Healthcare in India is a matter of concern not only for the planners but also for the whole of civil society. Despite 58 years of independence we have not been able to provide basic healthcare to all citizens. The Directive Principles of State Policy enshrined in the Constitution of India mention that the Government shall endeavour “to provide free and compulsory primary education” to every child in India. It is true that we have not succeeded in meeting this goal, however the Government has at least some responsibility to work towards this objective. The subject of healthcare has however not received even this much attention in as much as it is not obligatory for the Government to provide “free and compulsory healthcare” to citizens. India therefore presents a strange kind of paradox : on the one hand patients are pouring in from South Asian countries, the Gulf region and even Western countries to take advantage of our world class medical treatment at most affordable cost, and on the other hand the very health care is still out of reach for the majority of our own people because of poverty and lack of access. This article contains historical perspective of health care in India, present scenario, my own observations, expectations and suggestions for improving the healthcare delivery in India.

Health Care in Ancient India
While the whole world was living in primitive conditions, India had evolved its own life style and faculty of medicine and could boast of the best health care. Dhanvantari was regarded as the God of Medicine. He had seven specialists working under him. Well known amongst them was Sushruta. He was considered the Lion of Head and Neck surgery. It is said of him that he could perform even the most complex head and neck operations flawlessly. There was a time when the rich in India could rejuvenate themselves by undergoing a therapy called Kaya Kalpa to regain zest, virility and sexual power.

Concepts like Euthanasia - allowing a person to end life voluntarily under certain conditions, were very much known to people in India. Euthanasia was practised if a person could not perform his religious rituals due to old age or had been suffering from some incurable disease. Even the method to be adopted for dying was described; the person must burn himself in a pile of dried cow dung cakes or drown himself in the holy river. Jainism practised another kind of euthanasia called Santharo in which a person forsakes food and water and starves himself to death. Even today the practice is in vogue.

Over the years India lost its dominance in the field of medicine and healthcare. Perhaps that was due to the fact that we lost our scientific temper and the spirit of inquiry and became complacent of our achievements. What followed thereafter was a period of decline on the health front.

Healthcare in Western Countries
Ancient Greek had the best medical care. There are references to eugenic breeding - a science of improving human hereditary traits by controlled breeding for desirable characteristics in humans such as intelligence and good health and destroying the ill and the incurable. Adolf Hitler used eugenics for negative purpose. He wanted only the best Germans to survive and therefore resorted to racial cleansing.

Before I discuss the healthcare scenario in India, I would like to recall my own memories of healthcare delivery in the Western countries. My exposure to their conditions goes back to 1946. Soon after completing my FRCS, I went on a sightseeing tour of Europe. While in Sweden I saw the famous Government Hospital, Karolinska Institute. During my 15 months stay in England, I had never seen such an institution there. The Swedish government proudly advertised that the Government looked after its citizens ‘from cradle to grave’, which means no parent had to pay anything when a child was born and during various stages in its life. It was the responsibility of the government to provide health care to all citizens. Of course, there was heavy taxation for citizens and the Government even published a book mentioning names of persons and the amount of tax paid by them. The country had ‘nationalized health’ as its policy. Karolinska institute is still rated as one of the best in the world. Of course many other institutions were also looking after the health of Swedish citizens. The government healthcare was so good that nobody went to private doctors.

The situation in the UK on the other hand was gloomy. There were hospitals which were charging heftysums. Those who couldn’t afford and wanted free treatment had to go to the social worker of the hospital and get his recommendation.

Elections to the British parliament were only few months away. A debate was going on in the parliament. One day out of curiosity I went to witness the proceedings of the day from the visitor’s gallery. Winston Churchill was the Prime Minister of England while Clement Atlee was leader of the Labour Party. Atlee got up to speak and promised that if voted to power, his Party would do two things immediately - nationalise health and grant freedom to India. English people were unhappy with the medical treatment available to them from the government which the Labour party insisted was their right. As things unfolded, Labour won the election and Atlee became the Prime Minister. And true to word, he declared nationalisation of health which entitled every citizen of UK to free medical treatment. The new Prime Minister appointed Aneurin Bevan, son of a coal miner, as the health minister. Bevan became the pioneer in designing the new health scheme. Some years later Bevan visited India and gave a lecture on health care at JJ Hospital.

