Vinoth Ramachandra

Further Reflections on Healthcare

Posted on: April 9, 2010

We are so grateful for the comments and numerous letters expressing concern over my wife’s medical condition. Karin’s surgery was successful and she is recovering well at home under my expert nursing care. The wonderful news is that she does not need chemotherapy. We seem to have caught the cancer early, before it spread into her lymph nodes.

The topic of healthcare elicited more comments on my Blog than any other, including war and terrorism. This is obviously a topic that affects all of us directly, and it seems that the healthier we are the more obsessed we are with health issues. This is why health-care provision is a bottomless pit and generates such fervent political passions. But, as I tried to point out in my last post, it is dangerous and misleading to separate healthcare from debates about education, income poverty and the mass media. Healthcare budgets, in both rich and poor nations, can be greatly reduced by a multi-pronged approach to health. Bans on public smoking, stricter pub licensing laws, ethical codes on food advertisements, anti-pollution campaigns, safer work environments, shorter working hours and less stressful work conditions, inducements to families and local communities to care for their elderly and mentally handicapped… all these measures can significantly reduce what governments have to spend on a public health service.

This is why I am not impressed either by the oft-heard complaint that public medicine is too costly or by the charge that the system creates many “free riders”. Every system is liable to abuse, and ultimately if the moral ethos of a culture is disposed towards chronic dishonesty and corruption, obviously no economic system can work. But accusations of abuse are curiously selective. The indignation of the rich at the abuses of the poor are wondrous to behold. Who complains about the continued existence of offshore tax havens and anonymous bank accounts, by which the super-rich use public facilities without paying for them? Who protests at the “creative accounting” of multinational companies that enables them to hide their profits while enjoying lavish tax benefits? Before 2008, who complained when  corporations were bailed out by public funds? There are plenty of other anomalies that never get into the media. In Britain, for instance, elite private schools such as Eton and Harrow are registered as public charities. Donations to such schools can be exempt from personal income tax. What this amounts to is the diversion of taxes to subsidize privileged, private schools. Why is there so little hue and cry over these abuses compared to the rage over “welfare cheats”?

My recent experience with Karin’s surgery confirmed what others have told me about private hospitals in poor countries like Sri Lanka. Apart from speed, comfort and relative cleanliness (because far less crowded) private hospitals do not generally offer a better quality of medical and nursing care than government hospitals. We were also shocked at the doctors’ fees which seem totally arbitrary. Given a relatively small pool of specialists and the fact that it is the relatively well-off who use private hospitals, private medicine is enormously lucrative for the few. Surely, private hospitals can become fairer and more transparent institutions if the law insisted that the Board of Management had to include all stakeholders, including patient representatives and nurses (who are paid a pittance compared to the doctors).

I agree with those comments on my last post which called for more middle-class people to use government hospitals and other public services as the best way of improving them. Medical students in countries like Sri Lanka are trained only in public hospitals where the vast majority of patients they meet are poor. Thus they rarely learn to talk with their patients and to respect the latter’s rights. Little wonder that patients and even nurses in poor countries regard medical students and their professors as demigods. If more of us middle-class folk would use these hospitals and talk to the students and professors as our equals (which they are), perhaps that would help to improve the training of doctors as well as the efficiency of public health services. Or is this being naive?

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12 Responses to "Further Reflections on Healthcare"

Comforting to read that K does not need any ray therapy?

Your position on the middle class (medical student) attitude towards the poor public is not a norm limited to SL alone.

The poor/immigrant/visible minority/ones without ”connection” often suffer the same treatment even in Ottawa- a champion on HR at global level. My son (11) was sent home 5 hrs after admitting when he was hit by a double -decker bus.

At home, at night when he vomited blood we discovered he had 3 move fractures when we rushed to the hospital I felt I was at the GH of Colombo. (honestly in Colombo one has the option of bribing or threatening as well)

So this is a structural issue to do with power and its distribution. The post 9/11 securitized conditions have given the governments an unlimited amount of powers leading to abysmal arrogance towards the demos which is gladly borrowed by the professional power bases
The question then is how can a Jesus following Christian be different? Not only as a point of power (if s/he) gain it, But also as a recipient of this power based treatment from their society?

