Book review

This book openly tells the truth about how some doctors exploit their patients

Malpractices in corporate healthcare are documented with testimonies.

When you spend a lot of time in hospitals as a caregiver, you can go through many emotional phases simultaneously. In the past few years, dealing first with my grandmother’s medical condition and then with my mother’s, there have been days where I have felt like superman one minute – marvelling at my own energy reserves, patting myself on the back for having been in six different places at the same time and juggled small and big problems – and then, the very next moment, like an enfeebled old man, wanting to be free of all responsibilities, unconvinced that I’ll ever be able to get up from the chair I have just sunk into.

And then something new comes up and you’re smoothening your cape again and rushing to stop a wily doctor in the MRI room from repeating a procedure that had been done the previous day, while nurses and ward-boys giggle on the periphery of your super-vision.

One source of entertainment in these situations is to record stories (always through gritted teeth) about the goof-ups, which can make Catch-22 and M*A*S*H* seem like documentary realism in comparison: the miscommunications between teams of physicians, the exhaustion that comes with having to repeat all the details of your patient’s history to a new and oblivious doctor every couple of hours, the many little instances of apathy or insensitivity that can rise to depression-causing levels over a few days. I remember my dadi’s exasperated cackle when she was being sent home following a stint in Max Saket in late 2014: after five days in the hospital where a doctor would drop by once or twice a day, give a curt instruction and swish out in 30 seconds (having added Rs 900 to our already-sizable bill for each such “consultation”), she was discharged with a diagnosis of piles when, even in her groggy state, she knew it was no such thing; that her gastric problems were an effect of the blood-thinners she had been taking since her angioplasty. How she rolled her eyes and muttered as we put her on the stretcher for the ambulance. (Sure enough, after she spent a very uncomfortable month at home, we were back in the hospital explaining her case all over again to a new set of smiling doctors who made the correct diagnosis this time – not so much because of competence, I suspect, but because there were only so many available possibilities.)

The symptoms

With many such adventures having accrued over the years, the new book Dissenting Diagnosis: Voices of Conscience from the Medical Profession – co-written by doctors Arun Gadre and Abhay Shukla as an attempt to record some of the ugly truths about medical practice in India – contained much that was familiar, giving me the shudders as well as the jollies.

That malpractices in healthcare exist will come as no surprise to anyone who has dealt firsthand with the beast; the subject has also been covered in investigative journalism and in books such as Rana Dasgupta’s Capital: A Portrait of Twenty-First Century Delhi, one chapter of which has the author in conversation with three caregivers about dehumanisation in medicine. Dissenting Diagnosis, on the other hand, is an inside account, organised around the testimonies of 78 disillusioned doctors (nearly half of whom consented to have their names published) from across the country. It’s a well-organised book with predictable but to-the-point section heads such as “Diagnosing the Malady” and “Initiating the Cure”. You won’t read it for riveting prose or for a cleverly crafted narrative – many passages are simply made up of quotes by the participating doctors, placed next to each other, held together by some basic commentary, and some of this material is repetitive – but it has a raw, urgent directness that you might not find in a more polished work.

The initial chapters contain information about things that most educated people have an inkling of: the nexus between pharmaceutical companies and corporate hospitals; the pressure on doctors to prescribe as many costly investigations and tests as possible, to earn a pre-specified revenue for their hospitals; the lack of transparency and the emotional exploitation of patients’ families in situations where every second counts and composed reflection isn’t possible. Included here are many little stories that should startle anyone who still holds a worshipful view of the medical profession. The one about a speed-obsessed senior surgeon, for instance, who accidentally cut a major artery during a routine kidney operation, consequently had to remove the entire organ instead of just the stones – and later told the patient’s family that he had executed a heroic last-minute turnaround because the kidney was damaged beforehand. Or the one about a hospital that hid a deceased patient’s body to put pressure on the family since they hadn’t been able to pay the full bill.

There are also pointers to how advancements in technology and knowledge, welcome though they are, have had downsides, as all technology potentially does. The amount of material now available online – for patients and caregivers keen to do their own research – can be a double-edged sword (increased information about things like platelet counts, the authors say, can make people unduly alarmed about variations on test results, and thus vulnerable to avoidable prescriptions). The rise of pharmaceutical companies, which should be a good thing in principle, has resulted in excessive commercialisation, competition and questionable promotional measures such as taking doctors on sponsored overseas trips.

