October 07, 2000

When leaders shun AIIMS and Apollo
Good doc, bad doc

Chances are that you, like me, grew up in mortal dread of doctors, hospitals, injections and operations. At the best of times the thought of seeing a doctor, even for a vaccination, can scare the daylights out of most of us. We are obsessed with our bodies and our health and paranoid that a doctor might find something really wrong with us, that we may not come out of the hospital alive. Then, what happens if you are not even sure you can trust your doctor or the hospital?

Recent headlines give you very little comfort. You cannot grudge the prime minister the best possible medical care. So, no cribs if he chooses to seek second opinion on his knee in New York. Or when he calls in a renowned, US-based surgeon (even of Indian origin) to conduct his knee replacement surgery. He also sets the Apollo versus All India Institute of Medical Sciences (AIIMS) controversy at rest by preferring, instead, Breach Candy, a private hospital in Mumbai, where a whole ward is being emptied, fumigated, and sterilised.

No quibble with that as well. Except that it falls into a larger, worrying pattern that has firmed up over the past years but is highlighted by several, more recent, developments. Not only did Yashwant Sinha have his surgery abroad last month, former Prime Minister V.P. Singh has made it clear, though with an expression of regret, that he cannot go to AIIMS for dialysis because he tends to get infections there. Then he moved to Apollo and found that he had similar problems there as well until he began importing cleaner water for the dialyser from England. Now, Apollo has apparently cleaned up its water supply system. But where does the common man go? Even if he had some means or contacts, he couldn’t be sure of what he is getting into.

This is the crux of the Rangarajan Kumaramangalam story as well. The issues have, unfortunately, been obfuscated by the Apollo versus AIIMS controversy. See it from your point of view and mine. AIIMS is the finest, the most pampered, the best equipped and the most reputed government-run medical institution in the country. Apollo could claim a similar status in the new, growing world of private, corporate health care. If a senior member of the cabinet has been through both, for the same illness, and yet died in misery and pain, what might happen if you or I were to fall really, seriously, ill?

There must be some reason why India produces some of the world’s finest doctors, with the greatest of reputations internationally, and yet has a healthcare system which even its own topmost political leaders, bureaucrats, corporate czars do not trust. Dr Naresh Trehan has a favourite story from 1985 when he was planning to move back to India to set up the Escorts Heart Centre in Delhi. Rajiv Gandhi asked him, ‘‘Naresh, how is it that every doctor I meet in India says I am the greatest in my field, but my patient died because the nurses bungled, or something went wrong with the system etc, etc?’’ You could say that even today about most of our major hospitals.

AIIMS, for example, has some of the finest specialists anywhere in the world. Merely because of the overcrowding, they get experience their peers cannot dream of getting in almost any other country. But they are backed by a very poor nursing system, an administrative structure that is corrupt and unionised and never quite fetches up to the exacting standards of modern medicine. The AIIMS junior doctors go on strike more often than the air traffic controllers at our airports and some of the top-most specialists have left in disgust, unable to bring to book delinquent junior doctors because of union pressures and political interference. Nursing is so deficient that even in private wards you find freelancers handing out calling cards to work as paid, unofficial nurses. Sure enough, most of them are untrained and the hospital would, naturally, accept no responsibility for treatment under their care.

Most private hospitals, on the other hand, still do very little research or teaching. So the really brilliant, academically inclined, doctors are not inclined to work there. You have, therefore, this dangerous paradox where the best hospitals do not get the best doctors, the best doctors do not get the best nurses or even clean operation theatres.

The politicians were the first to figure this out. They were also the first ones to come to the conclusion that it was too complicated to change all that. In any case, why bother changing anything when your voters are so poor or helpless they’d be grateful if medical care of any kind were to be made available to them? As for them and their families, they, as public figures, have access to the best in the world. Their embassies will find the doctors and fix appointments and also feed their family members who accompany them. And the taxpayer would pay the bill. If we put our politicians to a simple test the findings might be revealing. How many of our MPs and ministers have had open heart surgery? And of these how many went abroad to get that done—probably at state expense—when India claims to have some really top class facilities in that field at AIIMS, Escorts, Apollo and elsewhere?

Politicians could argue that a similar set of statistics would hold true for top private sector executives and businessmen. But the differences are obvious and fundamental. Firstly, politicians use taxpayers’ money to create this very special medical insurance for themselves so they do not have to worry about how rotten healthcare may be within India. Second, they are the ones charged with building a healthcare system, not the corporates. If they, with state money, can perpetuate a system where they need have no stakes in the state of the Indian hospitals, you and I don’t have a hope in hell. One of the key lessons from the recent medical controversies, therefore, is that the state needs to be a lot more selective, and restrictive, in allowing reimbursement of expenses on foreign medical treatment. This needs to be adhered to very strictly in the case of politicians, maybe through a committee of Indian experts who could then approve the exceptional cases for treatment abroad where either super-specialisations or facilities are not available in India.

If we do not do that, there is no hope for healthcare in our country. Already, it is one of the worst even in the developing world. The World Health Organisation ranks us 112th in the world, a clear 24 places behind Bangladesh despite the fact that we spend more of our GDP on health (5.2 per cent compared to Bangladesh’s 4.9).

Or, maybe, it will go the way of our college education. In the past decade, with the liberalisation of foreign exchange norms, the number of politicians, businessmen and even bureaucrats sending their children abroad for college education has gone up in direct proportion to the fall in the quality and standards of Indian colleges. When the elites lose their stake in a system, it withers away. It has already happened to our higher education. In their own different ways, the sickness of Vajpayee, Kumaramangalam and V.P. Singh demonstrate how it is happening to our healthcare as well.

 

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