27thApril 2013

As the freemarket takes healthcare beyond the reach of the poor,Punyabrata

Goon is among the few fighting back.

FaisalThe 6 am start is annoying, but necessary. If Punyabrata Goon is to get through the almost 200 patients who will come to the Shramik Krishak Maitri Swasthya Kendra (Worker-Peasant Friendship Hospital) before noon, a morning lie-in is out of the question. Already, his team of health workers, girls from the vicinity of the village of Chengail, where the hospital is located, have opened the doors and begun the process of registering the swelling crowd of patients. The sight of his car causes a flurry of activity. The doctor is in.Stepping on the bridge of protruding flagstones over a puddle caused by the previous night’s rain, Goon points out to me a building in the distance: the Kanoria Jute Mills, whose trade union had started the hospital in 1995, taking inspiration from the Shaheed Hospital in Dalli-Rajhara, Chhattisgarh, where he had worked for close to a decade. The hospital, part of Goon’s Shramajibi Swasthya Udyog (Working Class Health Project), isn’t the only option for the villagers. There are a number of hospitals, clinics and nursing homes on the side of the highway; Kolkata is only 25 km away; and the district town of Uluberia has a large government hospital. However, it is a truth acknowledged by most doctors that the healthcare system in West Bengal, as elsewhere in the country, is exploitative of the poor and poorly managed. In a country where up to 80 percent of healthcare costs are borne by the patient, and where the World Bank estimates that 35 percent of hospitalised people fall below the poverty line as a direct result of their hospital expenses, Goon provides what he calls humanist care: healthcare at prices the poor can afford. The total cost of a visit to the doctor rarely crosses 100. But the hospital isn’t a charitable organisation; barring some equipment donated by well-wishers, it accepts no outside funding, instead using rational practices and common sense to keep costs low.

‘Rationality’ is a favourite word. Goon’s practice of taking detailed case histories is one such manifestation. His health workers — assistants he has trained himself — meet every patient and, through a comprehensive form, ask them questions about their physical and mental health, the languages they speak, their history of treatment and their socioeconomic conditions. This helps the doctors diagnose illnesses without having to resort to expensive (often unnecessary) tests. “Imagine you visit a doctor on a complaint of fever,” he wrote in an article about his initiative. “The doctor gives you a list of tests without enquiring about the history. The list includes blood and urine tests, test for malaria parasite in the blood, widal test for typhoid, culture sensitivity test of urine. In case of a big doctor there will be further tests of blood culture, malaria antigen, blood test for dengue, and so on. These tests are not always recommended in the interest of the patient. Many of us know that the doctors receive commission for recommending those tests.”

Goon meets his patients with a ready smile, without the brusque officiousness they are used to. He makes idle chatter while examining them; he asks one young man how married life is treating him, another whether working conditions in his factory have improved since a recent strike. He is irritated when a woman says she cannot leave her shop to come for her weekly injection. “Once you get sick, how will you work at your shop?” One patient has come from Bongaon, almost 100 km away, because of Goon’s reputation as a skilled doctor who cares for the poor.

In his chamber, with the scowling portrait of Che Guevara — another doctor-revolutionary — looking on, Goon tells me the story of his life in snatches. His politics are a major motivation; Binayak Sen, who worked with him in Shaheed Hospital, says that he is “a political worker whose chosen field of work was medicine”. Graduating from Kolkata’s Medical College in 1983, Goon wasn’t particularly interested in the traditional medical professional curve of post-graduation followed by a profitable practice or a secure government job. He had been deeply involved in student politics, most notably in the junior doctors’ strike of 1982 against the appalling conditions in the Medical College hospital, which is often the only option for quality healthcare for Kolkata’s poor. He describes himself as having been academically average, but committed to the role of medicine in improving society. As part of the Democratic Students’ Association, a politically unaffiliated student party which controlled the Medical College Student Union during the turbulent years from 1977 to 1983 — where “there was turmoil in every sphere of life”— he had spent his college years clashing with university authorities as well as the newly-elected Left Front government, while also providing free medical check-ups in the slums of Kolkata.

His friends Ashish Kundu and Saibal Jana, contemporaries at the National Medical College in Kolkata, had already begun working at the Shaheed Hospital with Binayak Sen and Pabitra Guha. Established by the Chhattisgarh Mines Shramik Sangh (CMSS), a union of iron-ore miners in Dalli-Rajhara, the hospital was unique for being a workers’ initiative after Kusum Bai, a vice-president of the union, died in childbirth due to lack of natal care. Jana, who read an article on the hospital in Sunday magazine and joined in 1982, eventually becoming head of the hospital, says the refusal by the union to seek outside help and run it themselves causes people to think of the hospital as their own. “Trade unions care only about the eight hours that workers spend at work, but the CMSS felt they should take all 24 hours into account.” A portrait of CMSS founder Shankar Guha Niyogi, assassinated in 1991, also hangs at the hospital in Chengail, as do those of Dwarkanath Kotnis, Norman Bethune and Dhiranjan Sen, doctors whose lives have inspired Goon. Also displayed prominently are the credentials of the medical staff, presumably to counter the questions of legitimacy that are invariably asked. Questions that were asked when doctors at Shaheed Hospital noticed a cholera outbreak in 1984, but their claim was rejected by the government, Jana says, because theirs was a workers’ hospital.