One minor problem with the book is that some of its observations are too abstract: vague-sounding statements about “cuts” or “commissions”, sentences that begin “A practitioner from a small town observes…” or “A big-city physician explains…” (The passages where doctors are named naturally feel more substantial.) At times, chatty stories pile up one atop another, and some of these can read like stray gossip which, even if true, adds little to our understanding of the big picture. I found it hard to swallow the idea that senior doctors mingling at parties would chortle about a new lamb being led to the slaughter – not because I think doctors are incapable of being malicious or greedy, but because in cases where individuals are mostly looking out for themselves and keeping their cards close to their chest, it is unlikely that dark plots would be discussed so openly or that they would mwa-ha-ha like 1970s Hindi-film villains.

Also, despite the candour running through the project, an attempt has clearly been made to avoid naming offending hospitals, individuals or corporates. There could be legal reasons for this, or it could simply be that the authors believe the problems are so deeply ingrained in the system that it would be gratuitous to single out specific individuals or companies. However, this might lead a suspicious reader to wonder if some of the book’s content reflects the disgruntlement of those who are on the outside of the corporate healthcare world, unable to get a share of the pie. (I am not one of those suspicious readers: I had no trouble believing in the authors’ sincerity or the honesty of their respondents. But again, this could be a result of my own medical experiences.)

The cure

While much of the book’s first half reads like a litany of everything that is wrong, the second section discusses possible remedies, including the potential for measures such as the impossibly idealistic-sounding Universal Health Care, aimed at ending the commodification of healthcare.

As the doctors themselves admit, there are many layers of problems and no easy answers. For example, it is undoubtedly true that some of the current ills of Indian medicine stem from the way in which a soft-socialist country made a (relatively) rapid leap towards privatisation post-1991, and how the upheavals involved affected both medical education and practice, especially in cities and big towns. The authors are probably right that some aspects of healthcare (such as the proliferation of donation-based private medical colleges that produce young doctors who then need to “recover” their “investment” by falling in with corporate pressures) have not been well-monitored, and that the promises of self-regulation made by doctors in private practice have proved less than reliable over the years.

However, it would be naïve to think that economic liberalisation abruptly opened a large Pandora’s box of misdemeanors 25 years ago – that would mean subscribing to a dewy-eyed vision of the past as a place where all doctors behaved like benevolent Gods and the state was the nicest big brother imaginable. It is more likely that a degree of rot in the profession has existed as long as men have been driven by self-interest. (While on the idea of the past as utopia, look at some of the less than scrupulous doctors and pharmacists in old Hindi cinema. Hrishikesh Mukherjee’s Musafir, made six decades ago, has this line, a version of which you might overhear in a private hospital in 2016: “Aaj kal toh milavat ka zamaana hai. Dava-daaru mein bhi milavat hoti hai.” “Everything is diluted these days – even medicine.”)

Which raises the question: is increased government interference in private healthcare – one of the proposals made in the book – an unambiguously good solution? Well-intentioned though the idea may be, it can set off alarm bells in even those of us who aren’t fans of unbridled capitalism: it would mean moving down a very slippery slope – and in any case, who can ensure that a state-regulated system would be free from corruptibility?

Given these difficulties, the solutions that I thought most persuasive weren’t the sweeping measures but the softer ones, such as the increase in and dedicated maintenance of doctor-consumer forums, and the spread of awareness through education and social action – and of course, through books like this one. Its closing passages provide many useful tips for concerned citizens, including lists of websites and information about organisations such as the policy-advocacy NGO SATHI, which the authors are associated with. A favourable prognosis may be a long time coming, but such initiatives should help make a dent in a hardened, often-impersonal system.

Read an excerpt from the book here.

Dissenting Diagnosis: Voices of Conscience from the Medical Profession, Dr Arun Gadre and Dr Abhay Shukla, Random House India.

We welcome your comments at
Sponsored Content BY 

How sustainable farming practices can secure India's food for the future

India is home to 15% of the world’s undernourished population.

Food security is a pressing problem in India and in the world. According to the Food and Agriculture Organization of the UN (FAO), it is estimated that over 190 million people go hungry every day in the country.

Evidence for India’s food challenge can be found in the fact that the yield per hectare of rice, one of India’s principal crops, is 2177 kgs per hectare, lagging behind countries such as China and Brazil that have yield rates of 4263 kgs/hectare and 3265 kgs/hectare respectively. The cereal yield per hectare in the country is also 2,981 kgs per hectare, lagging far behind countries such as China, Japan and the US.