The nationalised health in England extended to the rich and the poor. National health became a model for other countries. Till this date nobody in Englnd has asked for, or would ask for, denationalisation of health although people are not satisfied with the treatment. Those who are rich take full advantage of the free medical service while also taking benefit of private insurance. Germany was the first country where in 1886 Bismarck, the architect of unified Germany, introduced health service for the people. (Sardar Vallabhbhai Patel became the Bismarck of India as he too brought nearly 545 princely States and provinces into India’s fold). Bismarck’s was a path-breaking decision in the entire Europe then in as much as it brought home the point that looking after health of the people was the primary responsibility of the government. Today in Germany, France and other European countries a majority of the people are insured and get free medical aid.

Inventions of the Century
According to me two things changed the world of medicine. Invention of the first vaccine by Louis Pasteur was a major breakthrough. Thanks to him, the field of modern medicine was revolutionised. The so-called incurable diseases became preventable. Pasteur observed that all diseases were bacterial in origin. Till then, even in the West there was ignorance about the bacterial origin of diseases. A doctor who wrote an article advising fellow doctors to wash their hands after performing post-mortem if they were to cut the umbilical cord with hands immediately afterwards was ridiculed and later dismissed from service! All that the good doctor wanted to convey to his peers was that the newborn might catch infection if they didn’t wash their hands. This was the level of ignorance. Vaccines prevented many diseases including small pox.

Another breakthrough occurred in the 1930s when Alexander Fleming found out penicillin, the first antibiotic. Since then several and better antibiotics have become available and today most of the diseases of infective origin have become curable.
In the 18th century operations were done, but with poor results. Surgeons would still dare perform many surgical procedures, but many patients used to die during operations. Thanks to antibiotics, infections came under control and surgical procedures became more successful. In addition blood transfusion has become possible and with it better anaesthetic procedures. All these inventions came handy during World War II. The credit for these changes goes to western scientists and researchers.

Healthcare in modern India
Until the British arrived in India, Indians were living mainly on Ayurveda, Unani, home remedies and other traditional systems. The British brought with them modern medicine which was based on scientific research. Initially they started 3 medical colleges in India - at Madras, Calcutta and Bombay. By the time they left India in 1947, they had created 10 medical colleges in the country. Importantly they laid reasonably good infrastructure for health by building Civil Hospitals at district headquarters. Today we have nearly 200 medical colleges which also include those offering degree courses in Ayurved, Homoeopathy and Unani. Of these, 75 per cent are in the private domain.

India produces double the number of doctors than the United States. We have first class doctors who are very well trained. Our Surgeons are second to none in the world. Not very long ago the rich in India went to western countries for operations. Not any more.

Speaking for Mumbai, we have got medical colleges with attached hospitals in and around the city. The poor have full access to both government and municipal hospitals. But there are limited number of beds than the actual need of the city. Provision of inadequate funds prevent hospitals from providing free facilities to patients and they are often asked to replenish medicines and disposables, making hospitalisation expensive for poor people. Private hospitals have brought some relief. They offer excellent facilities to patients, comparable to the best in the West. They too reserve 10% of beds for the poor, but that is only scratching the tip of the iceberg. Bombay Hospital has got 300 free beds, and it is rendering unique service to all sections of people.

Despite the criticism of private medical colleges, I feel that on the whole they are doing good job. Today doctors from private medical colleges have gone abroad and are doing very well. India has excellent facilities in various branches of specialisation and super-specialisation, but the benefit goes to very few people. The majority can not afford specialised treatment and therefore gets marginal benefit of our advancement in the field.

The credit for development of various super-specialities and extending their benefits to people largely goes to private hospitals. Bombay Hospital has created a postgraduate research institute where most of the faculties are available.

