June 1, 2008
The World
Royal Care for Some of India's Patients, Neglect for Others
By SOMINI SENGUPTA
New York Times
BANGALORE, India — "To get the best care," Robin Steeles said gamely, "you gotta pay for it."
Mr. Steeles, 60, a car dealer from Daphne, Ala., had flown halfway around the world last month to save his heart, at a price he could pay. He had a mitral valve repaired at a state-of-the-art private hospital here, called Wockhardt, and for 10 days, he was recuperating in a carpeted, wood-paneled room, with a view of a leafy green courtyard.
A dietician helped select his meals. A dermatologist came as soon as he complained of an itch. His Royal Suite had cable TV, a computer, a minirefrigerator, where an attendant that afternoon stashed some ice cream, for when he felt hungry later. Three days after surgery, he was sitting in a chair, smiling, chattering, thrilled to be alive.
On his bed lay the morning's paper. Dominating its front page was the story of other men, many of them day laborers who laid bricks and mixed cement for Bangalore's construction boom, who had fallen gravely ill after drinking illegally brewed liquor. All told, more than 150 died that week, here and in neighboring Tamil Nadu State.
Not for them the care of India's best private hospitals. They had been wheeled in by wives and brothers to the overstretched government-run Bowring Hospital, on the other side of town. Bowring had no intensive care unit, no ventilators, no dialysis machine. Dinner was a stack of white bread, on which a healthy cockroach crawled while a patient, named Yelappa, slept.
Wockhardt has 30 ventilators, including some that are noninvasive, so the patient does not have to have a tube rammed down his throat. At any one time, a half-dozen are in use. An elderly woman had been in its intensive care unit for a week, on dialysis; her family wanted to do whatever possible to keep her alive, no matter the cost.
At Bowring, one of the young doctors, named Harish, said a ventilator and a dialysis machine would have allowed him to keep half of his patients alive. The most severe case, Mohammed Amin, was breathing with the aid of a hand pump that his wife squeezed silently. Dr. Harish sent the relative of one man to get blood tests done at the nearest private hospital; there was no equipment to do the test here. Then the doctor rushed to the triage section in Bowring's lobby, where the newest patient, writhing, resisting, disoriented from the poison in his gut, had to be tied down with bedsheets.
Where you stand on the Indian social ladder shapes to a large degree what kind of health you're in, and what kind of health care you receive. The beds in Bowring were taken up by small skinny men. One of Wockhardt's most popular offerings is a weight loss program, and the majority of walk-ins at its outpatient clinic suffer from diabetes, closely linked to obesity.
This is no anomaly. A government-sponsored National Family Health Survey released last fall says a woman born in the poorest 20 percent of the population is more than twice as likely to be underweight than one in the richest quintile, and 50 percent more likely to be anemic.
For children, the gap is equally stark. The poorest quintile is more than twice as likely to be stunted, a function of chronic malnutrition, and nearly three times less likely to be fully immunized.
It is not as if the poor do not seek treatment, Jishnu Das, an economist who studies health and poverty for the World Bank, points out. They do, and sometimes more often than the rich. It is just that they are more likely, Mr. Das says, to land at the doorstep of a caregiver who is incompetent, ill-trained or indifferent to their needs.
"The poor are not dying and sick because they do not go to seek medical care," he said. "In fact, the poor are going to doctors in droves. There are no good options for the poor. The private hospitals and care they are able to access is of very low quality, and when they try and access government care, they receive no attention whatsoever."
The survey found that two-thirds of Indian households rely on private medical care when sick, a preference that cuts across class. Asked why they don't use public facilities, the most common answer was poor care.
India has a countrywide network of government-funded primary health centers and hospitals, but staffing, medicines and resources vary widely. Some, especially in rural India, are notorious for having staff doctors on paper at best. This is only beginning to change. The government has increased health spending in recent years, and this year began a health insurance program that would allow people in poverty access to a hospital of their choice.
The Planning Commission of India this year found that in government-run health centers, 45 percent of gynecologist posts and 53 percent of pediatric posts went unfilled, and that salaries for government doctors are a fraction of those at new private hospitals like Wockhardt.
Wockhardt struggles to fill its slots, too, but its facilities allow it to aggressively recruit, including from among Indian doctors who have worked abroad for years.
The morning papers did not let Mr. Steeles forget the vast gulf between his predicament and that of the hooch drinkers fighting for life at Bowring. Yet as far apart as they were, their tales followed a somewhat parallel plot. The American health care system could no more care for Mr. Steeles than the Indian system could for Mr. Amin.
Mr. Steeles came here because he is uninsured, and could not afford heart surgery in the United States, he said, without liquidating most of his assets. After five months of research and e-mail messages to doctors worldwide, he chose a heart surgeon here in Bangalore. "I'm over here for a fraction of what I would have paid in the United States," he said. "In my personal situation, I'm just delighted I took the road that I did."
Mr. Steele's Royal Suite, incidentally, is available to anyone, Indian or foreigner, who can pay for it. After his stay here, he would move to a room at a private club for 16 days of further recovery, before flying home. All told, he said it cost him about $20,000, a tenth of what he would have paid at a private American hospital.
Across town, among the hooch drinkers, a few of the worst cases had been transferred to private hospitals that had agreed to take them, at the government's expense.
Mr. Amin was too frail to be transferred. He died at Bowring, leaving behind a wife and two young children.
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