Modern Medical practice & Malpractice

The city as patient

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The strike earlier this week by medical students from the Vardhman Mahavir Medical College attached to the Safdarjung Hospital may have seemed like an isolated flare-up. But it was actually symptomatic of what ails hospital administration throughout Delhi. The newly constructed VM Medical College including a Rs 33 crore hostel had been handed over to the “authorities” many months ago. The infrastructure and utilities remained dysfunctional, even as the medical superintendent of Safdarjung Hospital, the director of the college and its principal all asserted it was the other’s job to fix the shortcomings.

An absence of coordination caused more by infighting than lack of funds has plagued city hospitals for decades. The Central government runs four multi-speciality hospitals, exclusive of the All India Institute of Medical Sciences which is a conglomerate of six super-speciality centres within itself. The Delhi government runs 38 hospitals and the municipal corporation another 10, not to mention the hospitals of the ESI and the NDMC. Each hospital is headed by a specialist doctor who, besides coordinating the functioning of individual departments, is responsible for procurement and provisioning of equipment, consumables and drugs. Willy-nilly the repair of non-functioning equipment, absenteeism and hospital security, sanitation and containment of indiscipline, are a part of his duties, supported by more doctors who should instead be ministering to the “aam mareez”. Says Dr Veena Choudhury, director of G.B. Pant hospital, “The real trouble is that daily housekeeping takes most of our time.”

Power groups and coteries operate within and across most medical departments. If the hospital head wants to retain his leadership and authority, the only way is by remaining close to the centre of power that selected him in the first place. This means the directorate general of health services in the Central government, the Delhi government’s health department and their myriad political and administrative masters in the municipal corporation. Given the extent of lobbying and mischief-making that permeates the system, if the medical superintendent does not buy heavy insurance against troublemakers, he is sunk. Seeking constant protection from the fount of authority becomes a necessity, not an option.

Against this depressing background, the ordinary patient, whether from within or outside the city, is unable to distinguish between Central, state and municipal hospitals. Patients spend long hours in registration queues and then sit outside packed OPDs to gain momentary access to an overworked specialist. They opt for expensive private diagnostic and laboratory services even when government facilities are available free or at subsidised rates. In the absence of any networking or give-and-take between big and small hospitals, several facilities remain underutilised; individual hospitals cannot enter into arrangements with sister hospitals — except AIIMS which regularly offloads its overload to Safdarjung Hospital.

Some years ago there was a proposal to set up a Public Health Commissioner for all hospitals in Delhi to coordinate networking between tertiary, secondary and smaller hospitals, regardless of parentage. Supported with real-time computerised access to the availability of beds, specialists and functional diagnostic equipment, hospital and department wise, the commissioner was to coordinate between all government hospitals to derive maximum advantage from the gigantic facilities available throughout the city. He would be competent to divert patients to unused facilities and empty beds thereby rationalising their use. Most importantly, poor patients needing critical care could be dispatched by ambulance to a string of private hospitals that, having agreed in writing, have refused to honour their commitments towards the poor.

The commissioner would have reported to a board on which the DGHS, the Delhi government and the Municipal Corporation of Delhi would all be represented, so that each funding body had a stake in the efficient operation of the system. On the lines of Delhi University, which prepares panels of teachers, architects and contractors from which individual colleges make their selection, the commissioner could provide pre-selected lists to individual hospitals for procurement; even engage pre-selected hospital administrators to enable doctors to concentrate on healthcare.

Such a systemic change would have three advantages. First, it would obviate the need for heads of hospitals to look for constant protection, by building a buffer between the medical superintendent and medical bureaucracies. Second, it would bring economies of scale and efficient utilisation of medical services. Finally, as Dr Mahesh Misra, chief of AIIMS’s trauma centre has put it, “computerised networking of all hospitals throughout the city is essential to optimally utilise the total bed resource for needy patients and reward high performance.”

But such a system will work only if there is a willingness to devolve authority on an independent organisation accountable for efficient hospital management. The moot question is whether this aspiration can ever surmount the eagerness to wield patronage and protect one’s turf — concerns which unfortunately seem to matter more.