Potential for Medical Tourism
Before independence, Calcutta was the Mecca of medicine. In later years, Bombay emerged as the centre of modern medical treatment. Today besides Calcutta and Mumbai, cities like Delhi, Chennai, Bangalore, Thiruvananthpuram and Hyderabad have emerged as centres of medical excellence. The work being done at these centres is acknowledged and appreciated even in western countries. No surprise then that citizens from UK and US too are coming to India for treatment. A majority of those coming to India are cardiac and orthopaedic patients. India must take full advantage of its excellent medical facilities and personalised care and attract patients from other countries. In the UK patients needing surgery have to wait for long periods. Such patients will find travelling to India affordable, as medical expenses are much lower here than in their country.

According to a latest news report in the Economic Times (3 Jan 06), the Indian healthcare industry has drawn up plans to market Brand India globally. Healthcare providers in India are now working in collaboration with the government to launch a comprehensive programme to promote medical tourism. This includes putting in place an accreditation system for domestic hospitals and healthcare providers, drawing up a price band for superspeciality services offered by Indian hospitals, adoption of country specific marketing strategies, opening of overseas facilitation centres and tie-ups with overases insurance companies.
Till now only a few big private healthcare providers in India were creating their individual brand awareness in overseas markets through tie-ups with insurance companies and patient facilitation centres. However with the growing need to establish the Indian healthcare brand synonymous with safety, trust and excellence, industry-wide measures are being undertaken.

The National Accreditation Board for Hospitals and Healthcare Providers (NABH) set up by the Health Ministry under the aegis of Quality Council of India is currently busy finalising the guidelines for accreditation of hospitals and other healthcare service providers.

In yet another initiative, the Confederation of Indian Industries (CII) is partnering with 29 hospitals across 16 States to work out a price band for speciality services in cardiology, orthopaedics, oncology and minimally invasive surgery. The healthcare industry is working closely with the tourism ministry, which will incorporate these packages under its `Incredible India' compaign to promote medical tourism in overseas markets.

According to estimates, medical tourism currently pegged at $350 million has the potential to grow into a $2 billion industry by 2012. Last year alone around 1.5 lakh medical tourists visited India for cardiac care, cosmetic surgery, joint replacement and dentistry.

According to experts in the field, measures such as accreditation system and pricing band will help India establish its credentials as provider of quality healthcare at affordable costs. It will not only benefit the domestic patients but will also boost medical tourism.

The Buck stops here
Our health budget is just about 1% of our total plan whereas for Europe it is 6 per cent. In the UK, health budget is 8-9%. America’s health budget is by far the biggest with 12% of funds going to healthcare in the public sector. But even in America 45 million people are not insured and are thus deprived of medical aid. America has highest per capita spending on health in the world about $5400 in 2002, and still 18 per cent of the population under 65 remains uninsured. This shows whatever may the amount you spend on health, the provision is never adequate.

The Brihanmumbai Municipal Corporation is a star in the whole of India in respect of provision for public health. The BMC earmarks 12% of its budget for health, as good as America’s!

Another striking aspect of the distribution of funds for healthcare in India is that almost 70% of the budget is spent on urban population which constitutes 30% of the total population whereas only 30% of funds go to rural areas where a majority of our population lives. This uneven distribution of funds prevents the benefits of healthcare from reaching the rural poor.

Urban population has the advantage of receiving medical aid from public as well as private hospitals and clinics. In rural areas however private doctors are less than their actual requirement whereas public health centres are often located far from the place of residence of people. Quite often they are ill equipped or ill staffed and with short supply of medicines. Still, villages in Maharashtra are better off than their counterparts in some other States like UP and Bihar. For serious illness villagers in some States have to travel up to 200 km! If the patient still manages to reach the government hospital he is told no bed is available. Poor patient, he has to suffer and die. It is therefore necessary that the government increases its healthcare spending to minimum 4% if not 6% of the budget and strengthen health infrastructure in rural areas. Members of State Legislatures. Municipal Councils and Village Panchayats should take up the issue of small provision for public health in their respective forums. In fact village panchayats should revolt on the issue of insufficient budgetary provision for the health sector. Unfortunately the poor in India can’t cry and their whimper is seldom heard. Indifference to the twin sectors of healthcare and education is responsible for keeping India tied down at 127th position in terms of Human Development for the last two years.

