In answer to Hemadri, in my case I was seeing any patients in the outpatient clinic under the close supervision of an Indian colleague sitting at the same desk, reviewing the management of any patients I saw, and I will not comment further on my own situation here. However, Hemadri’s general concerns about MCI registration, in a country where the regulation of healthcare activity is at best inconsistent and where pharmacists freely sell prescription medications to the public without a prescription, illustrate beautifully the kinds of structural impediments which exist in India for doctors attempting to ‘do the right thing’. The MCI has been shown to be a corrupt organisation, which had to be dissolved by the President of India in 2010, and it can take years to process a registration. Some of the charitable hospitals in India, hospitals which serve the poorest of the poor, people who would otherwise have little or no access to healthcare, depend at least partly on Western doctors paying their own expenses and then volunteering their labour in order to provide a service. Without them, many charitable hospitals may have to reduce their operations drastically .
It is these kinds of paradoxes, and the invidious choices they demand, which underpin the delivery of medical care in India, where in order to function at all physicians and organisations need to find real world workarounds or else the system grinds to a halt and their personal practice is imperilled. Until such structural barriers can be removed, then the practice of medicine in India will remain fraught with such anomalies.
Hemadri will find very positive commentary on my article and its accompanying BMJ editorial in the mainstream Indian press in the last week. And not only is the interviewee and editorial comment positive, but the 440 comments (at the time of writing) on the Times of India’s article reporting the BMJ’s position are overwhelmingly supportive and reflect accurately the large email postbag I have received personally since the original publication of my article: http://timesofindia.indiatimes.com/opinions/37350397.cms. Dr Samiran Nundy, a distinguished Indian doctor and co-author of the BMJ’s editorial, has written another article, reprinted in the Indian Express, which is also supportive and puts forward some very creative solutions: http://indianexpress.com/article/opinion/columns/first-give-the-patient-... Two former Indian health secretaries have also commented positively on my article and highlighted the structural elements which contribute to healthcare corruption in India: http://indianexpress.com/article/india/india-others/bmj-article-on-graft...
Of course, Hemadri is correct that externally imposed solutions can never be the sole answer, but shining a bright, global light on local dark corners can be a helpful part of the answer by raising awareness, as we have done here. I certainly do not have any blindingly obvious answers and fully accept that what I have proposed may not be the way forward. Hopefully, however, the BMJ’s campaign, lead from within India by its Indian editorial team and in conjunction with major Indian healthcare institutions and NGOs will help to define a way forward. In the meantime, Hemadri must be aware through his own work which he tells us about that the levels of endemic, structural corruption in the Indian healthcare system are of an order of magnitude not seen in Western countries, where being corrupt generally remains a free choice, rather than a survival imperative. He should acknowledge that this is an important distinction, which will dictate the direction of any possible solutions.
Competing interests:
I am a director of the BMJ. These views are my own.
01 July 2014
David W Berger
District Medical Officer, Emergency Medicine
Broome Hospital, Robinson St, 6725 Broome, Western Australia, Australia
Rapid Response:
In answer to Hemadri, in my case I was seeing any patients in the outpatient clinic under the close supervision of an Indian colleague sitting at the same desk, reviewing the management of any patients I saw, and I will not comment further on my own situation here. However, Hemadri’s general concerns about MCI registration, in a country where the regulation of healthcare activity is at best inconsistent and where pharmacists freely sell prescription medications to the public without a prescription, illustrate beautifully the kinds of structural impediments which exist in India for doctors attempting to ‘do the right thing’. The MCI has been shown to be a corrupt organisation, which had to be dissolved by the President of India in 2010, and it can take years to process a registration. Some of the charitable hospitals in India, hospitals which serve the poorest of the poor, people who would otherwise have little or no access to healthcare, depend at least partly on Western doctors paying their own expenses and then volunteering their labour in order to provide a service. Without them, many charitable hospitals may have to reduce their operations drastically .
It is these kinds of paradoxes, and the invidious choices they demand, which underpin the delivery of medical care in India, where in order to function at all physicians and organisations need to find real world workarounds or else the system grinds to a halt and their personal practice is imperilled. Until such structural barriers can be removed, then the practice of medicine in India will remain fraught with such anomalies.
Hemadri will find very positive commentary on my article and its accompanying BMJ editorial in the mainstream Indian press in the last week. And not only is the interviewee and editorial comment positive, but the 440 comments (at the time of writing) on the Times of India’s article reporting the BMJ’s position are overwhelmingly supportive and reflect accurately the large email postbag I have received personally since the original publication of my article: http://timesofindia.indiatimes.com/opinions/37350397.cms. Dr Samiran Nundy, a distinguished Indian doctor and co-author of the BMJ’s editorial, has written another article, reprinted in the Indian Express, which is also supportive and puts forward some very creative solutions: http://indianexpress.com/article/opinion/columns/first-give-the-patient-... Two former Indian health secretaries have also commented positively on my article and highlighted the structural elements which contribute to healthcare corruption in India: http://indianexpress.com/article/india/india-others/bmj-article-on-graft...
Of course, Hemadri is correct that externally imposed solutions can never be the sole answer, but shining a bright, global light on local dark corners can be a helpful part of the answer by raising awareness, as we have done here. I certainly do not have any blindingly obvious answers and fully accept that what I have proposed may not be the way forward. Hopefully, however, the BMJ’s campaign, lead from within India by its Indian editorial team and in conjunction with major Indian healthcare institutions and NGOs will help to define a way forward. In the meantime, Hemadri must be aware through his own work which he tells us about that the levels of endemic, structural corruption in the Indian healthcare system are of an order of magnitude not seen in Western countries, where being corrupt generally remains a free choice, rather than a survival imperative. He should acknowledge that this is an important distinction, which will dictate the direction of any possible solutions.
Competing interests: I am a director of the BMJ. These views are my own.