Seven year old Aadhya spent the last two weeks of her life at a ‘state of the art’ private medical facility, her survival dependant on an artificial ventilator. Her brain had probably stopped functioning several days before she died, but we will never know for sure. While a young child suffered silently, for she had lost the ability to cry, Fortis hospital in Gurgaon – a corporate run Frankenstein – was busy planning how they could extract more from Aadhya’s frantic parents. After two weeks of extortion for charges booked on various heads by the hospital, Aadhya’s parents realised that they had lost their child and it was time to allow her to go peacefully. In the interim, the hospital had repeatedly put off a scan to determine if the child’s brain was still functioning. Aadhya’s parents requested the hospital to take her off the ventilator but the hospital refused and said that they could leave with the child after signing a form that they were ‘leaving against medical advice’. The family’s agony didn’t end there. The hospital refused to provide an ambulance and said that the ventilator would be removed in the ambulance (privately arranged by the family) outside the hospital premises. After the ventilator was removed the child died and had to be taken to another hospital to get a death certificate. While they were leaving the hospital after having cleared the full bill of over Rs15.79 lakhs, they were stopped and asked to pay for the hospital gown the child was wearing as the child couldn’t wear her own clothes because her entire body had bloated up.
The next shock came when they later perused the hospital bill. The bill included, among other items, charges for the use of 661 syringes and 1,546 pairs of gloves. On an average this works out to a claimed use of more than two syringes and five pairs of gloves every hour that the child was in hospital. An investigation by the government found that the hospital overcharged by 108 per cent profit for medicines used and by 1737 per cent for other consumables. It may be noted that no medical facility is legally allowed to charge more than the maximum retail price of a medicine. By charging double for medicines used, the hospital had added over 3 lakhs to the hospital bill.
Within two weeks after the Fortis case another horror story was reported, this time from Max hospital in Shalimar Bagh, Delhi. Parents of twins born prematurely at Max hospital Shalimar Bagh reported that the hospital declared both the twins dead when one of them still had signs of life. The parents were taking the twins for last rites when they discovered that one of them was still alive. The baby was taken to a local nursing home and died a few days later. Any small chance that the baby had of survival was snuffed out after suffering the ordeal of being wrapped in plastic and being exposed to Delhi’s cruel winter.
Fortis and Max: Industry Leaders in the Private Healthcare Sector
Fortis Hospital in Gurgaon is part of Fortis Healthcare Limited. The company’s website claims it “operates its healthcare delivery services in India, Dubai, Mauritius and Sri Lanka with 45 healthcare facilities (including projects under development), approximately 10,000 potential beds and 314 diagnostic centres”. The company is promoted by the former owners of Ranbaxy, once the largest pharmaceutical company in India. After divesting its assets in Ranbaxy the family invested in setting up Fortis Healthcare Ltd. Brothers Malvinder Singh and Shivender Singh who now own the company, inherited it from Parvinder Singh, CEO and major shareholder of Ranbaxy Pharmaceuticals. They are also, currently, the major investors in Religare Enterprises Limited (REL) which, on its website, claims to be a “holding company for one of India’s leading diversified financial services groups. REL offers an integrated suite of financial services through its underlying subsidiaries and operating entities, including loans to SMEs, Affordable Housing Finance, Health Insurance and Capital Markets”. It is surely not a coincidence that we see here the confluence of pharmaceuticals, tertiary healthcare and health insurance – the three key sectors that are in the business of generating super profits from India’s growing healthcare market.
Max hospital too can claims impressive credentials. Max Healthcare Institute is a wholly owned subsidiary company of Max India Limited. Its corporate website claims that they are “one of India’s leading providers of comprehensive, seamless and integrated world class healthcare services. With a network of 14 hospitals” and further that they “offer treatment across all 29 specialties… (and)… have 2300+ leading doctors with international level expertise who are committed to provide highest standards of medical excellence at a fraction of international costs”. Analjit Singh, founder and chairman emeritus of Max India Limited, is chairman of Max Life Insurance Company Limited, Max Healthcare Institute Limited and Max Bupa Health Insurance Company Limited. Note here again the confluence of the tertiary hospital sector and the health insurance sector.