A suffering servant (Mt 38-42) or a challenger? Lk. 3: (19-20)

And are these position exclusive and/or (inter)dependent? I suppose the struggle goes on?

Sure(n) Raghavan. not so ”sure” how the n got dropped :-)

Agree with you totally; it’s stimulating me to think…

India is the No. 1 destination for drug trials; trials on diseases majority of Indians do not suffer from. India has more malnourished children than sub-Saharan Africa while farmers grow crops to feed pets in the western countries. India spends % of GDP on health only more than that of Afghanistan and a few other countries, which is again hijacked by polio and other vertical programs. These health programs are driven by funding and available technology and not by the burden of disease. Health services is manned by doctors belonging to the upper castes (e.g. AIIMS doctors spearheading protests against the Reservation Bill) and middle upper class concentrated in the towns and cities while 70% of the Indians are in the rural areas. India has a booming Medical Tourism business while the collapsing health centres are the only available source of health care in the villages.
The choice seems to be either, ‘cheap, low quality public health care,’ or, ‘costly, high quality private health care’. I don’t think this is right. As you and Dr. Jamila have said and evidence shows, private health care isn’t found to be of superior quality. “Orthopaedics unit-I bed no. 1, a case of fracture left hip; bed no. 2 osteoporosis,” and so on goes the morning round. These patients have no names and the consultant doesn’t even look at their faces. This I experienced when I worked in a public hospital in Delhi.

When a doctor writes a prescription, where is the money going to come from for buying the medicines? How does road connectivity, primary education, NREGA, political insurgency etc interact with health status? These and other larger issues like bailing out corporations and military funding as you mentioned are most important.

My post is addressed to Sao Tunyi above… please dont bring Reservations Bill into this page. Prior to Reservation Bill,there were reservations upto 10% or 15%. There is already reservation given to SC/ST/OBC and other categories. When the Reservation Bill was implemented by Supreme Court, it gave 50% reservation to the above said category and 0.5 – 0.9% to other people ,so the General Category is left with just 49% seats.

People who perform badly in these tests are given a chance and those who do much better than them are kicked out! Its unfair to say that AIIMS had upper-caste doctors who opposed it but rather they wanted India to have its best doctors. One should not compromise on quality. Reservations are already implemented in many spheres.

@Manasi

There is 1 Indian doctor for every 1325 Americans in the US while in India, the doctor population ratio is 1:2400, in many areas exceeding 1:5000. Who are these 50,000+ Indian doctors who form 15% of the total doctor population in US while India is short of 6, 00,000 doctors? Study reveals that in AIIMS, doctors from upper castes are twice more likely to migrate than those coming from reserved categories. The result of this migration, BV Adkoli says is ‘disastrous’ to the health systems in India. Their studies are funded by public money, but they have no responsiblity to serve those who paid for their studies.
Who are these few people who are serving the people in smaller towns and villages? Where is your evidence that reservation has compromised the quality of health care services?
NDTV reports that in a medical college, doctors work together but eat by caste! Shantanu Dutta has rightly said that caste system is entrenched so stronly in the medical profession, and more difficult to eradicate than any other formal caste distinctions.
The large issue is decades of discrimination, e.g. primary education. How do one expect a tribal girl from Orrisa to compete with a DPS passed-out for an AIIMS seat?

Do you mean the General Category ? To put it briefly, what you are basically saying is that people without reservations ( not just Hindus! ) are more meritorious than the reserved category therefore are more likely to get a job abroad and fly off! Therefore, a certain section of people who are not meritorious and not anyone else who similarly lacks merit should study in AIIMS and other premier institutes , so they remain in India because they can not get a job abroad !

In general, both the general category and the reserved category lack commitment to their own nation. With the AIIMS tag , doctors usually work in urban areas and abroad ! How many of these AIIMS doctors do you find in towns and villages ? My childhood years were spent in a village and I studied in the nearby town in an English medium school. Our school bus picked students up from a few villages and the town. There were adjoining villages without even a dispensary! Till this day, I have not heard of any reserved category doctor in these needy places. So, they only make the best possible money they can make in urban areas without rendering their services in needy areas. That is not serving your country, excuse me!