The slow growth of agricultural production in India can be attributed to an inefficient rural transport system, lack of awareness about the treatment of crops, limited access to modern farming technology and the shrinking agricultural land due to urbanization. Add to that, an irregular monsoon and the fact that 63% of agricultural land is dependent on rainfall further increase the difficulties we face.

Despite these odds, there is huge potential for India to increase its agricultural productivity to meet the food requirements of its growing population.

The good news is that experience in India and other countries shows that the adoption of sustainable farming practices can increase both productivity and reduce ecological harm.

Sustainable agriculture techniques enable higher resource efficiency – they help produce greater agricultural output while using lesser land, water and energy, ensuring profitability for the farmer. These essentially include methods that, among other things, protect and enhance the crops and the soil, improve water absorption and use efficient seed treatments. While Indian farmers have traditionally followed these principles, new technology now makes them more effective.

For example, for soil enhancement, certified biodegradable mulch films are now available. A mulch film is a layer of protective material applied to soil to conserve moisture and fertility. Most mulch films used in agriculture today are made of polyethylene (PE), which has the unwanted overhead of disposal. It is a labour intensive and time-consuming process to remove the PE mulch film after usage. If not done, it affects soil quality and hence, crop yield. An independently certified biodegradable mulch film, on the other hand, is directly absorbed by the microorganisms in the soil. It conserves the soil properties, eliminates soil contamination, and saves the labor cost that comes with PE mulch films.

The other perpetual challenge for India’s farms is the availability of water. Many food crops like rice and sugarcane have a high-water requirement. In a country like India, where majority of the agricultural land is rain-fed, low rainfall years can wreak havoc for crops and cause a slew of other problems - a surge in crop prices and a reduction in access to essential food items. Again, Indian farmers have long experience in water conservation that can now be enhanced through technology.

Seeds can now be treated with enhancements that help them improve their root systems. This leads to more efficient water absorption.

In addition to soil and water management, the third big factor, better seed treatment, can also significantly improve crop health and boost productivity. These solutions include application of fungicides and insecticides that protect the seed from unwanted fungi and parasites that can damage crops or hinder growth, and increase productivity.

While sustainable agriculture through soil, water and seed management can increase crop yields, an efficient warehousing and distribution system is also necessary to ensure that the output reaches the consumers. According to a study by CIPHET, Indian government’s harvest-research body, up to 67 million tons of food get wasted every year — a quantity equivalent to that consumed by the entire state of Bihar in a year. Perishables, such as fruits and vegetables, end up rotting in store houses or during transportation due to pests, erratic weather and the lack of modern storage facilities. In fact, simply bringing down food wastage and increasing the efficiency in distribution alone can significantly help improve food security. Innovations such as special tarpaulins, that keep perishables cool during transit, and more efficient insulation solutions can reduce rotting and reduce energy usage in cold storage.

Thus, all three aspects — production, storage, and distribution — need to be optimized if India is to feed its ever-growing population.

One company working to drive increased sustainability down the entire agriculture value chain is BASF. For example, the company offers cutting edge seed treatments that protect crops from disease and provide plant health benefits such as enhanced vitality and better tolerance for stress and cold. In addition, BASF has developed a biodegradable mulch film from its ecovio® bioplastic that is certified compostable – meaning farmers can reap the benefits of better soil without risk of contamination or increased labor costs. These and more of the company’s innovations are helping farmers in India achieve higher and more sustainable yields.

Of course, products are only one part of the solution. The company also recognizes the importance of training farmers in sustainable farming practices and in the safe use of its products. To this end, BASF engaged in a widespread farmer outreach program called Samruddhi from 2007 to 2014. Their ‘Suraksha Hamesha’ (safety always) program reached over 23,000 farmers and 4,000 spray men across India in 2016 alone. In addition to training, the company also offers a ‘Sanrakshan® Kit’ to farmers that includes personal protection tools and equipment. All these efforts serve to spread awareness about the sustainable and responsible use of crop protection products – ensuring that farmers stay safe while producing good quality food.

Interested in learning more about BASF’s work in sustainable agriculture? See here.

This article was produced by the Scroll marketing team on behalf of BASF and not by the Scroll editorial team.