By M H Ahssan
Healing people is considered one of the noblest professions; doctors can do so much good to people without any cost to their own interests. But while competition goes to serve consumers as a rule, it does not always do so in this industry. That, together with the potential good it can do, has led to much government intervention in it in various countries, all the way to nationalization in some.
Competition has given India about the cheapest medicines in the world. The competition once served to evade the law. For like all industries, drug production was subject to industrial licensing. That led to the mushrooming of a few thousand small firms, all claiming to be below the ceiling beyond which licensing applied; competition amongst them kept cost of drugs down. It also led to rampant patent breaking. A long conflict between patent-breaking India and patent-devout industrial countries finally led to a compromise. But history has left us a questionable legacy. For one thing, it is impossible to know how genuine or effective drugs produced in India are. For another, collusion between doctors and drug companies can bias treatment.
Competition is strongest in the home of free enterprise, the US. Competition is supposed to minimize the cost to the consumer; but amongst Americans, the proportion of income spent on medical treatment is the highest in the world. And the results, as measured by longevity and healthiness of population, are unimpressive. Somehow, competition in the US has become a race to the bottom.
Why has it worked that way? A study by Atul Gawande, a surgeon, gives one answer. He went to the community which had the highest medical costs in the US — and by implication in the world — and tried to find out why. Surprisingly, the answer is not that medical stores or doctors there charge more than elsewhere; it is that doctors recommend more tests on patients than elsewhere. And the reason why they do so is that they get kickbacks from the firms or specialists who do those tests. This is similar to the collusion that can often be suspected between doctors and drug companies in India. A tour of pharmacists close to doctors’ practices will reveal that many doctors prescribe medicines produced by particular drug companies. Such biased prescribing could be due to kickbacks. But tests cost more than drugs, so American doctors overprescribe tests. It is the Indian ailment on an American scale.
It is not just tests that they overdo in America. They also refer patients more often to specialists, who are, of course, amongst the costlier of medical practitioners. Many of these referrals are unnecessary; specialists only confirm the referring doctors’ diagnoses. A physician is trained to diagnose all common elements and many uncommon ones. In their case, a referral does not add to what is known about the patient’s condition. Doctors would say that no diagnosis is a hundred per cent certain, and that referral reduces uncertainty. But it is one thing to reduce uncertainty from 50 per cent to 25 per cent, and another thing to reduce it from 2 per cent to 1 per cent. At one time, this obsession with certainty could have been attributed to Americans’ penchant for malpractice litigation. But most states have legislated it out of existence; today, the risk doctors run is negligible. But lucrative habits die hard; US doctors continue to make patients pay dearly for certainty.
But not all of America is dysfunctional. Medical costs per insured person vary by a factor of three to one between the worst and the best districts; how do some areas offer equally good service at much lower cost?
That question, too, does not have an economic answer; it all depends on the community of doctors. In the overmedicated communities, doctors get rich. The doctors who arrive want to belong, and to belong they too have to get rich. So they fall in line and overprescribe. No one has done a study of Indian doctors to my knowledge, but I suspect we will find the same thing. Doctors in rich cities like Delhi overprescribe and medical establishments overcharge; a village doctor charges much less.
Good and cheap medical treatment calls for dedicated communities of doctors. Doctors themselves must put together groups of specialists and resolve to serve their patients at affordable cost. They must use their informed judgment to make diagnoses, and spend no more on them than their trained common sense requires. They must aim to achieve comfortable lives, not to become Ambanis. They must want to be doctors, not businessmen.
And how can that be achieved? I must admit I do not know. Let me ask a doctor.
Quick Impact: I have received much response from the medical profession to my above article on doctors. One of the doctors said essentially that a corrupt society deserved corrupt doctors (he did not add, like himself) and that I, who belonged to the corrupt media, was unfit to call doctors names. Actually, I did not call them names. I was only reporting on what Atul Gawande had found when he travelled around the US and talked to doctors. I do not know about corruption in the media, but I have certainly not written anything favourable about anyone who was kind or generous to me. I guess Manmohan Singh was kind to me when he took me into the finance ministry; but I have repaid his kindness with criticism. I would like to think that it has been fair and objective, but I am sure the opposite view is supportable.
Let me go back to the state of healthcare in America. The Americans are themselves increasingly conscious of its poor state, and are investigating its reasons. One of the relentless investigators of medical fraud is Senator Charles Grassley. He has uncovered the enormous consulting fees pharmaceutical companies give to professors in prestigious medical schools. In America, drug companies are prohibited from trying out new drugs on human beings. So they pay doctors who hold dual positions as professors in universities and doctors in attached hospitals. In return, the professors try out the companies’ drugs on their own patients, and write scholarly articles claiming that the drugs are effective. Drugs have to jump a number of difficult hoops in America before they can be put in the market; apart from having to be ringfenced by patents, they have to be approved by Federal Drugs Administration.
The authority of well placed professors helps in this process. There is nothing wrong in the accumulation of knowledge by or through professors. What raises questions is what they are paid to publish. The payments are not always made directly to doctors. In one case, Glaxo-SmithKline gave a grant of $3.95 million to National Institute of Mental Health, which went to a research project whose principal investigator was Charles B. Nemeroff, professor of psychiatry in Emory University; he personally got $1.35 million for overheads (Marcia Angell’s piece in The New York Book Review of 15 January 2009 is full of such information).
The result is not simply that new drugs are coming on to the market based on investigations that are supposed to be objective but have in fact been bought. The cooperation of doctors and drug companies has led to the invention of new illnesses to fit expensive drugs. There is some ailment called bipolar disorder which I had never heard of. Now, apparently, children as young as of two years are being diagnosed of bipolar disorder and being treated with drugs whose side-effects are unknown and could extend over their lifetime.
While new ailments are being invented, old ones are being given new names. One disorder I know from past experience is acidity or hyperacidity; the common name for it is heartburn. The latest name for it in America is gastro-esophageal reflux disease. Another common, and even more dreaded, disorder is impotence; it is now called erectile dysfunction. And the billion Indians who suffer from shyness had better beware: they have got social anxiety disorder. Its treatment is a growth industry in the US.
These things are exposed in the US for a number of reasons. They have more honest and courageous legislators — not all, but some. They have less oppressive libel laws, and it is possible to write about people’s wrongdoings without going bankrupt. And they have public-spirited intellectuals. We do not; but it is not true that everyone in India is a corrupt scoundrel. I have come across many honest doctors; in fact, amongst the many medical institutions I have been to, only one was a racket.
So it is not on the basis of my experience, but of responses to my column, that I am inclined to think that there is malpractice in the Indian healthcare industry. I am not talking of doctors alone; the drug and test industries are intimately involved. But I am convinced that if ever this industry is to be reformed, it is doctors who will have to do it. They are a powerful force in our country; unlike in the US, politicians will never take them on. It is doctors who should look within themselves, and find solutions that would give patients treatment that the doctors would be proud of. Change, if it comes, will come from doctors’ professional pride.
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