There are missionary doctors in Ashakiran, Lamptaput which provides the best health-care facilities in undivided Koraput district. Koraput is considered as one of the three most backward regions in Orissa popularly called as KBK region. These days, most students from that school score over 80% marks in ICSE exams and approximately half of them score over 90%. At times, its 100% First Class with distinction.

There are tribal girls studying in English medium schools. Why should tribal girls be inferior to others ? If you speak of discrimination, forget it ! We shared our tiffins and enjoyed various kinds of Indian food during the tiffin-break. This is true of almost all schools in India. A particular case of one hospital can not be generalised.

There are also tribal girls in vernacular medium schools alongwith general category girls and boys. If you are burdened, then maybe you can start good English medium schools in the villages which will bring them of age and they can compete at par with others. AFAIK, there are programmes specially designed for rural children like Mathematics Olympiad and Camps specially for rural kids in my state.

Hence your argument fails to hold water to sustain 50% reservation for the reserved category at the cost of meritocracy!
However, you have addressed the commitment of Indians to serve their country which I appreciate and would like to see my countrymen challenged especially believers in Christ.

In the Christian community, there have been marriages between Christians. Caste is almost a bygone word!

From personal experience, I do know of some teachers ( including my school Principal) ,doctors , engineers, etc who have refused to conquer greener pastures and serve the needy in their country, Christians and Friends of other Faith alike !

I hope that Karin recovers soon.

I am sorry for the figures I provided

SC + ST + OBC + PH/VH = 50% reservation

This proposal was sent by Mandal Commission in 1980 and brought into effect in 2008.

A google search will show us the coping ability of reserved category students. The majority of people who do not do well in the courses provided by the premier institutes in India are from the reserved category.

**How one can actually benefit the Reserved Category and do away with reservations ?

1)Establish good schools which prepare the students for these premier institutes in needy areas or in areas with high concenteration of people in the reserved category.
Keep the school open for all. Hence most of the students benefitting are from the reserved category and there is healthy mixing.

2) Provide scholarships, books and financial assistance for the reserved category(excluding creamy layer) and also for those in the BPL category which is hard for any government to do cause it does not offer the easy way out for others and lesser vote banks. You can only rope in voters when what you do seems ‘big’ to their even though it is not actually big and detrimental to the progress of India like 50% reservations.

This way people can compete at par and one can do away with reservations. India and all Indians can actually progress…

@ Manasi
If Caste were almost a bygone word as you said, and the examples of the tribal girls and students in koraput excelling in studies through Christian mission schools were not simply pockets but the general condition in the country, I’d agree with what you say about reservation. 50% reservation is way too much.

But why does these popular notions still exist; that the lower caste kids are not interested in studies, even referred to as ‘inherently ineducable’, who at best can be sent to ‘harijan schools’ (meaning government schools)? Why are their names enrolled along with caste names? And why is this casteism not only prevalent among ‘ordinary’ people but also seen in discrimination by caste among educated, civilized people like Safdarjung Hospital and JNU professors, and in the example in a medical college I gave? And what about caste churches which still exist?

There was an article in ‘The Other Journal’ entitled ‘PRIVILEGE AS BLINDNESS’ which says the recent earthquake in Haiti seems to have woken up the Americans to the fact that a country called Haiti exist. Americans also seem to be bewildered as to why Haiti is so poor. Their ignorance of 2 centuries of deep connections between US and Haiti, and of America’s ruthlessly hostile and imperialistic attitude towards Haiti from the start; the author says; is strange. Moreover, the social location, the position of privilege have blinded the Americans to the fact that they not only participated and benefited from the oppression of Haitian people, but that they themselves are the oppressors.

I think that the blog writer’s(Vinoth Ramachandra) primary intention was to convey the state of healthcare in developing countries across the world.

We have sufficiently deviated the topic, it is not my wish to continue about reservations as comments on a blog dealing with healthcare and a problem particularly Indian.

You have the freedom to do one among the following : start another blog with a link to this page, add comments to any one of the two existing blogs or start some group on General Dicussions or something of the sort and create a forum topic on Reservations linking this page on UESI.in. I will reply back when I can.

@ Manasi

As you suggested, there’s a Delhi UESI blog site, which is continuing our discussion. The link is http://uesidelhi.blogspot.com/ . I’m going soon to a place where there’s no proper internet facility, but there are some people who also want to discuss the issue.

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