Hope and Expectations
When I was a medical student in 1937, patients used to die of typhoid, cholera, small pox, tatanus, gas gangrene, and such other diseases. No such disease existed in the Western countries then. Likewise there were nutritional disorders in India which again was not a problem in western countries. Almost 70% of pneumonia patients in India used to die for want of treatment. Today we do not see patients dying of these diseases. Modern medicine has brought about a revolution in almost every field.

Arresting Cardiac problems!
During my early days in medicine, nobody imagined that cardiac surgery would be possible. Any body getting heart attack had to take rest and that was the end. Those who survived were lucky. There was no positive pressure anaesthesia - only open ether and chloroform. Nobody could open the chest valve. I remember only one case where chest trauma had led to collection of blood under the pericardium of the heart. It happened in the evening. Thankfully, the Registrar and the General surgeon who were present took courage to remove one rib, made a small puncture in the pericardium and remove the blood. It was considered a miracle.

Again, patients with high blood pressure would die within five years because there was no treatment for controlling blood pressure. Today wonderful things are happening to the field of cardiac surgery. Angiography, angioplasty and bypass surgery have reduced the incidence of death caused by heart problems and as a result patients are living longer and healthier.

I have myself been a beneficiary of the progress in this field. I had developed blocks in my arteries and got my angioplasty and later bypass done. Today ten years on, I feel as fit as I were 20 years ago! Two years ago, my pulse rate suddenly slowed down and I fainted. Doctors put a pacemaker in my heart and the heart started beating normally! These are miracles of modern medicine.

The field of orthopaedic surgery has similarly seen dramatic developments. Patient with fracture of the neck femur had to lie in bed for 3 months. Many times the patient could never walk again and in time die. Today wonderful surgical procedures are performed and the patient is able to walk within 4-5 days after the operation.

I had fractured my femur (inter-trochantric) and was operated. Today I have no pain and walk like a normal person. Had this happened in the olden days I would never have recuperated and might have remained bed-ridden forever.

Gynaecology and Obstetrics
In olden days maternal mortality was very high. It was common for husbands to marry again if the wife died during pregnancy or due to some illness. Sometimes even the second wife died early and men would marry the third time. This time, the husband would die himself leaving his young wife as a widow for life. Women died early because of pregnancy disorders. Thanks to the evolution in the fields of gynaecology and obstetrics, such diseases rarely occur. My own sister and a cousin sister died during pregnancy. Now rarely do we hear women dying during pregnancy or childbirth. Pregnancy was a dangerous period for women. Rituals were practised during the fifth and seventh months of pregnancy. Pregnant daughter-in-law was sent to her parents to take rest and it was considered mother’s duty to look after the daughter and send her back to her husband’s place after safe delivery.

Cancer cure, so near and yet so far!
Treatment of cancer has witnessed remarkable developments in the last fifty years. For many years, surgery was the only treatment for cancer. Today we have got multiple treatments: radiation, chemotherapy, immunotherapy and now gene therapy. Evolution of each of these treatments has its own story.
No cancer surgery was done before the beginning of the early 20th Century. Few surgeons did venture to deal with cancer cases but with very poor results because of lack of anti-biotics, blood transfusion and anaesthesia. Roentgen invented gamma rays and another weapon against cancer was added. It was thought that cancer would be cured with radiation therapy. It did but only in the early stages of the disease.

