Bridgital Nation

by N Chandrasekaran

  Dr Das arrived in his operating coat, jeans, and a cap. A native of Silchar, Dr Das could speak at great length about airflow control in operating theatres, post-operative wound dressings, and the preventive use of antibiotics. Some of his ideas put him at odds with accepted practice of larger hospitals, but also put him on the same plane as his patients, whose needs and constraints he put above almost every other concern.

  ‘Giving a prescription is very easy,’ he said. ‘But when our patients do not have even one square meal a day, how can they follow the course of medicine post-treatment?’ He said the hospital treated nearly fifteen thousand patients on a budget of about two and a half crore rupees every year ($350,000, or less than $1,000 per day)—a remarkably small sum. There was no place for excess of any kind. He led us to a room where the beds were set right beside each other. Nurses squeezed between them to reach patients. ‘People say that you shouldn’t have a cramped room, and that there should be more space,’ Dr Das said. ‘But it actually helps us because one nurse can see and can take care of so many more patients at the same time.’

  Now the director and head surgeon at Kalyani Hospital, Dr Das joined its staff over three decades ago, in 1987. He left a successful private practice in the United States, turned away from the lucrative opportunities available in India’s big city hospitals, and followed his heart to his hometown, the ‘green and Bengali-speaking’ Silchar, he said. Decades here had made him a veteran of medical life on the frontline, where an absence of resources made the simplest procedures challenging. His patients travelled hundreds of kilometres for basic surgeries: Gall bladder stones, kidney stones, an appendectomy.

  There was no respite. Even after hours, when the outpatient department was closed and he was at home, sipping on lemon tea and reading the day’s news, patients approached him for an after-hours consultation. He was seventy-seven, and had deep reserves of energy. His tireless service earned him a nickname from locals: They called him bhagwan, God.

  As we spoke, he guided us to a room next door. People lay on operating tables. The room was the size of a handful of cubicles, and contained three beds with three patients undergoing surgery that moment. Doctors’ elbows touched as they made incisions on different patients. One nurse bumped into another while she changed an intravenous line. Dr Das didn’t have enough time to sit and talk, so he kept chatting while he performed a lumpectomy.

  Dr Das was proud of the operation theatre staff he had trained. They were efficient, and made do with very little. But recruiting and retaining a quality medical team was a problem, he said. There were staff shortages every day. The choice, for many of them, was between a comfortable life and a fulfilling one. Twelve of the hospital’s sixteen doctors were over sixty. Young doctors tended to have other priorities.

  Many of the support staff did not have a degree. Only three nurses had formal degrees in general nursing and midwifery. Physicians did not have assistants. The head administrator’s position was honorary, and currently occupied by a retired bank official. Dr Das seemed to spend as much time on paperwork and raising funds as he did on surgeries. To a visitor, many of his daily duties were not among a senior surgeon’s core responsibilities. He, and the other staff, needed to be everywhere because there simply weren’t enough people.

  Every day, the younger staff offered advice on how Kalyani could upgrade its operations. Dr Das found the suggestions unhelpful. ‘Any improvement that makes this hospital feel inaccessible to the poor defeats our purpose,’ he told them. Before our visit, he was deciding whether to purchase an oxygen machine or a CT scanner. The hospital needed both, but could only afford one or the other.

  Corporate hospitals and private nursing homes tended to have the best equipment and facilities; the government-run medical colleges provided free or highly subsidized care, but very few were able to maintain consistently high standards. A hospital like Kalyani bridged the two ends: Better care at prices dictated by the patients’ ability to pay.

  On the wall of the main outpatient department, the hospital displayed a rate chart with fees that were at least half those charged in other facilities. The rates had been revised in 2015, but none of that mattered to patients. Prices old or new, everything was only the start of a long negotiation that usually ended in free treatment. Dr Das estimated that almost half of his patients couldn’t afford the official rate, and about five per cent paid nothing at all. That was why, even though Tripura had government medical colleges, its people crossed state borders to seek treatment in Silchar. They knew that good doctors and a benevolent hospital awaited them.

  All of this came at a cost patients did not see: The hospital was running at a loss.

  Everything required money. There was never enough money. Yes, there were philanthropic gestures, but there was no telling what form donations could take. One time, a large oil exploration company decided it would be socially responsible by donating a thousand metal pipes to Kalyani hospital, which happened to be close to its facility in Assam, rather than shipping the pipes hundreds of kilometres to the nearest large city for auction. For months, the thousand metal pipes lay behind the hospital while Dr Das wondered what to do with the generous donation. One day, perhaps out of desperation, or out of exasperation, or even out of his instinct to stretch every possible resource, Dr Das used them as a barrier against landslides, and to shield plastic water pipes from the monkeys who swung on them.

  Dr Das and the hospital’s ageing committee members worried about the future. They were enterprising, and relied on jugaad—temporary measures widely celebrated as Indian resourcefulness—more often than they liked, but knew that philanthropy and scavenging could not keep the hospital running. It was unsustainable.

