“This year I was talking to my sister in London and I said, ‘I’ll have to get used to not having roses on Valentine’s Day.’ But on the fourteenth, I arrived home in the evening and there was a massive bunch of roses from her. Her note said, ‘Aarti, he never left you. He will always love you. These are from him.’”
• • •
For most people in the world, medical adversity represents the greatest source of financial crisis, and India has never been any different. Until liberalisation, however, the cost of healthcare was lower by several orders of magnitude, not only because doctors charged lower fees, but also because the whole business was significantly less technologically intense. Magnetic Resonance Imaging (MRI) scanning machines, for instance, were rare, and most doctors made their diagnoses without access to expensive tests of these sorts. Drugs and therapeutic equipment, similarly, were both more rudimentary and cheaper before liberalisation allowed the entry into India of the world’s major pharmaceutical companies. So if serious health problems inevitably presented periods of financial stress, the cost levels were such that middle-class people could usually meet them by pooling the resources of family and friends.
The system worked also because doctors had high levels of prestige and credibility. While many government hospital doctors supplemented their income by offering private consultations at home in the evenings, in the hospital itself they worked for a fixed salary and had no financial stake in the diagnoses and treatments they offered. Their medical judgement was, in their patient’s eyes, uncompromised. There was every reason to feel secure, when consulting a doctor, that his or her interest was similar to one’s own.
After liberalisation this equilibrium was significantly disrupted. Government hospitals had by this time become conspicuously under-resourced, and the middle classes flocked to the new corporate hospitals. But the costs here were such that, in the case of the most extreme and drawn-out of illnesses, even affluent families could stand to lose everything they possessed. And though the middle classes began in the same period to invest in the new health insurance packages offered by private financial institutions, these were often adequate only for relatively minor treatments. Even the most comprehensive of them excluded treatment for several chronic diseases — various kinds of cancer, all illnesses resulting from HIV, anything at all that struck past the age of sixty-five — and total re-imbursement in one year to any one patient was usually capped at a relatively low level, usually between $5,000 and $20,000. The most devastating financial territory was entirely unsecured.
This already-dangerous situation was exacerbated by the new suspicions introduced by the conspicuous profit motive of corporate hospitals. There was no doubt that these institutions were corporations: they looked like corporations, they expanded — and bought and sold each other — with corporate speed, and they were administered by some of the country’s major financial interests. Patients in these hospitals were fully aware of the aggression with which big Indian businesses operated; they also knew that corporations were something of a fiefdom, whose practices went largely unscrutinised by any independent body — and they were therefore racked with uncertainty as to the nature of what was happening to them. Was this expense necessary to treat their condition or was the corporation simply trying to suck up their money?
As everyone knows who has moved from one country to another, the last thing one becomes accustomed to is a new healthcare system; and the shift to this new healthcare regime in India would have produced suspicion even if its integrity were beyond reproach — and in many cases, of course, it was. But there was considerable disquiet within the medical establishment too, and many doctors confirmed that the storm in patients’ heads was not only in their heads. A surgeon from a leading government hospital felt that his entire profession was under threat from the new corporate hospitals.
“They are money machines,” he said. “They are about revenue maximisation, pure and simple, and they have led to a dangerous collapse in medical judgement and ethics.
“Let me give you an example. A leading surgeon left his job at the government hospital where I work to join one of the big corporate hospitals. He was offered a salary of 2.4 crores a year [$480,000], which was ten times his previous salary, but it was dependent on him delivering 12 crores [$2.4 million] of revenue to the hospital. Now, if he did the maximum possible number of operations in a year, he still would not deliver 50 per cent of that figure. So the rest had to be delivered by diagnostic tests. Which is why there has been such a huge escalation in tests. Patients are sent to do repeated MRI scans so that doctors can meet targets. Some patients have very high radiation exposure as a result of all this.
“Certain surgical procedures are carried out almost without indication. Anyone who has upper abdominal pain has their gall bladder removed. Forty per cent of these procedures are unnecessary. But the patient doesn’t know that. It’s usually not possible for a patient to find any evidence of malpractice.
“Look at the rates of Caesarian section. Some of the most famous obstetricians deliver 70 to 80 per cent of their babies by Caesarian. There is hardly a hospital in this city that offers a natural birth service. Why? Caesarians make more money than normal births, of course, but more importantly they allow doctors to determine the schedule and to fit more women in. It’s much more efficient.
“The pharmaceutical and medical equipment industries have a huge role in deciding treatment options because many of these doctors are working directly for those companies, which the patient doesn’t know. Drug companies pay many oncologists 10 per cent of the value of the chemotherapy they prescribe; a typical figure would be a crore [$200,000] of prescriptions a month. Cancer of the pancreas is a favourite, because if you get to the stage where you need chemotherapy you are anyway going to die within six months, so doctors can prescribe whatever they like.
“These hospitals are very dark institutions, even at the business level. Land is acquired for them by the government at an enormously subsidised level, and often the government donates money towards the cost of setting up the hospital, on the condition that it allocates a third of beds to the poor. But the hospitals never honour such commitments: there is no question of them writing off those kinds of profits. Later on, they sell a share of their company to the public for hundreds of millions of dollars and the newspapers laud them as self-made billionaires. But their fortunes were built largely from public money.”
He talks calmly, but with brimming outrage.
“You should write your entire book about this,” he says to me. “I can’t do it because all these people are my colleagues. But someone needs to write about all this. Pose as a patient and see what happens. Start telling people you need to buy a kidney and see where you are led. In my hospital I worked with an anaesthetist who was involved in a big kidney transplantation racket in Delhi. Kidney transplantation is very easy: you can do it in a normal flat. And India is the diabetes capital of the world, so many people are proceeding inexorably towards end-stage renal disease, which is completely wretched. Add to that a lot of poor people willing to sell a kidney and the outcome is obvious.
“The whole industry has become very sinister. Where does it find its cadavers, for instance? With all these new pharmaceutical companies and research laboratories, demand is growing on every side. Tissue banks need cadavers. Every company that manufactures implants needs to test them on cadavers. Now, the Mysore Anatomy Act of 1958 says that only unclaimed cadavers can be used for medical experimentation. But large-scale entrepreneurial medicine needs far more than this. So now you have bodies being stolen everywhere. They disappear from funeral homes and end up in surgeons’ colleges and corporations.”