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Physicians, heal thyselves

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The promulgation of the ordinance sending all office bearers of the MCI home has not come a day too soon. But some urgent concerns need to be addressed even as a bill is readied for Parliament’s monsoon session.

Public confidence has been temporarily bolstered by positioning seven medical professionals of calibre and proven integrity to run MCI’s affairs. The new governing body meets today; but precisely because its chairman represents the acme of liver and biliary science, another member is a top-ranking cardiologist, and a third the full-time dean of a private medical college (in Sikkim), there is a lurking fear that both patient care and critical decision-making may falter as these medical giants scramble to grasp additional responsibilities.

The foremost priority for the seven-member governing body is tackling the council’s contending priorities, some statutory, some time-bound — approving new colleges in the pipeline, recommending additional seats and new courses, inspecting the infrastructure of medical colleges, approving modifications to the curriculum, to name just a few. They are dependent on their secretariat, which has long owed allegiance to MCI’s departed office-bearers, raising doubts about where the loyalties of the former may lie. Whether this seven-member combination can perform the monumental Flexnor type clean-up that purged the medical system of the US and Canada in 1910 is yet to be seen.

Having said that, admittedly the governing body’s role is small compared to the impending challenges that lie ahead. The elimination of the old office-bearers is now history. But the MCI Act remains alive; and only its remodeling will decide the track medical education now follows. Health is a state subject under the Constitution and medical education is on the concurrent list. The bulk of the MCI’s members are elected from the medical faculties of state universities and from among practitioners. Another 40 representatives are nominated both by the states and the Centre, several of whom are products of “intense manipulation” says Dr Chaperwal, a former vice-president of the MCI who recently, reportedly, spoke of the Medical Council’s “loot” in a complaint to the prime minister. “The stakes are too high to prevent a repetition of the past,” he says. “We need an independent regulator because even in the future, elections and nominations can be stage-managed.” In the UK, the General Medical Council (GMC) is answerable to the Council for Healthcare Regulatory Excellence which oversees and can even overturn the GMC’s decisions. The proposed National Council for Human Resources and Health can hopefully play that role.

The second important aspect which needs to be addressed by the bill is whether lay people should be inducted on the Council. The Lancet, recently discussing “Trouble at the Medical Council of India” referred to the regulatory systems in the West where medical councils include non-doctors. The MCI has none; the UK Council has half its members from the lay public. “It is time to include non-doctors who can speak for patients’ concerns without creating a forum for activism and doctor-bashing” says Dr S. Dagaonker, member of the senate of Maharashtra’s University of Health Sciences.

The third important addition the bill needs to introduce: make the protection and maintenance of public health and safety the aim of the legislation, by emphasising the observance of proper standards in the practice, not just the teaching of medicine. The Medical Council Act 1956, unlike GMC, does not make this a direct responsibility. The new bill should specifically provide for this, around which cases of medical malpractice and negligence should be built. The law should also bind the council to declare professional standards it sets out for doctors, and the principles that underpin fitness to stay on the medical register. These are mandatory in other countries. It’s time the law enjoined MCI to follow suit.

Fourthly there is the issue of medical curriculum. The erstwhile Medical Council followed a caste system in which public health concerns normally elicited scorn from the overwhelming majority of specialists that saturated the Council’s bodies. Giving primacy to the containment of preventable communicable diseases is a fundamental tenet of the country’s health policy and, in the next MCI, should not be permitted to be dismissed.

Recently an opportunity has emerged to reach out to millions of Indians who live at an insurmountable distance from a health facility, by using mobile phones and remote-controlled diagnostics. We need to introduce a medical specialisation based on such technological solutions. That alone can bridge the disparities that confront more than half the districts. MCI will parry all such ideas unless the law provides for compliance.

Until now concern for profitable health care has driven medical education. Contemporary thinking and a few harsh decisions can inject equal concern for quality patient care into the Council’s ethos.

