Opinion » Columns » Harsh Mander

Updated: January 25, 2014 17:47 IST

A sick crime

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Care in the public hospital may be cheaper than in the private sector — but it is no longer free. File photo: N. Bashkaran
Care in the public hospital may be cheaper than in the private sector — but it is no longer free. File photo: N. Bashkaran

In India, one’s economic status determines life and death.

During my childhood, many like me in the middle classes went to public hospitals when they were sick, and the services they offered were completely free. Today every Indian city is dotted with expensive super-speciality private hospitals, which closely resemble five-star hotels, complete with a turbaned, often elaborately moustachioed, bellboy who opens your car door. The quality of services in public hospitals has declined since people of influence no longer have any stake in their effective functioning, but even more gravely for the poor, care in the public hospital may be cheaper than in the private sector — but it is no longer free.

The average per hospitalisation costs in a public hospital is estimated to be as high as Rs. 3,000, and over 70 per cent of the charges are due to drugs and diagnostics that are prescribed but not supplied. Many pharmacies and laboratories have mushroomed around public hospitals and there is a nexus that encourages government doctors to prescribe more drugs and diagnostics for outside purchase rather than provide them free within the hospital.

I spent early years of my working life as a civil servant in remote rural and tribal districts of Chhattisgarh and Madhya Pradesh. I observed how often large numbers of tribal and other villagers in rural hinterlands would die in multitudes in localised epidemics of gastroenteritis or malaria which would be barely reported even in the state media. These areas were meagrely served with any kind of primary health services. The major concern of most of the scant public health staff that was deployed was to find ‘cases’ for family planning, preferably terminal methods. Child health was reduced to polio drops, not comprehensive health care, sanitation, nutrition and clean drinking water; and maternal health to contraceptives.

After returning to Delhi, over the last decade, I began working with urban homeless people and found to my initial surprise that the urban poor were almost as poorly served by primary public health services. The urban homeless find it nearly impossible to find admission in urban tertiary care hospitals, stigmatised as they are by public authorities as illegal, illegitimate, unsanitary burdens on the city and its infrastructure, including hospitals.

Most cities have virtually no public primary health care services, except a few maternity clinics again focussed mostly on family planning. The few that exist have virtually no allocations for drugs and diagnostics. In many cities, slum dwellers spoke of the disrespect with which they were treated by the health personnel: doctors will not even touch them for a physical examination because they find them unclean, and often taunt them for producing too many babies. Public doctors demand that they buy not just most drugs, but even consumables like plastic gloves, before they can be treated. They wait long hours in queues, mostly in the mornings; therefore visiting a public health clinic meant sacrificing a day’s wages. They therefore find it more economical to go to a private practitioner, often unqualified, who also charges them money but then treats them more respectfully. Sadly the treatment they offer is frequently irrational and inappropriate. Those who cannot afford the private practitioners’ fees go instead directly to the pharmacist and take whatever drugs he suggests. Others just lived with their ailments, enfeebled and ultimately die.

The last four years, my ageing parents — both in their eighties — were in very frail health, with many life-threatening conditions. My mother recently passed away. We were in and out of an array of expensive private hospitals, each of which was staggeringly expensive. But they were always crowded: there was clearly no shortage of people who could afford their astronomical fees. My mother had 24-hour-nursing at home for the last three years. I realised soberly that if we were less privileged — like the majority of Indians are — my parents would not have been alive. Should only one’s relative wealth determine the possibilities of continuing life?

The runaway costs of health emergencies can have catastrophic outcomes for families. Some years back, I saw a television report which continues to haunt me, of a man in Uttar Pradesh who unsuccessfully tried to drown his nine-year-old daughter in a river. His daughter was devastated and bewildered, because she knew her father to be a loving and responsible parent. The broken man explained that his daughter’s kidneys had given way, and for the past two years he had spent all his savings and sold all his belongings for her treatment. As a result, his other children were pauperised, struggling even for their basic needs like food. He felt he had no option, except to drown his beloved sick child.

In our work with homeless children, we sometimes find that parents abandon their children if they have grave health problems like cancer and heart disorders. We take them to public hospitals, and even there unless you have a large sum of money you cannot admit them.