The third weapon against cancer, namely Chemotherapy was developed accidentally during the First World War. Nitrogen Mustard was used as a chemical agent against the enemy. It was observed that those who were exposed to Nitrogen Mustard and still survived had developed reduced white blood cells. Many of them suffered from leucopenia. This observation was confirmed when a similar thing was noticed during the Second World War. Then one day in 1962, a doctor saw a patient suffering from leukaemia and looking at the observations of mustard gas, it occurred to him that if Nitrogen Mustard could bring down the WBC count it was reasonable to assume that it would also kill abnormal WBC’s in leukaemia patients. He tried the Nitrogen mustard gas and it reduced the cancer cells. This became the starting point of Chemotherapy. Earlier all patients suffering from leukaemia died. Today 70% survive. Many chemotherapeutic agents are available now and their number is adding every year.

The latest additions to cancer treatment are Immuno-therapy and gene-therapy. With further progress in all the four treatments in the next ten years, almost 100 per cent cancer patients in Western countries will get cured; today 50% are cured. Now the question is : what about the poor patients in India? Chemotherapy and other treatments are very expensive and the poor cannot afford them. All the new treatments will be available only to those who have money. It is therefore necessary that we should strengthen our hospitals in public sector.

Thanks to the House of Tatas, India’s first and exclusive cancer hospital was set up in Bombay. I remember my late teacher Dr. AV Baliga, himself a very eminent surgeon, visiting the Tata Memorial Hospital regularly to observe foreign cancer surgeons performing cancer operations. The Hospital had employed surgeons from the United States to train our doctors in cancer surgery. After seven decades, the Tata Memorial Hospital is still the biggest and the best cancer hospital in the entire country. There are few other hospitals but none of the excellent stature of the Tata Hospital.

More than 40% of cancer patients in India have cancer in the head and neck region. This is mainly due to the habit of smoking and chewing paan. If we can make people kick the habit, we will be able to prevent cancer in at least 40% of cases.

In the western countries every cancer patient is seen and treated by the doctor, but in India only 10 to 15 per cent of cancer patients are able to see the doctor. The poor have practically little chance to get treated. Tata Hospital is perennially teeming with patients from different parts of the country. Often beds are not available. It is therefore necessary that hospitals like the Tata Cancer Hospital be set up in every State of India. Which brings us to the main contention of this article that we must increase our spending on public health.

Progress in ENT
I belong to ENT speciality and therefore speak from my own experience. Before the invention of antibiotics, infections were rampant. Many diseases required surgical procedures. Tonsil operation was the commonest because tonsil infection was the common problem among children. With the arrival of antibiotics, tonsillectomy has become very rare. Extensive surgical procedures were needed to treat sinus infections. Similarly ear infections needed operations. Today these procedures are performed in limited cases and the techniques have vastly improved. These include microscopic surgery and endoscopic surgery.

Advances in Imaging Techniques
Wonderful progress has been made in the area of imaging with procedures like CT Scan, MRI and ultra sound coming into the area of diagnosis. I remember in 1937 when I was in the GS Medical College as student, there were only plain X-rays. Even the use of plain X-rays was not very easy. The cost was Rs. 5/- per plate. But due to shortage of funds with the hospital, doctors were asked not to advice X-rays in order to save money on the plate, and only screening was done for lung diseases. Tuberculosis was the most common lung disease then.

Lens Implant Surgery
I had developed cataract in both eyes. After removal of cataract, one had to wear their glasses. Luckily lens implant surgery had come into existence. Were it not for the lens implant surgery, I would have been wearing thick glasses after the operation, which would have put me out of work! This is a miracle.

HIV/AIDS : Acquire Efficiency
About 20 years ago, after attending a Conference in Japan, I was travelling to the Philippines. The passenger sitting next to me in the plane was an American soldier. The Americans have their security forces stationed in Japan. As usual I engaged in conversation with the soldier and asked him why he was going to Philippines. ‘For sex’ came the reply! Wasn’t it available in Japan, I persisted. He said it was very costly in Japan and only the officers could afford there. In Philippines it is much cheaper even with the cost of air travel included. But then didn’t he fear contracting syphilis, I asked as AIDS was still to be known. He said, he would take the penicillin shot after the sex. The point I wish to make here is that the people were at least aware as to what is to be done after unsafe sex. We have 5 million people affected with HIV and there should be matching awareness campaign to pervent the disease.