Needed, helping hands

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Instead of creating a sub-caste of rural doctors that will willy-nilly opt for the allurement of urban medical practice sooner than later and abandon the rural populace, the licentiate system of creating a cadre of non-doctors authorised to conduct limited professional practice must be revived
The Medical Council of India has recently decided to address the glaring shortage of doctors in rural India. As early as 1996 the Central Council for Health and Family Welfare, had unanimously decided to make rural medical service compulsory for new doctors. For 14 long years every Health Minister has repeated this aspiration, only to have the idea trounced by MCI as ‘unfeasible’. The council has consistently argued that doctors cannot function in the absence of “proper infrastructure”. Hence the recent decision of MCI to confront the shortage of rural medical manpower by creating a new stream of doctors drawn from rural areas, for rural areas comes as a surprise.

According to reports, these doctors would undergo a four-year course as against the five-and-half-a-year degree course prescribed for MBBS graduates. District hospitals would be used for medical training and the entrance eligibility of candidates would hinge upon continuous residence in a rural area. This way MCI hopes to catch 12th pass science students from rural secondary schools and convert them into ‘basic doctors’ and keep them rooted there. Is this fair? Is there an option?

There are 6,00,000 villages in the country, tens of thousands of which are located at a distance of more than 10 km from a Primary Health Centre and devoid of traversable roads. The amalgamation of GIS maps and census data portrayed on the website of the National Population Stabilisation Fund shows how PHC’s established in more than 300 districts out of 620 districts remain clustered in privileged talukas, even as interminable lists of villages with populations running into hundreds of thousands remain without reachable medical cover. In the foreseeable future it is unlikely that new PHCs would get established to cover the gigantic gaps that exist in the spatial distribution of rural health facilities, particularly in the Hindi belt states. It is even more improbable that new doctors moulded from the rural hinterland would agree to cater to such remote areas for long before the lure of urban practice entices them.

President of MCI Dr Ketan Desai is sanguine that “such doctors would not be interested in learning about kidney transplants and angioplasties and would instead concentrate on local diseases and basic health problems of villages.” The inequity of sculpting a second class set of doctors only for rural areas does not seem to have struck the council. As to how overworked, poorly staffed, undeveloped district hospitals that cater to thousands of patients and exist as such in more than half the districts of the country can become training ground for doctors remains doubtful. Training imparted in this milieu can hardly convey the essentials of anatomy, pathology, microbiology and pharmacology which are essential to secure grounding in medicine.

It would have been far more practical to have revived the idea of licentiates a system that was very much in practice in India, before it was abhorred by Sir Joseph Bhore in 1946, who despite strong dissension from several Indian members of his committee abolished the scheme forever. The Western medicine doctors that came into being then became the only source of medical care.

The revival of the licentiate system — preparing a cadre of non-doctors authorised to conduct limited professional practice — was recommended by the National Health Policy 2002 and later by a Task Force on Medical Education in 2007. Nurse practitioners, and medical assistants handle patients in rural areas in Canada, parts of the US and the UK even today. Policymakers in India have not considered this alternative seriously because they are influenced hugely by what the MCI and the Indian Medical Association think and want. The licentiate idea is an anathema to the MCI and the IMA, because both the bodies are strongly political and the only way to maintain and expand the constituency of voting doctors is to keep medical practice confined to doctors. Witness the brouhaha created each time there is a move to involve even the five-and-a-half-year degree holders of Indian medicine.

The way the health infrastructure is clustered in more than half the districts in India, the needs of people living there would continue to be disregarded if a workable alternative is not found. Were licentiates to be re-introduced, they would be akin to diploma holders on the engineering side. They would be eminently suited to give the first line of medical advice, provide basic treatment and to make referrals. They would have no claim to be called doctors but would function as a strong bridge, particularly if the advantages of telemedicine and mobile phones are used imaginatively. Looking at the scale of deprivation that exists in rural areas, there is an urgent need to establish a separate council to regulate the education and practice of such licentiates.

Before Joseph Bhore, two thirds of the practitioners in India were licentiates. We need to reconstruct that bridge instead of creating a sub-caste of rural doctors that will willy-nilly opt for the allurement of urban medical practice sooner than later, leaving the rural populace where they are.

Is this the tipping point?

