 70 kms to the nearest specialist in Nasik. He recalled “There was no blood bank, no paediatrician, no hi-tech equipment when I started. In case of an emergency, it would take over eight hours for a bottle of blood to reach here from Nasik. Yet, I could successfully operate even on patients with a uterus rupture, because they had faith in me.”

Dr Abhay Shukla and Dr Arun Gadre work for SATHI (Support for Advocacy and Training to Health Initiatives).

They inform us in their introduction that concern for the quality of the care provided by private medical facilities and the bitter opposition by associations of private doctors to The Clinical Establishments Act, 2010 prompted the study that has resulted in this book. They decided to interview members of the “dwindling but significant number of rational doctors” practising ethical medicine.

Dr Gadre appears to be the prime mover and posed nine questions (reproduced on pages xxi–xxii) to selected doctors. It would have been helpful if a tenth question had been added: “What have you done to correct the deficiencies and malpractices you have described? Did you take action against the guilty, bring these malpractices to the notice of authorities and pursue the matter further through Right To Information queries?”

Seventy-eight doctors, “well-known and less-widely-known from Maharashtra, Chhattisgarh, Bangalore, Delhi, Kolkata and Chennai”, were surveyed. The doctors in Maharashtra included those in Mumbai, Pune, Nasik, Sangli, small towns and villages. The authors make special mention of Dr Vijay Ajgaonkar, Dr Sanjay Gupte, Dr HV Sardesai and Dr Sanjib Mukhopadhyay.

The doctors were selected on the basis of personal contacts and through a “further chain of doctor contacts”. In the authors’ opinion, these doctors were ethical and rational in their practice. The authors chose those who were willing to be interviewed and place their views in the public domain. Despite meeting the latter criterion, only 37 permitted the authors to use their names. The rest feared alienating their colleagues, having fingers pointed at them by their colleagues in the private sector, and physical attacks.

Some details on all 78 doctors are tabulated on pages xvii–xix. At the end of Dr Ajgaonkar’s interview, reproduced in full as Chapter 1, we are told: “Dr Ajgaonkar is not alone in speaking up… another seventy-eight doctors… are sharing their experiences…”. Do we, then, have 79 testimonies?

The methodology is described in the introduction, as follows: “…the essence of what each doctor was saying (was broken up and included under) categories… to help the reader sharply understand the critical dimensions of each situation…”

The authors sum up the findings: “… all point towards an important and serious reality. This reality is the deplorable decline in ethical standards in private medical services and also the highly commercialised form that such practice has acquired……We hope that the searing testimonies will help awaken the general public, citizens’ groups, social movements and political representatives to the urgent need for regulation in the private medical sector in India…”

Part I of the book provides the gist of what was learnt during the interviews, broken up into categories. Part II puts forth a range of possible solutions.

Each chapter in both parts concludes with a section titled “Summing up”. Some of these sections do not provide the gist of the foregoing chapter. One such example may be found after Chapter 3, on pharmaceutical companies: “You might feel a shiver of apprehension after reading all of this. Maybe a certain sense of helplessness too. There is absolutely no doubt that it is high time to take the entire situation seriously and to do something about it.”

Part I contains, in addition to Dr Ajgaonkar’s interview, sections on malpractices in private hospitals; the toxic influence of pharmaceutical companies; the role of corporate and multispecialty hospitals in turning healthcare into an industry; the role of society in the growing commercialisation of medicine and the solutions suggested by doctors for curing the maladies outlined by them.

These malpractices are described in fair detail and lay readers will benefit from a study of this part of the book.

The solutions suggested by the doctors range from the declaration that “there is no solution to this mess” to changes in rules and regulations, strict control over the private sector in medicine, strengthening of public health services and improved legislation. Unfortunately, whilst rules, regulations and laws can be passed, the failure to implement them can exacerbate the current frustration. A doctor–patient forum has been proposed. Even a simple reading of chapters 6 and 10 in Part II (regulating the private sector) is sufficient to make the reader aware that there are no easy answers and sustained hard work is required on many fronts if any change is to follow.

Part II has a chapter on the rights of the patient in a private hospital and another on how a rational, ethical doctor can be recognised. These chapters contain many helpful pointers for the lay person. Chapter 11, which is on universal healthcare and provides examples of countries that have attempted to implement such a system, with varying degrees of success, provides food for thought.

I am puzzled by some facts.

1. As individuals with close connections with the Centre for Enquiry into Health and Allied Themes, the authors are well aware of the Forum for Medical Ethics Society and the journal published by this Society, the Indian Journal of Medical Ethics. This journal – the only one of its kind – has, over the past two decades and more, published several essays on wrongdoings in medical education and practice in India, both in the public and private sectors. It has also published essays which are critical of such public, policy-making bodies as the Medical Council of India and Indian Council of Medical Research, and contain suggestions for improvement. The authors have failed to make any reference to the Society and refer to just one paper published in the journal on page 174 of the book. Consequently, neither the Society, nor the journal finds a place in the index. I wonder whether the Society and journal have fallen short of the expectations of Drs Gadre and Shukla or whether they find them unworthy of mention.
2. From a study of this book, it would appear that 2016 has seen the first appearance of this text in print. A brief survey, however, shows that it was published in a book entitled Voices of conscience from the medical profession, released on February 26, 2015 at AIIMS. The text of that book was based on the Marathi Kaifiyat – Pramanik Doctoranchi, which has been brought out in two editions (2014, 2015).
1. As far as I can gather from news reports, all three publications are based on the same interviews with 78 practising doctors.
2. I am unable to find references to these earlier publications in the book under review and wonder why this is so.
3. Dr Abhay Shukla is a member of the advisory bodies for the National Rural Health Mission and the National Human Rights Commission. It would be of interest to know what these national bodies, especially the latter, have done to rectify the wrongs listed in this book and how effective those measures have been. Unfortunately, there is no mention of these in this book.
4. Publishing books and reports is a very worthwhile activity. It spreads information far and wide. We know from experience, however, that their impact on wrongdoers is limited. It would have helped the reader to learn of the efforts made by the authors themselves to compel the guilty to change their practices and the success attendant on their endeavours.
5. The authors have not addressed in any detail the failings in medical colleges run by governments and municipal corporations, the reasons for their decline over the past few decades and the consequences for the very poor who are forced to flock to them. The focus on the private sector has resulted in a lopsided consideration of the ills that plague the poorest of our citizens.