Introduction

This past summer I had the opportunity to spend a month observing the healthcare system in India as part of a global health education internship on maternal and child health. While I did not expect to change the state of healthcare in India by any means, I wanted to see, for myself, what healthcare looked like in a developing nation where traditional culture and religion often conflicted with the impacts of modernization and economic growth. This is what I saw.

Upon my first outing with the other five female American students who were participating in the program, I quickly realized that we would draw a bit of attention when traveling as a group. As a traditionally male-dominated society where sex selection and female infanticide are still widely practiced, it was quite a shock to be mocked openly for what felt like no reason at all, but turned out to be due to our “western” clothing and obvious foreignness. Though we quickly learned to ignore this kind of treatment, it was unsettling to accept that women are thought of as second-class citizens, and will continue to be viewed as such for a very long time. One particularly exasperating incident occurred when we toured the Aurangabad Caves. By that point we had become accustomed to the obvious stares, but never before were we followed by a handful of adolescent males taking pictures of us and refusing to leave us alone. Though appalled that this was acceptable male behavior, we realized that harassment laws are not quite the priority when an estimated 41.6% of the Indian population lives below the international poverty line [1].

Observations on Maternal Medical Practices in India

This gender inequality was perhaps more clearly reflected in the medical practices we observed. Like most countries with a combination of private and public health care, the public hospitals cared for the poor while the private hospitals tended to the wealthy. Though I have volunteered at several underfunded county hospitals in the U.S., patients there received five-star treatment compared to some of the conditions in public hospitals in India. Gloves were reused after surgeries, sterilization meant wiping down the bed in the operating room, and flip-flop sandals were the preferred footwear. In fact, when we wore surgical booties that were to be donated to the hospitals, the surgeons told us to take them off. When we suggested that using these might be more sanitary, we were rebuffed as ignorant of the healthcare practices in this country. A similar situation occurred when we observed our first surgery, a tubule ligation, the first of many female sterilization procedures we observed. Out of curiosity, I asked why female sterilization was so common when male sterilization is cheaper, safer, and faster. I received a confused and irritated look from the surgeon, who simply said, “that’s just the way it is”. While I initially thought this kind of arbitrary medical practice was a transient phase in India’s transition from a traditional society to a modernized one, I later realized there was little incentive for physicians to change their ways and encourage health education.

Of all the surgeries we observed, the majority of them were some form of female sterilization. As the most commonly used form of population control, wives in lower-income households are more or less obligated to undergo sterilization after their second child [2]. Much can be said about the human rights issues with these practices, but it was most strange to me that this happened to be the most prevalent form of birth control. It all came back to gender inequality. Depending on the area, education and literacy can be incredibly scarce [3]. In rural communities, most men receive information about contraception from the media, but have little substantial knowledge about the use and effectiveness of each form [4]. And since men are almost always the sole decision-makers in a household, they are driven by social norms and peer pressure to choose female sterilization over emasculating male sterilization or other stigmatized forms of contraception, such as condoms and oral contraception.

Public Healthcare Provision: Quality vs. Quantity

Intuitively, it would be up to the physicians to take initiative and implement change in the perception of family planning methods, but such an undertaking is easier said than done. The shortage of physicians combined with overpopulation renders little time left to plan for the future, especially when the present is so tenuous. When a successful day in public health “is the ability to stave off crisis for another day”, there is no wonder why few physicians and policymakers are willing to take on more responsibility than they already have [5]. While one can argue that small changes in health education can be done on an individual level between the doctor and the patient, in which physicians explain the nature of different family planning options to their patients, this is also easier said than done. Peter Selby, a medical graduate from Bombay, claims to have seen 70 or so patients between 8 am and noon. Before he hears the problem, a government doctor is already writing the prescription, he says [5]. With physicians and resources spread thin, a physician cannot spare the personalized attention with patients we have come to expect in North America. Only in private clinics are patient consultations even practiced.

The cost of overpopulation is obvious in the quality of patient care in public hospitals. Despite the nominal universal healthcare system, most impoverished patients I observed received a meager two to five minute diagnosis and treatment from the physicians. Yet, most of the hospital staff seemed to work tirelessly to accommodate as many patients as possible. Indeed, the tradeoff between quality and quantity of healthcare provided is heightened in a country where the physical infrastructure of hospitals and clinics cannot meet the public’s demands [6]. A two to five minute visit would only be able to treat common, easily identifiable illnesses, whereas more severe illnesses such as cancer or diabetes are ignored or misdiagnosed. This poor quality of public health may be contributing to the increase in lifestyle diseases in India, including cancer and heart disease [6,7]. Additionally, the amount of waste and suffering caused by wrongly prescribed medications is immeasurable.

Though it is arguable that it may be more cost and time efficient for physicians to see fewer patients per day, this will result in more patients receiving no, or delayed, healthcare. From speaking with our supervisor, the head of the OB/GYN department at a major medical school in India, the physicians in India must operate under statistics. Most of the patients they see will have common diseases, such as the cold, the flu, or a vitamin or mineral deficiency. Hence, from their eyes, greater good can be done by seeing more patients quickly, and diagnosing their symptoms with the most common diseases an Indian national would contract. The downside, of course, is that a portion of these patients will be misdiagnosed.