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Trading in medical education has to stop. The arrest of the Medical Council of India president on charges of bribery could just be the tipping point to precipitate long overdue change. Merging the best from two existing Bills may be a starting point to bring about this change

The murky deals involving the president of the Medical Council of India might look like piffle compared to the IPL imbroglio. But despite being an insignificant side show, the MCI scam is far more worrisome because the MCI is responsible for administering and enforcing standards of medical education for the entire country. So if the president of such an organisation is embroiled in a bribery and extortion racket involving a medical college, it questions the degree to which standards are at all being met by other colleges. The quality of the products of such a wayward system will ultimately impact upon individual health and safety. The absence of a trustworthy oversight body is a matter for grave concern.

On paper the MCI is a truly representative body with the bulk of its members elected from the medical faculty of every State and every university. Added to this long list of nearly 100 elected council members, there are another 40 representatives nominated either by the State Governments or by the Union Government. If one cannot trust such a democratically established body set up by an Act of Parliament, who then can we trust?

First a little history. For decades after it was set up, the MCI performed a limited role — to register medical practitioners and to lay down standards for a handful of medical colleges, mostly in the Government sector. Up to 1992 the requirements for setting up of medical college were simple. The MCI was an elite body that invariably advocated against setting up more medical colleges. Some Chief Ministers, notably Janardhan Reddy of Andhra Pradesh cocked-a-snook at such prescriptions and permitted new medical colleges to start in his State. This incensed then Prime Minister PV Narasimha Rao so much that he had an Ordinance issued; overnight the Union Government assumed authority to permit new medical colleges to be established, to open a new courses of study or to increase the intake of students. But — and this is extremely important — only by acting on the recommendation of the Medical Council of India.

The Ordinance became law but nothing was done to alter the structure of the council to fulfill its new responsibilities. In 1999 new regulations were notified which set out all the requirements that a medical college needed to fulfill to come into being, to diversify its courses and increase intake. These requirements call for the injection of an extraordinary amount of resources (Rs 500 crore) while constantly running the risk of rejection at inception or midstream. Only the rich and powerful dare try.

There are now 300 colleges in the country with an annual intake (all levels) of more than 50,000 students. More than half are in the private sector. The latest annual report on the council’s website, shows that in two years about 180 letters of intent were issued but an equal number failed to secure MCI’s recommendation. The council recommended 30 new colleges but more than half that number was turned down. While the continuance of recognition was recommended in four cases, five times that number was recommended for rejection. Detractors say that unrealistic conditions have been prescribed, leaving the ground clear for quid pro quos and barter.

Supporters of the MCI say that the council runs through independent committees whose deliberations are transparent and available for scrutiny; and the president does not direct the show. Critics say that MCI’s committees are run by cartels carved from grateful elected representatives who do as they are told. MCI’s inspectors are briefed in advance where to say “yes”, “no” and “if”. Handpicked committees just stamp their reports.

And in this entire where does the fount of all authority, the Union Government feature? For the most part it does not. In the fullness of time when MCI’s recommendations reach the Ministry of Health and Family Welfare, the cases can be returned with comments or questions; clarifications can be sought; but the Government cannot overrule the council or convert a case of acceptance into rejection and vice versa.

Should such a situation just be allowed to continue in the name of self-rule conferred by a 1956 Act? Medical education is on the concurrent list of the Constitution. It is serious business — even of wrong medication if not life and death. In 2005 a Bill was prepared called the Indian Medical Council (Amendment) Bill, 2005 which sought to modify the composition of the MCI by drastically reducing the elected element. The 2009 National Council for Human Resources in Health draft Bill went a step further by proposing the replacement of all health councils with a largely professional bureaucracy to perform those functions.

There can be no ideal answer but a business as usual approach cannot go on; trading in medical education has to stop. Merging the best from the two Bills may be a starting point and the arrest of the president of the MCI could just be the tipping point to precipitate a change — long overdue. But only if the voice of reason, not the powerful that run private medical colleges is heeded.