Not Isolated Incidents
The two reported incidents are clearly not isolated cases. They represent the true face of corporatised hospital based care in India. They are examples of medical malpractice, criminal negligence (at least in the case of Max) and extreme overcharging for procedures and consumables (in the case of Fortis). Such incidents happen every hour, every day, round the year, in corporate run hospital chains across the country. Almost all of them go unreported. They are a manifestation of a two decade old trend, ever since corporate groups, hungry for new avenues of profit making, muscled into the growing tertiary healthcare market in India. Gone are the days when most private hospitals were run by genuine philanthropies or groups of doctors. Most doctors in today’s corporate hospitals are mere pawns, forced to act at the bidding of the corporate controlled management. There are several reports which suggest that doctors are set targets that need to be fulfilled – read targets for performing unnecessary procedures, diagnostic tests and use of consumables such as high cost medicines. It is a system that is corrupt to its very roots and currently almost entirely out of the purview of effective regulatory mechanisms.
People are the most vulnerable when they or a close relative is sick and corporate hospitals see this as an opportunity to squeeze out the last drop possible from grieving relatives. Like any other business their sole aim is to maximise profits. Industry estimates indicate that the healthcare industry in India is expected to become a $238.76 billion industry by 2020. When the system allows corporate hospitals extreme avenues for extraction of super profits they do so with impunity. As Marx once wrote “Capital eschews no profit, or very small profit, just as Nature was formerly said to abhor a vacuum. With adequate profit, capital is very bold. A certain 10 per cent will ensure its employment anywhere; 20 per cent certain will produce eagerness; 50 per cent, positive audacity; 100 per cent will make it ready to trample on all human laws; 300 per cent, and there is not a crime at which it will scruple, nor a risk it will not run, even to the chance of its owner being hanged”.
Who is to blame?
Responding to public outrage, the governments of Haryana and Delhi have slapped serious charges against the hospitals concerned. The National Pharmaceutical Pricing Authority (NPPA) has also sent a notice to Fortis for overcharging for medicines. All these steps are necessary, but none of them address the core issues. Why have we allowed these Frankensteins to develop and flourish? For Frankensteins they are, monsters that make a mockery of the Hippocratic oath, whose first principle is “primum non nocere” (first do no harm). Any system that survives on the motivation for generation of more profits must do wrong in order to survive.
The Indian healthcare system suffers from decades of negligence. Public health expenditure has languished at around 1 per cent of GDP for decades – 1/5th of the global average and what the WHO recommends as the minimum. Public healthcare and public hospitals are in shambles – the child deaths in Gorakhpur hospital are testimony to their pathetic state. They have been converted into caricatures of what public healthcare should be by decades of neglect. Today it is convenient to term public care as inefficient and ineffective. It need not be so. All examples of successes in healthcare relate to well resourced public systems – Cuba, Costa Rica, Thailand, Sri Lanka, UK, France and so on. Yet the neoliberal logic provides our governments with a tubular vision where they seek virtues in the private sector, when there are none. Every few months, both central and state governments announce grandiose plans of ‘partnerships’ with the private sector that would magically rescue India’s healthcare system. The Niti Ayog, a few months back, had unveiled a grand plan to outsource district hospitals run by the government to the private sector. The Delhi government, a couple of months back, had unveiled a grand scheme that was designed to seamlessly allow patients to be referred from government hospitals to private facilities. A moot question is why is there never a planned attempt to build, sustain and strengthen the public system?
Confronted with a failed public system people, even when they sell assets and sink into lifelong penury, flock to the private sector. For years we have only talked about regulation of the private healthcare industry. In 2010 the Indian parliament adopted the ‘Clinical Establishment Act’. The Act, designed to regulate medical facilities, needed to be adopted by states as health in India is a state subject. Seven long years later no state in the country has a functioning Act. The original Act was deliberately shorn of teeth when it was enacted and did not include caps on treatment costs. It was, however, a beginning and states had the opportunity to provide teeth to the Act. It never happened. Sporadic attempts to do so, as in West Bengal and Karnataka in recent months, have been met with stiff resistance from the lobby representing the corporate sponsored medical establishment. The latter represent a minority of doctors in India but is the most visible face.
Humans have a natural tendency to rally behind their own kind, and this is clearly true of the medical profession today. Confronted with multiple horror stories, they remain in sullen denial. The profession needs to wake up to the fact that most of them have become victims of a corrupt and rotten system. Aadhya in Fortis and the newborn in Max would probably not have survived in the best of ethical facilities. Aadhya was suffering from complications of dengue which carries a very high risk. The newborn in Max was born only after 22 weeks of pregnancy, and possibilities of survival were remote. But surely they deserved a more dignified and painless exit from this world. Doctors agitated by a perceived threat to their profession, remember –
primum non nocere. If you can’t do good, do no harm.