Every year sixty thousand babies are born with HIV. HIV has become a major problem all over the world. In India it has already acquired fearful proportions. It is like another plague. Plague killed patients almost immediately. But HIV kills slowly and patients die a miserable death. There is no cure for the disease and no preventive vaccine. But now drugs are available which can suppress the progression of the disease and many patients survive. Till this day there is no vaccine against HIV. All the scientists of the world are trying to find the vaccine but haven’t succeeded so far. But I am sure one day the vaccine will be found. In South Africa one in every 5 patients is HIV positive. We must adopt preventive measures. It is no use telling people to observe celibacy before marriage and fidelity after.
Today Brazil has shown us how HIV virus can be controlled and will be ultimately eliminated. Because of the lead Brazil has taken in the fight against HIV/AIDS, its capital Rio de Janeiro chose to host the 2005 conference on HIV. In 1990 the World Bank had predicted that by 2000, 1.2 million Brazilians would be infected. In reality only 600,000 were infected. Judging by the response of the government it is hoped that the disease could be extinct in Brazil in the next 10 years! The following measures were taken

1. Brazil is a Catholic country where birth control measures are prohibited. Despite that condoms are freely distributed. 20 million condoms are given every month free of charge. Drug users are given free disposable syringes. All men and women of the night are educated regarding the disease.
   
2. Anti-retroviral drugs are given free of charge to everyone with HIV because if people are asked to pay nobody will bother to buy them. Best drugs are purchased and given free. It is a very expensive affair, but the Government thinks it is worth spending.

We in India should lay emphasis on two things

1. The objective should be preventing the disease rather than treating if Circumcision does help reduce infection and should be advised.
   
2. Secondly, use of condoms should be encouraged to prevent the disease. All Hospitals should arrange lectures and training programmes to educate common people like rikshawallas, drivers, labours and such other vulnerable groups about the disease and preventive measures.

Ayurveda : Need for Scientific Analysis
Ayurveda has been practised in India for centuries and it definitely has some wonderful drugs for several diseases. The problem is we do not know the active principal agent in each herb or medicine which is beneficial for a particular disease. For Ayurveda to gain universal acceptance, every medicine will have to be subjected to analysis to find out the active principal agent involved. The Government can take up the initiative by asking laboratories to conduct the analysis of ayurvedic medicines.

Some 40 years ago, a patient with high blood pressure went to see Dr. Vakil, India’s pioneer cardiologist. He told the doctor, whenever he took the medicine called Sarpagandha he felt better. Dr. Vakil thought that Sarpagandha might be reducing the blood pressure of the patient. He started prescribing it and found that it was effective. He got the medicine analysed from Ciba Laboratories, a foreign pharmaceutical company and the active principal agent was separated. It was named serpina. This was the first drug for blood pressure in the world. Had the active principal agent not been separated, the world would not have manufactured the drug. Ayurvedic specialists should themselves see to it that every Ayurvedic drug is subjected to scientific analysis. Earlier anybody having high blood pressure used to die within 5 years. Today there are many drugs against blood pressure and patients are living for many years!

Conclusion
Health care should be the fundamental right of every citizen. South East Asian countries like Korea, Indonesia, Malaysia etc, have overtaken us in terms of economic growth and human development because of their progress on social indicators. Unless we increase our budget provision for healthcare to minimum 4% we will not be able to make overall progress. All our advancement in medicine and surgery is meaningless if our poor agriculturists, working class and ordinary citizens do not get the benefit of health care and our infants continue to die of preventable diseases due to lack of vaccines.

Scientists from the West are talking of the possibility of reviving life after death at a future date and for this people are urging authorities to preserve their bodies so that they might get a chance to live again. This is called ‘Cryonics’. As soon as a person dies, he is frozen in liquid nitrogen or helium. At some future date when a cure for the disease will be found, the body can be thawed, treated and revived. It is said that Walt Disney’s body is lying in a frozen state for a possible future revival! We in India should make effort to see that at least those who are alive get a chance to live their full life with proper healthcare and medication. I hope our Prime Minister will look into these issues.