Abolish MCI, councils

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Abolishing all health sector councils and replacing them by a single national council would perhaps be the best thing, given the nadir to which critical aspects of medical education have sunk. To cleanse the system, Government must act now without any further delay

The Ministry of Health’s Task Force proposes to discard the Medical Council of India and all other health sector councils and replace them with a single National Council for Human Resource in Health. Abolishing the elected bodies that have held sway for decades would perhaps be the best thing that could happen, given the nadir to which critical aspects of medical education have sunk. Unfortunately, the truth is that the running of professional medical and allied colleges is the uppermost Indian business interest, with the exception of cricket.

I had the somewhat dubious experience of dealing with all the councils in the medical sector for over seven years in the Ministry of Health. Those years stand out most in my memory because it was my maiden voyage into the machinations of big Government. It was also the only period when Chief Ministers knew me by name and rang me directly with ‘chhota kam’ .

It was August 1992. Mr Narasimha Rao was the Prime Minister. I was the newest Joint Secretary in the Health Ministry and had just been given charge of medical education. On August 27 morning I was sent for by the Health Secretary and told that an ordinance was to be promulgated that evening. I was dispatched to the Ministry of Law where the ordinance was dictated line by line by an Additional Secretary.

I came to know only through him that the ordinance was intended to thwart the Chief Minister of Andhra Pradesh for wantonly granting permission to establish around 20 medical colleges. This act of Mr Janardhan Reddy provoked judicial strictures to the point that the Chief Minister lost his chair. Bringing an ordinance was the brainchild of Prime Minister Narasimha Rao, a former Chief Minister of Andhra Pradesh. At 6 pm the legal officer handed over a typewritten draft to me and I rushed back to Nirman Bhavan every inch the cog in the wheel that I was. Late that night the President’s assent to promulgate the ordinance was obtained. I retired to bed much wiser.

Overnight, the Central Government had wrenched all powers from States to give permission to establish new colleges, increase seats or introduce post-graduate courses in medical colleges. It was an extremely well-intentioned move, but unfortunately the next 17 years have not been a happy experience. An unending tussle has gone on between the Ministry and the MCI. Colleges sans teachers or patients have managed to successfully manipulate both admissions and degrees with constant wrangling and countless court cases.

What is at stake for the common man? The conditions imposed by the councils in the name of setting standards are generally elitist and out of tune with India’s growing needs for professional manpower. The MCI makes short shrift of pressing requirements like public health and family health, driving graduates into specialisations which are lucrative but irrelevant, looking at India’s rural as well as a fast growing urban population and the twin challenges of communicable and non-communicable diseases that confront us.

At the root of the problem is the fact that all the councils are elected bodies and candidates spend huge money to get elected. Professionalism is not the primary concern of people who have to get a return on investment. The idea of an overarching council is fundamentally a good idea but it should also not be left to the States to grant approvals based on centrally dictated standards. That will delight them no doubt, but that would be leaving the door open for resurrecting the horror stories of 1992.

It is equally the constitutional duty of the Central Government to see that the standards are not just set but followed. For that an oversight mechanism has to be in place to see what is happening, otherwise we may well have sub-standard medical practitioners let loose on hapless citizens. The fact that medical graduates will need to pass a common centrally organised examination to practice in another State would hardly be a fair way of fulfilling a responsibility envisaged by the Constitution.

In a democracy the answer lies in appointing a nominated body for three years to fulfil the functions of medical and allied councils. But ultimately within that period the complexion of the electoral colleges given in the different Acts should be changed through an omnibus legislation so that each profession can be represented by a cross-section of stakeholders, not just a bunch of cronies. The criteria for individual nominations should also prescribe evidence of professional caliber and experience, not merely belonging to a specified category.

In the formative period an ordinance is the only way that can enable the Government to establish a nominated national council. Within a reasonable period the system for holding elections should be put into place as that obligation cannot be wished away forever. For the time being, however, only an ordinance can ensure safe passage in Parliament within six months. Otherwise the players involved being among the most influential in the country, and the wheels of Government and Parliament being so slow, a business as usual approach will be doomed to dust.

Make me a takeaway baby

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The booming ‘business’ of renting wombs to produce babies will drive a beautiful alternative like adoption underground which instead we ought to encourage seeing the need of thousands of abandoned and orphaned children that crave for parental care

A recent Internet advertisement posted by a Medical Tourism Corporation made me fume. It brazenly advertised surrogate motherhood options available in India, bellowing that it costs “a fourth of what it would cost in the United States”. It slobbered over the fact that “surrogacy in India has few legal hassles and India’s laws allow the surrogate mother to sign away her rights as soon as the baby is delivered”.