It was at Shaheed Hospital that a number of the practices Goon implements in Chengail were first attempted. The World Health Organisation (WHO) had published its first List of Administrable Drugs in 1977, and Dalli-Rajhara became a laboratory for its execution. The list, which specifies a certain number of medicines that are necessary and sufficient to “satisfy the healthcare needs of the majority of the population”, was adopted by the hospital, which only prescribed drugs that were included, mostly in the generic form. The WHO list began a national debate on essential medicines; a number of developing countries immediately banned all other formulations, but India did not, allowing the continued sale (and prescription) of unnecessary drugs. The Indian government would eventually bring out its own National List of Essential Medicines in 1993, but the list merely enumerates which drugs must be accessible, and is rarely enforced. This, Goon says, means that though simple, single-ingredient medicines exist that can cheaply treat most illnesses, they are not always made available, and the patient is forced to buy expensive, unnecessary formulations. The hospital at Chengail, like the one at Dalli-Rajhara, prescribes generic drugs, which cost as little as a tenth of the market price for brand-name pharmaceuticals. “These drugs aren’t different from commercial ones,” he says. “The companies buy the same medicines and mark up the price.”

Another measure that continues in Chengail is the focus on primary healthcare. Goon, who is trained in most complex surgeries, finds general practice much more satisfying. “Surgery is a really romantic thing,” he said in an earlier interview, “You get to go into the operating theatre and come out a hero. But this isn’t what I want to do anymore. There is so much one can do with a rational system of allopathic treatment.” No one is turned away at the hospital — those who can’t pay even the meagre fee he charges are treated for free, while those with ailments for which the hospital isn’t equipped are referred to other centres, where their treatment is subsidised — and days when he works from dawn to midnight are not uncommon.

On this particular day, the crowd isn’t too large, which is just as well, since he has to leave for Jadavpur University in the evening, where his organisation is supporting a student protest calling for the release of Soni Sori, the first street demonstration on the issue in West Bengal. Every free moment is spent calling colleagues in Kolkata, urging them to join the protest. Another phone call has bad news; they won’t be able to carry out their medical camp in strife-torn Lalgarh this week, since the farmers there need to tend to their crops. Before joining Shaheed Hospital, Goon worked in Bhopal, treating victims of the 1984 disaster. When the violence in Nandigram broke out in 2007, his Shramajibi Swasthya Udyog was one of the first on the scene, sending a team of doctors three days after police firing had killed more than 15 people, to assess the situation and provide free check-ups. Their damning report revealed the scale of the violence, which was being downplayed by the government at the time, exposing how many victims, mostly women, had been denied medical aid.

The narrative on rural healthcare today focuses on the question of how to induce young doctors to work in the villages, either through compulsion or incentive. For Goon’s generation of doctors, medicine as public service was as valid an idea as that of medicine as a career choice. One reason, says Piyush Guha, who was incarcerated with Binayak Sen in Chhattisgarh on charges of being a Maoist and is a friend of Goon’s (he was present at the Jadavpur rally), was the influence of politics on student life. “Our generation was politically active. We had role models in the Naxalites, for better or worse, who were willing to give up their lives to work in the villages.” Goon doesn’t see a decline in volunteers, pointing out that the youngest doctor in his organisation is only 19. Jana, though, has had major problems attracting volunteers; just six doctors manage his significantly larger hospital. “Medical education needs to be reformed,” he says. “With the large increase in private medical colleges, students have to spend a lot of money to get a degree and, naturally, they have to earn that money. If we increase the number of government hospitals and give chances to lower middle-class students, many more will come to work in rural areas.” He is, however, against the idea of forcing doctors to work in rural areas, citing his experience of medical students who have “no idea how to treat patients, how to diagnose malaria or diarrhoea. There is no one to train them here. They’re not doing any good, only harming people.”

One initiative that has acquired much traction is the training of quacks in the elements of medical philosophy, something that Goon’s organisation has attempted in a number of places. This sort of training has had a mixed response from the health establishment. The Chhattisgarh government introduced a pilot project in training village youths in basic medicine, which helped to a large extent to fill the vacancies in the state’s community health centres. An attempt by the central government to introduce a Bachelor of Rural Healthcare course, however, was met with protests by the Indian Medical Association (IMA), and other similar associations, which alleged that such a measure undermined a villager’s right to life, and had to be eventually watered down. “Quackery will not change in the near future,” says Jana, “They have a small knowledge base, but if that is sufficient, what is the problem? In any case, a urologist has no knowledge in neurology. Is the IMA in a position to provide doctors to rural areas?”

Even as other doctors choose cushy jobs over public service, Goon continues to live the life of the committed revolutionary. “If what doctors are doing does not challenge the status quo,” he said in another interview, “what is the point of practising medicine?” He has earned the respect of his peers, many of whom periodically come to his hospital to see patients. More important, he says, is the love he has received from the people he serves, and he doesn’t see himself stopping anytime soon.