To be poor in India is a crime. To be poor and also gravely ill is a crime deserving nothing less than the death penalty.

I completely agree with the writer.We can easily fill thousands of
pages with different medicare problems.I am an MBBS,DCH. studied in
govt.schools and worked in govt hospitals only.Not practiced. Received
award from CM.Got awards to my hospitals.I was witness to all the
fall. we can't deal problems in isolation.Health depends on mostly on
securing social determinants and medicare play least role.Medicare
accrues only ' Medicare dependant health' We can't improve medical
care with out improving medical education.As investments are flowing
in to medical education, patients are after all consumers.The
relationship is that of seller and buyer.According to noted economist
Paul Krugman,US can provide satisfactory medicare to all with 40% of
present expenditure if medicare is socialised. It is applicable to us
also.State is supreme. Any parallel system to state is dangerous to
state.Private sector got glory by destroying public sector.Destroy
private sector and bring glory to govt medicare.

Posted on: Jan 26, 2014 at 17:04 IST

I thank the author for bringing up the vital issue of healthcare in
India.Being poor or even as a lower middle class citizen in our country
will expose us to defunct medical infrastructure.People can safely rely
on their prayers to god for physical well being.The last lines of the
article sums up the fate of nearly half a billion life's.

Posted on: Jan 26, 2014 at 14:02 IST

The author's remark that to be poor in India is a crime is by all means
true. But at the same time, one feels,people must work hard to lead a
life with dignity.As Ruskin correctly put it Toil is the law. The
fatalistic attitude of the people must change as it is one of the root
causes of poverty.

from:  S.Ramakrishnasayee
Posted on: Jan 26, 2014 at 13:04 IST

Nice article depicting the sad state of our present Indian health care system provided to poor. I really appreciate Hindu for publishing this. Television Media does not have an inch of responsibility in highlighting these social issues. They are equivalent to those private hospitals whose aim is to make as much money and TRP rating. People are falsely influenced by these media which constantly show Bollywood parties and list of destinations they travel as they always tent in airports to click them. What a shame. Reason being is our rotten education system which does not allow us to THINK..Foundation should be laid from primary education concentrating on ETHICS, HONESTY, INTEGRITY, PRIVACY DURING EXAMINATION, TREATING PATIENTS AS FAMILY MEMBERS ETC. Do we know the meaning of these and the answer is unfortunately NO!!..Reality is this sad situation is going to continue for decades to come as even few honest people working in Govt hospitals are not allowed to perform their job.

from:  Ananth
Posted on: Jan 26, 2014 at 12:39 IST

The last two sentences - "to be poor in India is a crime. To be poor and
also gravely ill ......deserving nothing less than the death penalty".

A haunting reality beautifully expressed. To attempt to add anything is
superfluous. We need to feel ashamed that such is the state of affairs.
And our IAS/IPS officers have now been cleared to go abroad for
treatment at public expense!!

from:  R Sukumaran
Posted on: Jan 25, 2014 at 23:09 IST

I confer with Harsh's view. Surviving itself is a torture (worse than death) for the poor.
Yes, we (urban / educated) wish to have facilities and amenities at the cost of exchequer, failing to understand that there is a large segment of population is not being catered to by the government even for basic necessities. Charity is easy to preach and difficult to follow. Austerity - is the other side of the coin; How many well to do people understand this? Every penny saved can be used for some underpriviledged person in your neighbourhood. We have ourselves given away our human sensitivity becoming disconnected with the social responsibility, limiting ourselves to paying tax to a government which has failed to deliver to the poor. Development model based on consumption is used in such a distorted fashion that the gap between the have's and have-not's has only increased.

from:  sameer bahadur
Posted on: Jan 25, 2014 at 21:37 IST

This situation is appalling in a country where medical education is highly subsidized and we invite foreigners to get treated by our doctors! First abolish medical visas and second make it mandatory that MBBS and MDs need to spend at least 25% of their time treating poor patients for free. Make mandatory rural service a must for their degrees. Like RTE the government needs to come up with a RTH which mandates that all private hospitals need to set up and maintain clinics in rural areas and treat 25% of their patients free of cost based on letter from NGO.

from:  Sridhar
Posted on: Jan 25, 2014 at 19:01 IST
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