The patronisation of India as a cheap place to get ‘takeaway’ babies sounded abhorrent and ethically questionable. I consulted two protagonists representing differing points of view. The first, Prof Uma Chakravarti, a historian and an academic doyen among women activists; the second Dr RS Sharma, Deputy Director-General in the Reproductive Health and Nutrition Division in ICMR who was actively involved with assembling the 2005 guidelines for Assisted Reproductive Technology clinics and later the draft ART Regulation Bill and Rules, 2008.

Let us hear what Ms Chakravarti had to say. She basically raised four issues: First, we in India staunchly protect our national identity and take umbrage at the first signs of exploitation by the white man. We bristle at a whiff of racism or veiled dominance and are quick to lash out on grounds of sovereignty, independence and freedom. Why then do we allow commercial exploitation of Third World women’s wombs by baby seekers from the first world?

Second the surrogate mother is expected to enter into an agreement which is contractual and legally enforceable. While the law gives her the normal right to terminate the pregnancy and refund all the expenses incurred by the biological parents, this is easier said than done: In the case of illiterate and uneducated women with no economic independence reneging on the contract would be next to impossible.

Third, dangling Rs 100,000 before a poor family would lead to women getting coerced into unwanted pregnancies for money. The plethora of consent forms and protective clauses cannot belie the fact that poor women are already exploited in umpteen ways and thumbing or signing a piece of paper does not constitute the exercise of independent choice. Oversight committees cannot get inside male dominated homes where the woman has no choice but to acquiesce to patriarchal diktats.

Finally, the whole business of surrogacy will drive a beautiful alternative like adoption underground which instead we ought to encourage seeing the need of thousands of abandoned and orphaned children that crave for parental care. Counselling about the goodness of adoption is unlikely to appeal to ART seekers once the road-map is clear before them.

Dr Sharma did not directly allay these doubts but gave convincing justification for regulating the whole business of ART. This is what he explained: Infertility can be placed at 10 to 15 per cent among the reproductive health seekers in hospital settings. Most of them approach infertility clinics that lack technological expertise and infrastructure. The clinics exploit anxious couples by charging exorbitant rates for even inexpensive procedures. In order to regulate and supervise the existing clinics and contain the mushroom growth of substandard infertility clinics ICMR issued the 2005 guidelines.

Several countries in Europe and West Asia had issued ART guidelines. So had Japan and USA done so. ICMR’s guidelines aimed at filling the lacuna that existed in India. Publicised widely they were discussed in six major cities where over 4,000 participants including doctors, scientists, public servants, legal experts and infertile couples voiced their opinions. Both the National Human Rights Commission and the National Commission for Women had reviewed these guidelines before they were notified.

In 2008 a draft Bill was formulated on which public comments have again been sought before taking it to the Law Ministry and Parliament. The Bill sets out a national framework for the regulation and supervision of ART. The process for registration of ART clinics, their standards and duties have been laid out explicitly. A National Advisory Board and similar set ups in each State would exercise the powers of a civil court to extend supervision and oversight over implementation. The system for sourcing and storage of gametes and embryos, the regulation of research, the rights and duties of donors and patients and the determination of the status of the child have been detailed comprehensively. Most couples using the ART clinics would not be foreigners but millions of Indians. The accompanying Rules spell out detailed requirements of infrastructure, staff, counseling, donation and cryopreservation.

Medical specialists that service an unregistered ART facility or contravene the provisions of the Act would be punishable with three years imprisonment. More importantly the offences are all cognisable, non-bailable and non-compoundable. The outcries about the non-bailable provisions have already created enough of a flurry among practitioners-a pointer to the Bill’s potency in preventing medical malpractice, Sharma added.

No doubt the debate will go on .This is not a perfect world but considering everything on balance, much more will be gained than lost by supporting the Bill to make it law.

