CR Soman February 4, 2007
Kerala is on the brink of a public health crisis. The state, which sets an example for the rest of India and third world countries in providing primary health care, now gropes in the dark and is fast losing the edge. The great achievements in the fields of mortality and fertility have reached a plateau, the near universal immunisation coverage achieved in the nineties has fallen in most districts.
The state is regularly visited by emerging outbreaks of leptospirosis, dengue fever and other insect borne viral fevers; the latest entrant is chickungunya. Natural ecology has been tampered with and the once-famous backwaters of the state are polluted and weed infested. Waste disposal in the municipalities and corporations still remains a formidable challenge. Conventional methods like land fill evoke furious protests from local inhabitants. Critics have re-christened 'God's Own Country' as 'God's own junkyard'.
The state health department is no longer the prime mover of health development. With less than a third of physicians, beds and institutions under the government, the state health services department is a mute spectator to the rapid decay of health services, particularly primary healthcare. Many primary health centres are unmanned. Drug procurement and distribution systems are outmoded and complaints of drug unavailability appear frequently in the media. The state-run medical colleges have no longer bright young academics to work for. They opt for more lucrative placement in the burgeoning private sector instead. Many super-specialty departments face the threat of closure in the absence of new recruitments.
There are worse problems. Recent studies suggest that Kerala has the highest burden of coronary heart disease, stroke, hypertension, diabetes and over-nutrition. Conservative estimates put the number of people with diabetes at three million; people with hypertension at 4.5 million and those with overweight and obesity at 10 million.
Every year in Kerala, between 45,000 and 50,000 people die of heart attacks, while stroke kills over 20,000. In comparison, the annual death toll from HIV/AIDS is just over 200. But both the government and the people perceive HIV control as a greater priority than lifestyle interventions aimed at curbing the epidemic of non-communicable diseases.
It is the healthcare industry that benefits from this sordid state of affairs in Kerala. Private hospitals offering sophisticated tertiary care are mushrooming, even in villages. By-pass surgery and coronary artery stenting are buzzwords familiar even to the children. One would be lucky if an MRI scan is not ordered if you reach a physician with a headache. The doctors prescribe laboratory tests even for minor ailments.
They may argue that a variety of investigation is necessary for complete profiling of the disease in modern medical practice. According to the Indian Medical Association, the doctor would be in trouble if the diagnosis goes wrong. It argues that they practise defensive medicine. But defensive against whom? Implied in this approach is the assumption that people, individually and collectively, are enemies of the medical profession. The IMA cites stories of attacks against doctors and increasing trend towards litigation against hospitals to buttress their arguments.
These are convincing arguments for the naïve. The sad truth is such arguments are alibis offered to mislead and misinform. The over-use of technology and drugs is driven by greed – a greed that is fuelled and perpetuated by an unholy nexus between doctors, the drug industry and the diagnostic sector. Huge rewards are offered to the physicians for prescribing expensive investigations. Anywhere between Rs 2000 and 2500 is offered as commission for an MRI scan; 40 per cent of the fee levied from laboratory investigations reach the doctor as commission.
Private hospitals make more money through over-investigating patients in their own laboratories than from providing care to the patient. Profit at any cost is the watchword. Doctors in the government sector also gain through the nexus between the industry and the profession. The government has made no attempt to regulate the healthcare industry, and often goes out of the way to provide them with more concessions and soaps.
Naturally, the victims are common men. Falling sick has become a reason for one to be pushed into debts. The Kerala Sasthra Sahithya Parishad's (KSSP's) studies revealed that at least 15 per cent families spend over 30 per cent of their income on healthcare alone. While private healthcare costs exceed Rs 55 billion per annum, the government expenditure is falling steadily. The government's failure in providing affordable healthcare is likely to fuel public anger. Hospitals and doctors are likely to be targets of public attacks. Facilities for medical education are being auctioned off to the highest bidders.
To complete undergraduate course in a private medical college requires Rs 3-5 million. Naturally, they would expect quick returns for the investment. Fleecing the people would be the only choice! Those who get state-funded medical education are only too eager to fly abroad. And those who choose to stay home prefer to work in cities and towns, leaving primary health centres unattended.
Medical care in the state has become dehumanised and privatised. Commodifying healthcare – increasingly driven by profit – will demolish all that the state had achieved in the health sector during the last decades of the 20th century.
The big question is: will the present government, keen to articulate people's causes but principally concerned with factional feuds ever be able to stem the rot and usher in rays of hope?
The future looks bleak for Kerala.
Dr CR Soman is a leading public health expert and a former professor at the Thiruvananthapuram Medical College and also chairman of Health Action by People, an NGO working in the field of public health. He can be contacted at email@example.com