Monday, 3 October 2011

Sufi Doctors and Nehru’s Ailing Centre of Excellence: by Kaveri Gill

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AIIMS is like my aging mother, whose clothes are in tatters, and I feel I must hold them together to cover and protect her”. A senior anaesthetist said this the evening before I was due to have a relatively small but complex surgery, and my search for the best surgeon had bought me to the institute's doorstep. Fifty five years after Nehru's dream of a medical centre of excellence materialised, with state of the art teaching, world class research and high quality patient care, the All India Institute of Medical Sciences in Delhi is mostly in the news for all the wrong reasons: fracas over reservation, cheating on entrance exams and charges of mismanagement.

And yet, conduct a quick informal survey amongst your social set (even those with endless willingness to pay) and you will find that most choose the hospital because it has the best doctors in the country, and the world. When you have a population of a billion to serve, with diseases that span all development phases, there is not much you have not seen and treated, more than once, under intense pressure. Of those who frequent private hospitals, many will disclose that the top specialist doctor they consulted has either trained or worked in the past at AIIMS. Clearly, the doctors are delivering despite the institution!

To an economist, health care is a commodity unlike others. One reason is that information asymmetry between patient and the doctor is heavily skewed. My own brush with auto-immune illness in the last three years has demonstrated the truth of this in the way that no amount of abstract theorising could ever have done. I learned that it is a very bad idea to self-interpret diagnostic results (for 'antibody counts' and 'positive serology' mean nothing without clinical symptoms), and to Google one's supposed condition (envisioning dire 'Three Men in a Boat' psychosomatic scenarios). As a social science doctor, I realized that a layperson's 'elementary, my dear Watson' deductions in the medical sphere were likely to be just that -rudimentary but also wrong. And I came to have a profound respect for doctors 'specialist training and knowledge' in India, five and a half years for an MBBS; another three for a MD or MS (equivalent in surgery); and yet another three years for a super-specialisation.

The other principal agent problem, of moral hazard and greedy private hospitals gaming the system for profit by ordering unnecessary laboratory and diagnostic tests, added considerably to the cost and fatigue of my unexpected illness. Such peculiarities of the health sector posit that even where the state is not directly the biggest provider of health care, it ought to play a large role in regulation of the sector. I leave the reader with the scary thought that if an educated patient with considerable agency had such an experience, imagine the plight of a poor and illiterate patient thrown at the mercy of an unregulated private sector.

The need for a surgery became apparent because doctors at AIIMS refused to accept the results of prior tests carried out elsewhere. A simple x-ray, carried out in a dilapidated and crowded but functional lab, immediately showed what had been missed by previous consultations, which meant I’d had high doses of unnecessary allopathic medicines for more than a year. My next task was to find a suitable surgeon. I turned to a surgeon who is a giant in a different field, and who in a patriotic and public-spirited act that was not unheard of at the time as it is today, returned from the best Ivy League schools and associated hospitals in the UK and US to India in the mid-70s, to work at AIIMS for over two decades. In the most scientific and yet empathetic manner possible (narrowed to number of surgeries performed by the doctor, type of surgery that my condition dictated, and estimated probability of risk in procedure versus benefit in prognosis), he helped me decide on an ex-student of his, someone who pursued his passion for staying abreast with cutting edge technological developments in his area by going abroad for further training, and is consequently now is the only surgeon in the country to conduct the newest robotic procedure. By now, it did not surprise me to find this surgeon works at AIIMS.

I met with him to set a date, only half-joking that my one request was not to be left alone with the robot. He was highly amused, and assured me that it isn’t an android. Instead, it refers to the use of console-operated ‘arms’, ‘wrists’ and a tiny camera, with an overhead LCD monitor, which allows magnification of the site with minimal invasion and no tremor. What in the old days would be an open surgery, involving scarring and a lengthy recovery time, are now three little punctures that disappear without a trace, and me writing this piece a few weeks after the operation. The machine is expensive, and hence shared, with it available only once a week. Patients from across Asia flock to this surgeon, who accommodated me as soon as possible after the repair and renovations of the OTs allowed.