Coping with death

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High-tech hospital care must include mandatory counselling by advisers, independent of the medical management. This will enable us to take rational decisions in time. If we don’t, we will end up spending most of our money on healthcare in the last years of our lives

Quite unlike the ‘developed’ world, India does not have an ageing problem. With an overwhelming number of young people, its population will remain youthful for at least two decades more. While the grey may never show, the addition of 90 million elderly in the next 20 years will increasingly make hospitalisation a longevity hazard. A couple of decades ago, 80 was considered a ripe old age. Nowadays people live into their nineties and the chances of confronting serious medical problems swell.

In recent months, I have witnessed three old men in the 80 plus age group getting hospitalised post a sudden stroke. The first stop is naturally the ICU, entailing a battery of investigations, followed by ventilators, tracheotomies, oxygen masks, feeding tubes and day and night nursing. The family does not have a clue about where this is leading, but cannot bear to see the old man go. They plead with the doctor to tell them what his chances are.

The doctor does not have an answer, but he abstains from giving false hope, while trying not to upset the stricken. He also cannot predict things, but stands to lose clients by seeming hopeless or helpless. Looking at the patient’s age and general health, he knows that the old man should survive in an unconscious state – maybe a month or two, on ICU support systems which cost a whopping Rs 10,000 to Rs 15,000 a day. He elects to tell the anxious relatives, “The old man can pull through if he shows will power. We will do our best of course. The rest is in god’s hands.” The family huddles together observing the old man breathing heavily through masks and tubes, his eyes closed to the world.

Meanwhile, distraught children (now in their forties and fifties) fly in from the US or Europe, balancing last minute tickets and hard to get leave. Thoughts of unsupervised teenage children, wrecked official commitments, and a home devoid of domestic support, loom large on the flight. Every day spent in India is an extension of that anguish, but any mention of returning meets with dismay and disapproval from resentful siblings who have tended the old man for the past 20 years. Throwing money at the problem only generates bitterness and the charge of callousness. Yet, visiting an unconscious parent in the ICU at the appointed hour, twice a day, becomes a painful and meaningless chore, followed by pointless family conclaves in crowded hospital lobbies.

Only when the costs of ICU become unmanageable, does pragmatism overcome emotion and impart courage enough to demand a step down to less intensive care. Legal and medical advice cautions that the ventilator would have to be removed and the old man may succumb on the spot. “We are prepared,” says the family in unison, confronted with soaring ICU bills and demands for instant payment. The old man remains unconscious but does not collapse. He adjusts well to his step down status, but remains near comatose and dependent on props.

But costs in the private ward too become prohibitive, eventually making yet another step-down unavoidable. “Can we remove him to a smaller hospital, doctor?” “By all means,” says the doctor, “but wherever you take him, the new hospital will insist on putting him back in the ICU and will re-run all the investigations from scratch, I warn you. All hospitals are bound to do that.” A parley with smaller hospitals confirms this statement. The new management scans through the case papers and flatly refuses to handle the patient unless he comes as a “new case”.

The last resort is to nurse the old man at home. As usual, it becomes the responsibility of the harassed spouse or the non-NRI progeny, to engage nurses, attendants and physiotherapy services that constitute the gruelling job of providing home care. The beleaguered offspring returns home to the US after spending a miserable fortnight in India, dejected, remorseful, but hugely relieved to get away. Those left to care for the old man feel forsaken at such cavalier neglect of filial responsibility. They curse the cult of self-centredness that comes from living in the new world.

The old man lingers on. Domestic management of apathetic paramedics, attendants and physiotherapists becomes a nightmare. There is little sadness when the end comes. Indeed, it comes as a relief.

Increase in life expectancy is good news but alongside the likelihood of critical conditions developing at an older age will increase. Scores of multi-specialty hospitals already vie for national accreditation and international recognition. As more Indians live to see what the French call the quatrieme age, some are fated to spend their last days and lifetime savings on dying under ISO 9001:2000 care.

It is time that high-tech hospital care includes mandatory counselling by advisers, independent of the medical management, but competent enough to give meaningful counsel. This will enable the family to understand what is going on and take rational decisions in time. Lest like America, we too end up spending ninety per cent of our lifetime expenditure on health, in the last year of life.