DISSENTING DIAGNOSIS
Arun Gadre and Abhay Shukla
Vintage Books
187 pages; Rs 399
At a time when dissent has come to connote disloyalty, even treason, instead of being understood as an opposing viewpoint necessary for evolution, two doctors introspect on the maladies afflicting their profession in a brave new book, Dissenting Diagnosis. The focus of the book is an elemental question: how has a critical, service-oriented profession been transformed into a market-driven commodity and a corporate-led profiteering industry? Why is the logic of rational and ethical medical practice being swept over by the imperative of profit? When asked from within the normally close-mouthed medical community, these questions have taken on a chilling significance not simply for the medical profession but for every member of society who is most vulnerable when s/he needs a doctor.
Authors Arun Gadre and Abhay Shukla have based this book on a set of 78 interviews with leading doctors across the country conducted at Support for Advocacy and Training to Health Initiatives, a Pune-based non-governmental organisation. Each interview lays bare the maladies that afflict India's healthcare system - "mall-like" corporate hospitals for whom profits come before patients; Big Pharma that subverts doctors and drives medical fads like the current one for Vitamin D supplements; private medical colleges that provide sketchy medical education to all who can afford their massive fees and most of all, doctors who have eschewed the Hippocratic oath in favour of personal gain. Given that the respondents in the study (most with about 30 years of practice) are located in Maharashtra, Chattisgarh, Karnataka, Tamil Nadu and Delhi, it is safe to say that this decline in ethical standards in private medical practice is a reality across the country.
Everyone who has lived in India for any length of time would have observed, if not experienced, some of the symptoms of this malaise. Doctors in corporate hospitals suggest unnecessary surgeries (hysterectomies being the most common) and tests. Caesarian section deliveries are on the rise, as busy obstetricians have little time to wait out a long labour. Others simply put patients under anesthesia, make an incision and stitch it up, passing it off as major surgery. General health checkups have become the norm, wherein perfectly healthy individuals go through a battery of unnecessary tests and are invariably prescribed drugs and supplements they probably don't need.
Doctors themselves, Gadre and Shukla aver, have noticed a gradual but steady erosion of their own skills as they have become excessively reliant on lucrative medical tests and investigations. What a good GP could diagnose simply by examining the patient and his medical history, can now be achieved only after endoscopies, ultrasounds, CT scans and more.
One of the most serious maladies that grips the Indian medical system is the widespread system of cuts and commissions given to doctors by pharmaceutical companies, pathology labs and other enterprises who profit from medical emergencies. A Kolkata-based GP states that doctors routinely get as much as a 50 per cent commission from pathology labs. Pharmaceutical companies host medical seminars in exotic locales, which are mere excuses to indulge doctors with lavish holidays. In smaller towns, the authors note, even autorickshaw drivers get a commission when they drive a patient to a private hospital. Another significant contributor to the public health mess is health insurance. The book is full of anecdotes about patients being over-treated simply because their insurance cover allows it. And thanks to the Rashtriya Swasthya Bima Yojana, even patients under the poverty line and in the unorganised sector are feeling its ill-effects.
All in all, the anecdotes and testimonies present a scary picture. After a while, however, this reviewer found herself craving the unlikely solace of statistics to restore some objectivity to this analysis. It is true that elective surgeries are on the rise, but equally, life expectancy in India has gone up by five years for men and women in the last decade thanks to advancements in medical technologies. The problem with an over-reliance on anecdotal data is the lack of balance - exactly what the authors seek to restore to their profession.
Another flaw in this otherwise brave analysis is the poor editing. Many of the individual testimonies say pretty much the same sort of things about the rising corruption in private medicine, so the book becomes repetitive. The authors are also prone to the rather distracting use of ellipses where commas or full stops would have sufficed. Here's a sample: "only those who engage in politicking...want to inflate their own sense of importance...only such people enter the professional organisations, and power is their only motive."
The doctors/activists have prescribed some thought-provoking treatments for the medical system. Ban commissions to doctors and regulate commercially-driven private medical colleges. Make generic drugs freely available and cheap. Ensure that Medical Council is socially responsive and ethical. Regulate the private sector and introduce standard treatment for all, subsidised by the government on the lines of UK's National Health Service.
None of these changes are going to happen in a hurry, as they will entail a significant increase in government investment in healthcare and medical education. In the short term, the authors have thoughtfully written a chapter on how to figure out if one's own doctor is ethical or simply profit-driven. Either way, one thing is for sure. Dissent had never been this disturbing.