  ‘I imagine Kalyani will become like any other nursing home or hospital—more mercenary than missionary,’ Dr Das said. ‘We’ll have to charge a lot to the patients, earn a lot, and spend a lot on doctors.’ The thought upset him. ‘I would hate to see our mission change, even if we really are running in the red. Our aim is and always has been to give cheap but good care to those who need it.’

  He threw up his hands. ‘To do anything less would be a sad fate for a place like this. What would happen to our patients?’

  7

  The Big Disease

  Cachar Cancer Hospital was on the north-western edge of Silchar, about 10 kilometres away from Kalyani Hospital, but the journey was slow and halting. Signs of prosperity and progress stood along the road: Innumerable building sites, trucks carrying construction material, and traffic squeezing into every gap to be found.

  Inside the cancer hospital, the head physician flipped through a patient’s medical file. With salt-and-pepper hair cropped short and razor-straight posture, he had the air of a military general. His manner with patients, though, was gentle and calming. He was speaking with an elderly lady, who had been advised to undergo surgery, but was frightened by the prospect of an operation. He spoke softly. ‘This is a big decision, and it is important that you take the time to think it over. Go home, take some rest, and you will do what’s right.’

  As he stepped outside, patients swarmed around him immediately. Walking the length of the hall took at least twenty minutes. Two members of the hospital staff chased after him, waving an equipment purchase form that needed multiple signatures, and also to let him know about a package for delivery. A number of patients made emotional appeals to him to personally perform their surgeries. A woman, nearly bald from chemotherapy, said, ‘Will my son also get cancer? Everyone tells me he will. He is only ten years old.’

  ‘No, he won’t,’ the doctor said patiently, amid the chaos. ‘There’s no truth to that. Cancer can happen to anyone, but just because you have cancer doesn’t mean he will too.’

  ‘Oh, thank you. Even if he doesn’t eat properly? He refuses to eat meat. Will he be okay?’

  The doctor laughed. ‘Neither do I! He will be just fine.’

  On the other side of the hospital, three young women waited anxiousl
y near the outpatient department. They were dressed in Khasi attire: a bright blouse and skirt, a chequered shawl knotted at the shoulder and draped across their bodies. They formed a protective circle around Lariti Nongrum’s four-year-old son Headingson, trying to shield him from the light drizzle. Nestled in a sheet slung across her back, Headingson burrowed closer to his mother. Lariti named him Headingson because he was her firstborn. She imagined that he would one day head a tribe of his brothers and sisters.

  They had travelled over three hours and some 70 kilometres from their village, Byndihati, in Meghalaya. The village was remote. There was no power, and water was difficult to find. When it rained, Lariti left open plastic containers outside. The family of five ate whatever grew on the trees nearby. The previous year, they had earned no more than ₹60,000 ($860) by selling the harvest from the betel nut trees outside their home.

  A month before their visit, Headingson was walking home from school when he stumbled and fell. By the time he reached home, his upper right leg was painfully swollen, but there was no visible cut or scrape on his skin. His family applied herbal oils to the afflicted area, to ease the swelling and make the pain go away.

  A week ago, Headingson could manage a shaky walk. Now, he groaned every time his foot touched the ground. Headingson could not bear the pain any more. His leg was disfigured. Lariti decided it was time for more definitive medical action.

  A nurse saw the X-ray of Headingson’s leg and scheduled an appointment with a surgical oncologist. For two hours they waited silently outside his room. Then the oncologist called them in, assessed Headingson’s thigh, and told them it was a tumour. He ordered an MRI and tests to assess the size and progress of the tumour. This was vital. It was possible to cure bone tumours that had not spread if the conditions were favourable.

  In shock, the family turned to leave as quickly as possible. They paid for the consultation without a word.

  The family discussed their doubts about the diagnosis. They did not trust the doctor. How could someone so tiny have ‘the big disease’? Was the hospital just trying to make money off their fears? To compound matters, they had already spent a meaningful portion of their annual earnings on this trip. They decided to head home and get another opinion later, preferably at a hospital in Shillong with Khasi staff.

  Their mistake became all too clear when Headingson’s illness worsened back home. Only then, all too late, the family decided that he would undergo proper treatment at any cost. Once more they undertook the long journey to Shillong, and did tests that cost them a full year’s income. The new tests showed them that the wait had proved fatal. The cancer had spread. A Khasi doctor asked Lariti why they hadn’t come sooner. But to Lariti, the doctors and hospitals had been alien, and she hadn’t believed them when they said that Headingson had cancer.

  One day, six months after Headingson had died, Lariti finally stepped out of her home. She walked down an uneven path carefully, between the betel trees, until she came to the river near their house, one that separated India and Bangladesh. The water gurgled as it rushed past her, birds cried around her, and the household’s voices were behind her, but the sound she heard most clearly was silence.

  8

  Out of Reach

  How did India get here? How did it end up with a patchwork healthcare system where patients believe that opting out of life-saving treatment is in their best interest?

  We believe this is a story about good intentions that went awry, at whose heart lies a brutally simple explanation: An endemic shortage of medical personnel.

