Book: Dissenting Diagnosis
Author: Arun Gadre and Abhay Shukla
Publication: Random House India
Price: Rs 189
To those embedded in the medical profession, this incisive expose of the pernicious practices of private healthcare providers and the pathetic state of the public health care system will come as no surprise. What is a matter of some surprise is the candour with which several doctors themselves have commented on the ills of the medical profession in India, while identifying themselves in print. Even the non-medical reader who may have grown disillusioned with the way medicine is practised, through personal or shared experience, will find the revelations shocking beyond their worst suspicions.
Arun Gadre and Abhay Shukla, one a practising doctor and the other a doctor-turned-public-health activist, present a searing critique of various distortions that have converted medicine in to a cynically commercial activity. The first part of the book is based on interviews with 78 doctors, mostly private practitioners, and draws on their narratives to identify the several fault lines that lie across healthcare in India. The second part suggests correctives to curb professional misconduct and indicates the path forward for rescuing the health system that has gone astray. The fact that many ethical private doctors feel concerned enough to speak up indicates both the gravity of the situation as well the potential for the “dissenting diagnosis” in to radical cure.
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From the pained voices of doctors, who are disturbed and dismayed by the fallen standards of their chosen profession, we hear of the different types of malpractice: unnecessary tests and treatments; commissions and kickbacks on referral to diagnostic labs or other doctors; willingness to be corrupted by the pharmaceutical industry from which they eagerly receive many favours; deliberate misguiding of patients to extract more money and false claims of specialist medical qualifications or expertise.
The rise of corporate hospitals has also legitimised a commercial model of healthcare. However, the pressure exerted by hospital managers on doctors, to generate more revenue by whatever means, leads to their being compelled to practise unscientific medicine by performing needless but expensive procedures. Canons of medical ethics are cast aside, as blatant advertisements are used to entice patients with the promise of medical miracles being delivered with the aid of the latest gizmos. They also benefit from government largesse in the form of many concessions and subsidies, while drawing patients from government-funded insurance schemes, but flout their commitments to provide services to the poor.
The authors also describe how misguided social attitudes and patient behaviour are also altering the patterns of care for the worse. Patients often demand procedures like hysterectomy, caesarean section and pre-natal sex testing of the foetus. Misinformed patients, whose false beliefs have fed on flawed practices by unethical doctors, resist honest advice when tended by ethical and competent doctors. When even an exceptionally conscientious and public health-oriented paediatrician like Vandana Prasad confesses to prescribing more cough syrups under patient pressure, the reader cannot but despair.
However, hope does spring forth in the second part of the book. After the disconcerting diagnosis, the doctors offer a slew of potential remedies: stronger and more transparent social regulation of medical education and practice; strengthening public health services and promoting genuinely charitable hospitals; establishment of forums for doctor-patient dialogue and moving towards universal healthcare. Rights of a patient in a private hospital are detailed and guidelines are provided for identification of an ethical doctor who practices rational medicine.
A passionate plea is made for a system of universal healthcare which is based on public financing. A call is made for concerned citizens to join hands for demanding reform and setting up of citizen-doctor forums to catalyse change.
While the authors have performed a commendable job in drawing public attention to the sorry state of health care and suggesting remedial actions, the publisher could have made the book more readable by better editing. The initial narratives by the doctors are often repetitive. Even more tedious is the repeated formal introduction of each doctor whenever he or she is cited. When “a gynaecologist from Pune, Dr Pratibha Kulkarni” is so introduced repetitively in close sequence, on pages 65, 66 and 67 (apart from several other pages), it appears the reader has been subjected to a presumptive diagnosis of advanced amnesia.
The foreword, by former health secretary Keshav Desiraju, is worthy of mention by itself, for its succinct and sagacious summation of the book and the sharp comment on the state of India’s health system. As he recommends: “All doctors must read this book, and health policy makers, and all those interested in the future of public health in India.”