Problems in the health care system - a brief appraisal
Dr. V. Murlidhar

A friend joins the rat race
I saw a friend of mine, a consultant, earning a hundred rupees from a patient. He placed sixty rupees into the ever willing hands of the local general practitioner (G. P.) who had brought the patient to him with a diagnosis of ‘chronic appendicitis’. The G. P. instructed my friend to get a host of investigations from a specific pathologist and a radiologist who in turn gave their respective cuts to the G. P. All my friend’s medical learning was of no avail as he subjected the patient to a host of tests that were not needed and removed the healthy appendix of a person who actually had a mild attack of amoebic typhlitis. Twenty- six years of honesty, integrity and self respect were washed down the drain in just a day. He has joined the rat race to earn a living in the modern world.

Various unethical alliances
Nearly 80% of private health practice is based on this nexus of commission and cuts between the G. P. and the consultant. They go to any lengths to earn their bread, butter and jam. The alliance may be as part of the so called ‘Arab practice clique’ or the ‘kidney transplant mob’. Such doctors admit patients to their ‘I. C. C. U. s’ with a (mis) diagnosis of an infarct. They (mis) manage seriously ill patients till their condition is critical before sending them to a general hospital. They even have an understanding ith medical representatives who give cuts for prescribing specific drugs although they are spurious or banned (like ‘EP’ forte).

Healthcare - an industry
The health service of our country, like pharmaceutics, is an industry in itself. It is profit oriented. The state run health services are poorly equipped to deal with the illnesses of 900 million people. The government is not interested in providing better facilities because of the poor cost- to- benefit ratio.

After the arms industry, pharmaceutics is the most profitable industry in the world. There is a flood of spurious, banned and substandard drugs in the market. Most doctors support this industry by their dependency on it for favours (such as trips in and outside the country), funds (for bashes, ‘workshops’, ‘seminars’ and conferences in five- star hotels) and, worst of all, updating their own medical knowledge.

The dilemma of the honest doctor
Where does the honest doctor figure in the above maze of profit- oriented industries?

On the one hand is what we have learnt and understood as ethical and correct medical practice over the past two decades and more. On the other is the pull exerted by profit- oriented industry. Most of us do not have a capital to rely on, hence, tend to get tempted towards the latter.

We have to choose between rational medical practice and the rat race. The latter choice is irreversible. If we choose the former, we can set an example for others to follow and hope that the profit- oriented economy of drug and health services will meet its hour of crisis when patients say in unison ‘We shall not stand malpractices any longer’. Can we stand the test of time?

The doctor of the past was an independent healer. He examined, diagnosed, investigated and treated the patient under one roof. He can be compared to the artisans of medieval times.

In modern times large- scale capital- intensive diagnostic and therapeutic centres like the CT and MR scan units and the shock- wave lithotripsy units - have been set up by businessmen. For these centres the doctor is just a pawn in their endeavour to increase profit margins. The doctor, consciously or unconsciously, falls prey to industry.

Serving hospitals and clinics in the public sector
The option of working in state and municipal hospitals was very attractive once upon a time. The cream of the profession competed to gain attachment to them. They served with devotion and sincerity to bring themselves and their institutes enviable reputations.

Alas! These hospitals are falling upon hard times. The indifference of the government and other agencies in the public sector towards health in general has starved them of funds and equipment. The respect with which administrators and other doctors in these institutions were once treated has given way to the imposition of dictats and encouragement of servility. Ministers, legislators, secretaries in the various departments of government and other bureaucrats revel in making the staff members beg for what should be theirs by right Playing one against the other and using the weapon of transfer from one city to another, those wielding the political reins of power have plaved havoc with once respected institutions such as the Sir J. J. Group of Hospitals. Staff members are made to kowtow to their political masters. Loyalty to the institute has been replaced by homage to the powers- that- be. Is it any wonder that these institutions, once internationally renowned, are now in disgrace? Their place is being taken by the private hospitals that have commercial gain as their guiding principle. With a plentiful supply of funds and the ability to provide gold mines for those serving in them, they prove powerful magnets. Fine young doctors who would have otherwise graced the teaching hospitals and done full justice to patient care, teaching and research are now, instead following the pipes played by those in command in these five- star settings.

The diversion of the cream of the profession from the task of building and sustaining public institutions of merit to that of accumulating ever- increasing riches is destroying the public health system.

This is the reason India is burdened with an infant mortality rate of around 100/1000 live births, or blindness in 30,000 children every year for want of vitamin A and other such tragedies.

The cure? Is the disease too far advanced? Is it beyond cure‘? I disagree with the pessimists who shake their heads in sorrow. I strongly feel that there are many in the medical profession who remain true to their ideals, favour honest and sincere practice and consider the health and general well- being of their patients their chief aims.

Such individuals need to get together and develop into a force to reckon with. As the group swells and shows by deeds its resolve to fight malpractice, corruption and mismanagement, the situation must change for the better. Let us work towards this goal. The Forum for Medical Ethics is a step in the right direction.

I have noticed a tendency on the part of an occasional elderly and distinguished man to think that the rules of medical ethics were meant for young fellows just starting out, but not for him.

J. Chalmers Da Costa (1863- 1933) The Trials and Triumphs of the Surgeon, Ch. 1

Dr. Murlidharis a consultant surgeon at the L. T. M. G. Sion Hospital, Bombay.