  In 1946, the Health Survey and Development Committee made a crucial decision to give Indians access to high-quality healthcare by turning the district public health system into a three-tier model (primary, secondary and district-level), with each level staffed by trained medical officers. 1

  The Committee, also known as the Bhore Committee, was set up in 1943 to devise a single national standard for the healthcare sector—a necessity, since healthcare in pre-Independence India was fragmented and uneven, regulated by provincial governments, each in their own areas. At the time, there were about 47,000 registered practitioners of allopathic medicine. A little over a third of them were university graduates, who had been through a five-and-a-half-year course in a medical college—the equivalent of a graduate doctor today. Two-thirds were licentiates—lesser qualified practitioners who went through shorter three- or four-year courses in medical schools. It was these licentiates who, besides practitioners of traditional systems of medicine, delivered much of rural healthcare. 2

  The Committee was concerned about the quality and completeness of training licentiates had received, and of their ability to deliver effective care. ‘Having regard to the limited resources available for the training of doctors,’ it recommended that the country direct all efforts to the production of ‘basic doctors’, with the minimum acceptable training of five-and-a-half years. 3 Only these most highly qualified doctors would be allowed to treat patients. In one swoop, they set aside the entire range of licentiates and indigenous ‘semi-doctors’, who were the only kind of health providers close enough and inexpensive enough to meet the needs and means of most Indians.

  This meant that while India was given excellent medical standards, there were never enough doctors to practise those standards.

  Fast forward to today. Official figures based on the set of doctors registered with the Medical Council of India (MCI) show India having just over a million doctors. This means there are about 8 doctors for every 10,000 residents, a ratio similar to that in South Africa, Vietnam and Thailand. 4 The MCI’s registry, however, includes doctors registered to practise in India since 1961. A more realistic ratio would be closer to 5 doctors per 10,000 population, estimated from a 2017 study in the Indian Journal of Public Health that adjusted the registry figures to account for doctors who had emigrated, left the profession or died. In contrast, China has a doctor-to-population ratio three times this adjusted figure. 5

  These are all indicators, but the disparity they reflect is real. It will take approximately 600,000 more doctors and nearly 2.5 million more nurses for India to reach the minimum population coverage levels recommended by the World Health Organisation. This means nearly doubling the number of its current practising doctors if the country hopes to provide a basic level of care. 6

  At the level of specializations, the pinch is even more acute. A 2014 study in The Lancet found that India had approximately 2,000 surgical oncologists and radiologists. India needs double that number, if not more, given the number of new cancer cases emerging every year. The situation looks even worse in fields that have typically received less attention, such as mental health, where there may be only a few trained professionals for millions of citizens. 7

  What’s worse: Almost 65 per cent of the country’s medical practitioners—doctors, dentists, physiotherapists, nurses, health assistants and registered practitioners of traditional systems—are based in urban India. 8 Meanwhile, about 67 per cent of the country lives in areas considered rural. If you’re in Delhi or Mumbai, there’s no shortage of doctors. If you’re outside the big towns and cities, finding solid medical advice is an ordeal.

  This chasm between where authorized medical practitioners are, and where patients live, is at the heart of the access predicament in Indian healthcare. The fact is that India’s healthcare system demands a great migration from those it would heal, across geographies, across financial compulsions, across language barriers, and across deep-rooted belief systems—a migration that few have the resources to undertake.

  9

  Imbalances

  It has been clear for some time to those who use India’s healthcare system: It does not work. Primary health centres and sub-centres are at the frontlines of the public health system, and they exist in a constant state of shortage and disrepair. In theory, each primary health centre is supposed to serve a population of 25,000. In practice, though, some of the nearly 26,000 centres serve triple that numb
er. 1

  Across the country, nearly one in three primary health centres lacks a labour room. A similar number have fewer than the four hospital beds mandated for each centre. Only a fifth of all primary health centres have two doctors, the very minimum required number. Many states report shortfalls in required medication and, in one survey, almost half of all doctors and healthcare staff were missing from their posts on any given day. 2

  With nowhere to turn, and unsure of doctors at primary health centres, patients seek out their own solutions to problems. They ask for a second opinion in their community, or turn to a local traditional healer for help.

  They are entirely rational in doing so.

  In 2014, for a study led by researchers at the World Bank, actors were trained to visit healthcare facilities and complain about symptoms that corresponded with common illnesses that people in the area suffered from. 3 The actors were dispatched to public health centres (with a formally qualified doctor), private clinics run by unqualified practitioners, and private clinics run by qualified doctors. The fake patients were trained to assess the quality of care they received on various parameters, including the time each doctor spent with them, whether the doctor asked them relevant questions, the provision and accuracy of the diagnosis (given the symptoms the ‘patients’ reported), and whether the treatment prescribed was correct.

  The study found that there was no difference in the quality of care between a government-run public health centre and an unqualified doctor. The quality of care only improved if patients met qualified doctors outside public health centres, such as at their private practice. Even then, patients felt better cared for by unqualified doctors, who asked them more questions, than by qualified public-sector doctors, who tended to rush through the consultation. This may explain why unqualified medical practitioners account for the larger share of rural primary care visits. 4