Healthcare in Relation to Wealth Discrepancies

This leads to the other curious healthcare observation related to the socioeconomic gap between the rich and the poor. Because wealthier individuals have the means to pay for private healthcare, a few affluent families reaped the benefits of the best treatments in the world, while the majority of the population lived in squander. This discrepancy in wealth was underscored when we attended a presentation on “robotic surgery” at one of the public medical schools. My initial excitement to learn about an innovative surgical technique was quickly replaced by a realization of the disparity in access to new technologies between rich and poor hospitals and medical schools. The “robotic surgery” was merely laparoscopic surgery, a technique that has been in practice for decades. It was strange that some of the hospitals and clinics we visited in India were already practicing laparoscopic surgery while others had not even heard of the technique. Unlike associations of physicians present in developed nations, such as the American Medical Association, healthcare practitioners are fragmented in India. It is every person, and every physician, for him or herself. There is no medium or uniting organization that allows healthcare practitioners to come together and share ideas. This, plus the extreme wealth disparity, conferred a wide discrepancy in the type of health services accessible to different demographics of people.

This discrepancy was further underscored when we visited a fertility clinic in a wealthy district. It was ironic to see a few women doing everything possible to conceive, while a large proportion of the female population was being sterilized to decrease the birth rate.

Corruption Preventing Reform

When I began researching political reform to rectify the inequality in standard of living, I realized how discouraging it is to even begin undertaking any public service project. The severity of corruption and bureaucratic inefficiency has been considered on par with the HIV/AIDS epidemic and climate change [8]. It is estimated that approximately 1.26 percent of the GDP is siphoned away in corruption [9]. This, plus the money that goes to bureaucracy, leaves few funds for development. Despite the supposed commitment to universal health care, clean water and education, India ranks 171 out of 175 in public health spending, with a mere 0.9 percent of the GDP spent on public health and 4.3 percent spent in the private sector [10]. The entire system appears to be a skirting of responsibility. Peons are hired to shuffle papers and avoid the job of actually doing something. This extends all the way up to the prime minister. Although subsidizing small items like gasoline and food may provide minor benefits to the poor, little progress has been made by Prime Minister Manmohan Singh in the proposed 16-year campaign to decentralize power from the states to local governments since his appointment in 2004.

Corruption plays a major role in precluding the advancement of developing nations [11]. In addition to the funds siphoned away to bribes and scams, a high level of corruption “discourages the investments needed for economic progress” [11]. The social effects are subtler, but perhaps even more pervasive. An acceptance of bribery discourages ambition and initiative. Why be the bigger person when everyone else is cutting corners? It fosters resentment and disrespect for authorities, and compels even the most avid reformers to throw their hands up in dismay. While this effect is amplified in regions where payment for service is low, it is not unique to India or other developing nations.

After volunteering at both county hospitals and private hospitals in the U.S., I noticed that the staff members of private facilities were kinder, more attentive to their patients, and even allowed them to stay longer if they so pleased, whereas county hospitals had policies ordering the release of patients as soon as they were stable. This is likely due to a difference in payment methods, with private hospitals in many countries, including France, Austria, and New Zealand, operating under a fee-for-service payment method [12]. Public hospitals, in contrast, pay physicians on a salary. Hence, the physicians at private hospitals are likely to over-supply services in order to maximize profit, whereas physicians at public hospitals will under-supply services because of overcrowding and fewer expendable resources [12]. While the financial effects on quality of care are less egregious than the explicit bribery and corruption in India, it makes clear that even benevolent physicians can be swayed by incentives. On the other hand, without opportunities to be rewarded for services, which is the case with salaried physicians in public hospitals, there is little motivation to do the best job possible. Without oversight or incentives to perform, it is human nature to do the bare minimum since any additional effort is unappreciated.

In the U.S. and other developed nations, wealth and structured governments with checks and balances prevent injustice and minimize corruption. This is not the case in India, where a lack of resources and corruption from the top down amplifies inefficiency in healthcare and other government-run systems. Though the prospect of overhauling the entire government seems impossible, something has to be done. The consequences may be disastrous for the Indian economy if corruption is not diminished. The question now is where to begin and who should get involved.

Conclusion

This leads me to the question I’ve been pondering since my return from India. I wonder if these global health education programs geared towards college students are truly beneficial for the people they claim to help, or if they are merely a form of exploitation. To me, it was evident that the program I participated in had a little bit of both. Though I did not mind the tourist tax, I did question the extra charges of attending medical conferences imposed on the students by our supervisor. I had to take his word that the majority of our money went to the hospitals and clinics that invited us, but admittedly, it was difficult to see any difference it made. My few dollars could help a dozen or so patients, a worthy cause in itself. Yet, such a small act of generosity is made even smaller when considering the vastness of the issues that need be addressed. I can only hope that my dollars did not simply go to making the rich and well-connected richer, while again leaving the poor with nothing.

In addition to this potential exploitation of us students, there was also potential for exploitation of Indian patients. As we shadowed physicians, most of them took it for granted that their patients would assent to student observation. Though the patients did not complain, it was discomforting to gain access to extremely personal healthcare procedures, such as pelvic exams and even medical terminations of pregnancies, without prior consent from the patient. Furthermore, unlike healthcare the U.S., where patient-centered care empowers patients to voice their opinion about their doctors’ orders, India and other developing nations operate under a paternalistic system in which physicians propose treatments without much patients input [13]. From the physician-patient interactions I observed, not a single patient questioned the physician’s prescribed medications, asked about potential side effects, or voiced other concerns. Hence, patients probably feel that they are not in a position to disagree with or question their physicians, and will accede to requests they are uncomfortable with. This disparity in authority between the physician and patient sets up a relationship in which callous physicians can easily exploit their patients for financial gain. Though I do not doubt that citizens of developing nations have different standards of privacy and patient protection than those of developed nations, I still found it objectionable that our program coordinators could have easily used leverage to obtain student access to hospitals and clinics at the expense of patient consent.