Wednesday, April 15, 2015

"Loot in the name of Cholera" published in

Loot in the name of Cholera: Sabareesh Gopala Pillai

This is a guest post by SABAREESH GOPALA PILLAI
The meaning of “health is wealth” is changing. Health — the lack of it in fact — is a gold mine today. India’s health industry is almost growing at twenty per cent year-on-year, and is estimated to reach probably about Rs 1.3 trillion by 2020. While many would attribute this to the increase in life expectancy, higher income levels, greater reach of health insurance and growing lifestyle-related diseases, the story is not so straight or simple.
Today, business opportunity lies in the creation of the demand, which in the case of healthcare, is the creation of ill-health. The health sector in the matrix of capitalism is quite unique in the sense that it is inherently vulnerable to the creation of demand by the very people who directly control the supply of the service. This vulnerability is evident in various dimensions.
Firstly, the measurement of the magnitude and intensity of demand — the diagnosis — is incomprehensible to most consumers and most importantly done by the same person who supplies the service. The service provider therefore, has overarching control over the service recipient. This can lead to extreme forms of fraud and exploitation that can even put the life of the service recipient at risk. For instance, the provision that families living below the poverty line could claim insurance up to Rs. 30,000 for treatment under the Rashtriya Swasthya Bima Yojana, a government-sponsored insurance scheme, was misused by private doctors to remove the uteruses of 16,765 women in eleven districts of Bihar and perform 1,800 hysterectomies were in Chhattisgarh.
Secondly and most importantly, healthcare is perhaps the only area where it is very easy to directly create a demand and sustain it perpetually. Health and ill-health are two states between which a reversible continuous reaction is always taking place. This may not happen in a related social infrastructure area like education. One cannot make a person illiterate after he attains a basic level of literacy. In healthcare, it would be in the natural interest of the service providers to maintain a perpetual state of ill-health in some form or the other. In fact, improving the general health and well-being of citizens especially at a preventive level can virtually lead to destruction of the health industry.
Furthermore, health is not a sector where the free will or choice of the consumer can spontaneously operate. In most cases, the requirement for service is urgent and taking well-thought decision after all relevant consultations is not practical. These factors, apart from the technical nature of the service, prevent the consumer from making an informed choice of service provider.
Measures to control the health industry have been countered with stiff resistance. The Indian Medical Association had been running a sustained campaign against the Clinical Establishment (Registration and Regulation) Act, 2010 passed by Parliament in August 2010 but is only in force in a few states. Medical associations are one of the most powerful pressure groups the world over in most societies and this is true in India as well. Emile Durkhiem, the French sociologist and philosopher, in his book “The Social Division of Labour” had shown even in the beginning of the 20th century how medical associations had restricted entry into the profession so as to control their supply and thus reap more profits.
The very placement of the health sector in the middle of a capitalist jungle has tampered with the fiduciary nature of the doctor-patient relationship and the only solution perhaps lies in uprooting the health sector from this capitalist jungle. That alone will make the transaction between the provider and the consumer non-commercial. The fear that diseases can even be created by the very people who are supposed to control them is neither new nor rare. Lynn Payer in her 1992 book Disease-Mongers: How Doctors, Drug Companies, and Insurers Are Making You Feel Sick elaborates that disease mongering is the practice of “trying to convince essentially well people that they are sick, or slightly sick people that they are very ill”. Ray Moynihan, Iona Heath, and David Henry have also called this strategy “the corporate construction of disease” in the British Medical Journal. In more extreme cases, it wouldn’t be a surprise if drug companies indulge even in the creation of diseases, which would bolster their commercial interests.
Doctors form just one of the links in a long chain of commercial vested interests from global pharmaceutical companies to local medical laboratories that loot the poor in do-or-die situations. The chain spreads into the non-medical sphere also, as illustrated by the proliferation of gold loan companies in and around medical colleges and hospitals in the state of Kerala, once regarded as a model state for public health. These companies (mostly non-banking financial companies) cash in on the patient’s urgent requirement of money and have a direct nexus with laboratories and other parts of the medical fraternity that recommend expensive tests. Since the queue in a government hospital would be too long and waiting would be risky, patients end up begging at the feet of these gold loan companies. Since everyone in Kerala keeps gold in some form or the other, it is the best resort in times of distress but the “blade” interest that is charged on it ultimately results in the gold being retained by the company. When they have enough and more of this hoarded gold, they start a jewellery shop or enter into an agreement with a jeweller. The jewellery sector ranks among the largest sources of advertisement revenue for the media in Kerala. This makes them a powerful pressure group capable of restricting damaging news and creating false needs that help in increasing their business interests. Prima facie, there is nothing illegal in this chain, which makes it even more dangerous
The counter argument against putting healthcare sector entirely in the social public sector would be that it may hinder innovation. But institutions like the All India Institute of Medical Sciences, which Peter Drucker described as the world’s best medical school, is a central government institution. In fact, doctors who graduate from Government medical colleges are considered to be far better than graduates from private medical colleges.
Kurt Vonnegut would have never thought of another interpretation of what he said some time ago, “We are healthy only to the extent that our ideas are humane”. The very idea to commercialise the health sector is inhumane and unjust. It literally violates the fundamental right to life enshrined in our Constitution since it deprives the citizen of access to affordable health facilities. It enlarges the gap between the rich and the poor, makes a particular section more privileged and others physically incapable, and has the potential to make an ordinary middle class person an undischarged insolvent in a single day. The intervention should be at the level of public policy that changes the very locus of the healthcare industry from the private sphere to the social platform and it would take real character and many a fight from the government to act against entrenched and powerful interests in this sector.

(Sabareesh Gopala Pillai is an Assistant Commissioner in the Indian Revenue Service currently posted at Ratnagiri, Maharashtra. Views expressed are purely personal)