Wednesday, July 29, 2015

The IMA Should Stop Playing Victim

Guest article by Dr Sanjay Nagral

The citizen is being shortchanged by the medical fraternity, but try telling the IMA that

A surgery in an Indian private hospital. (Photo-Asian Development Bank)
A surgery in an Indian private hospital. (Photo-Asian Development Bank)
A few paragraphs in a social sciences textbook of the NCERT for Class VII is hardly the kind of writing that makes major news. But when the Indian Medical Association (IMA) petitions the Prime Minister objecting to some sentences it should arouse curiosity not only because it seems like a trivial matter being blown out of proportion but because it suggests a lot about an organisation that has a critical role in health care discourse in India.
The issue is as follows. In the VIIth standard NCERT textbook chapter on the “Role of government in health”, under the sub-head “Private health facilities”, it says,
“In order to earn more money, these private services encourage practices that are incorrect. At times cheaper methods, though available, are not used. For example, it is common to find doctors prescribing unnecessary medicines, injections or saline bottles when tablets or simple medicines can suffice”.
This is the bit that has provoked the IMA, the largest umbrella organisation of the practitioners of modern medicine in the country, to write to the Prime Minister and a host of other state functionaries demanding that it be deleted. In its letter the IMA warns, “The message which will go to the students is that “private sector fleeces money”. The letter goes on to explain how the cost of the public and private sector cannot be compared since the public sector is supported by state funds and hence the comparison is unfair.
In the narrowest sense what the IMA says is true but what the textbook has actually done with some clarity is to connect the basic logic of the private sector to unethical practices. What it is not doing is to locate the blame on the state, which over the years has encouraged an unregulated private sector by wilful neglect of the public sector, a point that the IMA misses in its rhetoric. It is, after all a 7th standard textbook and the authors were constrained by the need for simplicity and brevity.
IMA is pro private sector
The IMA has in its ambit all types of practitioners of modern medicine in India, public and private, specialist and general, rural and urban. Logically, therefore, it should represent the interests of all sectors. However, it is obvious that every time there is an attack on the private sector’s excesses, the IMA displays a prompt knee-jerk response, often in the form of victimhood. Whether it is the episode of ‘Satyameva Jayate’ on unethical practices where it called for an apology from Aamir Khan, or the nationwide strike the body called in 2012 to protest against the promulgation of the Clinical Establishment Act which sought to regulate the private sector, the IMA has consistently betrayed its bias towards the dominant entrepreneurial interests in health care. This obviously goes down well with its core constituency in the profession. On the other hand, the IMA has had nothing substantial to say about the complete decimation of the public health system with the resultant marginalisation of large sections of our people from access to decent care.
I was recently a member of a committee of the Maharashtra government which was set up to promulgate a modified state level version of the Clinical Establishment Act. Although it was one of the official briefs given to the committee, IMA representatives stonewalled all attempts to bring in some form of regulation of the fee structure in the private sector.
In many countries national medical associations have played stellar roles in promoting pro-people health policies, advocating patient’s rights and even resisting the state’s attempts to privatise health care as in the case of the British Medical Association during Margaret Thatcher’s time. Why is it then that the IMA has come to this sorry pass?
Control by market interests
One apparent explanation is that those with market interests are dominant in the leadership. Many office bearers of the IMA themselves own nursing homes and hospitals. But this has also been possible because the larger mass of medical professionals wittingly or otherwise have internalised the ideology of market medicine. Doctors from academia and those working in grassroots level NGOs who are capable of offering counter viewpoints have in a sense vacated this space. Many of them work and debate outside professional organisations offering alternatives but feeble internal resistance.
The state of the IMA may not be very different from other professional organisations in the country that primarily function as guilds to protect the narrow interest of their members, which can clash with the interests of the citizenry.
Many of these organisations are unable to think independently of the dominant market discourse as it applies to their profession. In that sense it may be unfair to single out the IMA. However, historically in India and across the world, medical professionals and organisations have provided resistance to dominant ideologies. Healthcare is one area of social endeavour where inequity is so stark that for medical professionals and organisations not to be concerned about the policies that nurture this would be shocking.
One wonders what Class VII students will remember from what has been taught to them as they grow up; some of them may even join the medical profession. It demands extreme innocence to assume that such textbook paragraphs will shape their long-term thinking. But when the principal association of lakhs of doctors across the country does not go beyond playing up to their constituency in response to a naive but important attempt to highlight the problems of private medicine in a school textbook, it reflects their lack of imagination – and more worryingly – their guilt.
Dr Sanjay Nagral is a surgeon practicing in Mumbai. He is a member of the Indian Medical Association and is on the editorial board of the Indian Journal of Medical Ethics