My thoughts turned to the dismal findings of the latest report of the Parliamentary Standing Committee on Health and Family Welfare (2010), expressing “anguish” at the “procedural hassles” (a euphemism for botched up management, delayed approvals, suspect contractors and corruption) delaying “urgent developmental work” (including construction, OT/ICU/private ward refurbishment and purchase of high-end equipment) at AIIMS. Of 21 such projects envisaged for the 11th Plan, 14 are yet to start in its last year, and it’s not for a lack of money as unspent allocations are significant. No wonder I saw seriously ill patients, especially from the poorer strata of society, lying in the sweltering heat on campus pavements. It’s hard to take up cudgels with God on one’s own behalf in India, even with just cause, for the thought is quickly chased by evidence of how relatively lucky people from our class are in every situation.

The operation itself, without some drugs that were costlier, set me back Rs. 5000. Apart from the fact that this skill and procedure is not available at private hospitals in the capital and hence the question is moot, it would cost about Rs. 3 lakh if it were. To those who would argue that it is only privileged patients who get treated at AIIMS, it is a cynical misconception. My anaesthetist asked if she could keep the unopened remains of an expensive drug for a patient who might not be able to afford it, and my surgeon is waiting to operate on patients who are too underweight to withstand a surgery and cannot afford the diet to gain pounds. No doubt, those with our network links have speedier access to over-worked AIIMS doctors, but at least prohibitive cost does not keep out poorer patients, as it does at many top-quality private hospitals that are not empanelled for Rashtriya Swasthya Bima Yojana. Bravo for the Planning Commission’s expert health panel, which is currently resisting the government’s idea to impose user charges in public hospitals.

As the Committee observes, “pathetic working conditions” are cited by prominent doctors leaving the hospital as a major factor in the “acute shortage of manpower in recent times” at AIIMS. They withstand the lure of a 2 to 3 times larger salary (even post the 6th Pay Commission) offered by private competitors, only to succumb to the relief of working in more ordered, less rushed and better surroundings. Who can blame them, for even Sufi doctors who have spent years perfecting their art and patients (pun intended) have their limits, especially where dispiriting institutional failures prevent them from doing their job. A 2008 WHO Bulletin publication found that approximately half of AIIMS graduates during 1989-2000 reside outside India, and that graduates from premier institutions (within that exalted subset, the better doctors), account for a disproportionately large share of emigrating physicians.

The solution to this flight and brain drain is hardly to get them to sign bonds, as the Committee recommends, on the basis that the self-selected brightest in the country have received subsidised education. Rather, it is to boost retention by promising merit-based promotion, improving working conditions, as well as offering better housing and non-remunerative benefits. The other pressing need is to fix the pathetic supply side of doctors, fuelled by the dismal state of medical education in the country under the dysfunctional Medical Council of India (MCI), where places in state schools are far too few; a post-graduate seat in a private school costs approximately 1.7-2 crores, resulting in a perverse incentive to recoup this money by joining a highly-paid private hospital and gaming innocent patients after; and where private colleges of shoddy quality continue to flourish, despite shocking Tehelka exposes.

Sudhir Anand has recently analysed census data for the Planning Commission, to find that not only do we have less than half the doctors per head than China does, but half the so-called doctors do not have any medical degree. Are we relying on elite graduates of above mentioned money-spinners, some of which are fake institutions, to pick up the slack? It appears so. In 2003, the Pradhan Mantri Swasthya Suraksha Yojana valiantly promised to set up 6 “AIIMS-like institutions” across regions so as to reduce structural inequities in the availability of tertiary health care. In 2010, the Committee notes it will take “at least another Plan period” before these institutions are functional and they remain “a distant dream”.

Nehru realised his dream, while today’s India struggles to do so, despite two decades of sustained high growth. What galls my generation, which grew up in the age of pre-liberalisation restraint, is that we still see individuals who are as idealistic as ever. They may be a dying breed but they exist. I was humbled by my experience at AIIMS, for the highly-sophisticated in training but simple in demeanour Sufi doctors I met there embody old-fashioned qualities of a serious work ethic and service to society, honesty and putting others’ welfare before one’s own. For that is what it takes to survive working on the 8th Floor OT, with its spectacular views of Delhi but its adrenaline-pumping pressure, week in and week out for years. And yet the system consistently lets them down. I wonder, in a decade or two, will AIIMS even be what it is today? And something quite different to my operation wound hurts, for the death of a dream in a country I love.

(Kaveri Gill worked on public health at the Planning Commission, 2008-09.)

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