Negative effects of modern healthcare

No one can allege that India’s health care system is all bad. It has worked some wonders. Two generations ago children grew up with worm infestations and scabies. They were also afflicted with the more dangerous, life changing small pox and polio.  Now these are among the health problems consigned to the past, totally or almost totally. Life expectancy has increased. Diabetes and high blood pressure are no longer the killers they used to be. Nearly three decades ago there was a five-year survival for one third of all cancers if detected and treated early. Today more than half could survive for ten years or longer. 

At least 63% of all health care expenditure is out-of-pocket in India. This expenditure is neither State-funded nor covered by any insurance

Modern medicine has kept most of us healthy, but modern medicine has been unable to dispel the negative effects of modern 'health care'. Among the four major problems in healthcare today, is first and foremost, the indifference to treating pain and suffering. Today’s healthcare system in India just does not treat pain and suffering. The Bioethics unit of the Indian Council of Medical Research says mitigation of suffering is the fundamental duty of a health care provider. “There is no exception to this rule”, they say. But less than 4% of our people have access even to basic pain relief, leave alone other aspects of palliative care.

Secondly, those left behind by the modern healthcare system are the most in need in the country. Those with disabilities, those who are culturally or geographically isolated, the elderly or those facing gender discrimination, especially if poor, have no access to reasonable health care.

Thirdly, inappropriate care is provided to the dying, forcing them to die imprisoned in intensive care units, with only pain and suffering for company. Death that was once a part of life – unwelcome, yet accepted as inevitable - is today an enemy to be fought at all costs. Even if every moment of the war causes agony, the painful process of dying is stretched out to days, weeks, even months. 

And fourthly, to top it all, the growing catastrophic out-of-pocket expenditure pushes more than 4% of our population below the poverty line every year. At least 63% of all health care expenditure is out-of-pocket in India. This expenditure is neither State-funded nor covered by any insurance. The World Bank lists India among the worst 12 countries for such social destruction.

In short, while the health system provides health care with one hand, it strangles health with the other.

The picture is dismal. The damage cannot be undone in a year or two. It is akin to rearing a baby elephant at home. The elephant will continue to grow and those in the house will learn to walk around it. But it needs to be taken out even if it means breaking open a door or a time will come when it destroys the whole house.  In Indian health care, we are now at a stage where the elephant can be taken out if a door is broken open. Must we wait till the house comes apart?

Health care professionals must learn to treat pain and suffering as they treat diseases

Fortunately, the solutions are low-cost and not difficult, if only the health care system accepts its duty of care to alleviate suffering. This mandates health care professionals learning to treat pain and suffering as they treat diseases. This is the practice followed in Western European countries and even in some low-income countries in Sub-Saharan Africa like Uganda and Kenya. Once the healthcare system accepts this responsibility and overcomes needless regulatory and procedural barriers to access essential medicines, the solutions are easy.

The good news is that India has taken steps in this direction already. The draconian Narcotic Drugs and Psychotropic Substances (NDPS) Act that prevented access to controlled pain medicines was simplified by the Indian parliament in 2014. From 2019 on, every medical student learns pain management and palliative care as an essential part of the curriculum. The National Health Policy of 2017 is currently in the process of providing palliative care education to health workers in 150,000 Health and Family Wellness centres across the country.

There are is a catch, though. The budget allocation for health care by the Central and State governments together, continues to be too low in India – 1.6 % of our GDP. Most countries spend an average of at least 5% of their GDP on health.  Most of us learnt, on our grandparents’ laps, the precious lesson that health is more important than wealth – a lesson long since forgotten.

It is necessary to make people aware of the serious, growing health issue amidst us. Many countries are working on commitments made at the global primary health conferences while others have much ground to cover. Three years ago, 2000 delegates from 120 countries met in Astana, Kazakhstan for a global primary healthcare conference and made a commitment to the “fundamental right of every human being to the enjoyment of the highest attainable standard of health without distinction of any kind”. This was a renewal of the commitment made at the first global primary health conference in Alma-Ata, Kazakhstan, 40 years ago. Though India was among the countries renewing the commitment to healthcare for all, it is also among those with a lot of ground to cover.

The ailing and suffering have no voice now; they need to be heard. As the Astana Declaration of 2018 (of which India is a signatory) points out, “health for all can only be health with all.” Treating serious health-related suffering is not rocket science; it just needs commitment to the treaties and policies that we have signed. India needs to keep that commitment.

(Dr. Rajagopal is a palliative care physician and the Chairman, Pallium India)