Post-Covid, healthcare in India must take a Gandhian turn
Many years ago, on a train journey from Mumbai to Wardha, to appear for the entrance exam to the Mahatma Gandhi Institute of Medical Sciences in Sevagram (India’s first rural medical college), I hurriedly read through a book on Gandhian thought, because it was a part of the exam curriculum. I did well in the examination, but chose not to join the college which was run by a board of Gandhian scholars and doctors. Instead, I chose the King Edward Memorial (KEM) Hospital in Mumbai. After spending 12 long years at KEM, I became a qualified super-specialist and then continued my supposedly stellar career path by eventually joining as a consultant at a ‘five-star’ private hospital, which primarily caters to the upper strata of the society and provides world-class care and results.
Unfortunately, India’s healthcare, too, followed a similar trajectory: it moved away from villages into the metros, from preventive and primary care to curative and tertiary care, and from the public sector to the private sector.
Today, as I reflect back, I wonder if joining the Gandhian institute would have been a more satisfying career choice. Also, had India decided to develop not just one, but hundreds of such rural (Gandhian) medical colleges and hospitals in the villages and small towns of our country in the 1960s and 70s (the Sevagram-Wardha medical college was started in 1969), the whole healthcare pyramid in India would’ve been the right way up, and not turned upside down, as it is today. If Gandhiji would’ve lived longer, it may have actually happened.
Today, our erroneous health trajectory and our poor health infrastructure have been thoroughly exposed by the Covid-19 pandemic. Now, eight months into the pandemic, as we are coming to terms with the virus, it’s time that governments must start thinking and planning about how to rectify the wrong path that we have taken. It is time for India’s healthcare to take a Gandhian turn, or shall I say, a U-turn.
The young Mohandas was eager to become a doctor, but his brother and father had nipped his desire in the bud – the reason being that Vaishnavas should have nothing to do with the dissection of dead bodies. So he went to England and studied Law. But even for the Barrister Gandhi, health –both personal and social – was of great importance. His life, principles and writings, hold many lessons about health and healthcare.
The first turn: From healthcare to health
The first Gandhian turn – that we as individuals as well as a nation – must take, is to move away from just thinking about healthcare, without thinking about health. Prioritising health over healthcare means living healthier lifestyles as individuals and as a society and enabling its citizens to lead such lifestyles. It also means prioritising preventive care over curative care and primary healthcare over tertiary care. Not just Gandhi, but recently even the dean of the Boston University School of Public Health, Dr Sandro Galea, in a live online dialogue about Indian healthcare, in the wake of the pandemic, pointed out the need for India and Indians to emphasise health over healthcare.
Gandhi was a short and lean man, but had a healthy disposition. Throughout his life, he was more than conscious about what and how much he ate, avoiding intoxicants and the need for regular exercise. An interesting example of his diet fanaticism was how during a serious illness, he refused to take cow’s milk (because of a vow he had taken to abstain from it due to ill-treatment of cows while milking them), and was then persuaded to take consume goat’s milk – which was much more expensive. That is probably why Sarojini Naidu once said to him, “How costly it is to keep you simple.” Gandhi, after a pause, had replied in a contemplative mood, “Yes, God will forgive me. I have to maintain my body in a healthy way so that I can carry on my mission.” Gandhiji was also a fitness freak, and walked nearly 18km every day for over 40 years. It has been estimated that he must’ve walked enough to go around the earth twice.
Gandhi was equally concerned about the health of his colleagues and of the poor masses. He realised that health also depends on the air we breathe, the earth we live on and the water we drink. It meant that to be healthy, one needs to live in simple, but clean and uncongested dwellings. In his book ‘Key To Health’ published in 1948, he says that the general rule should be to live in a locality which is not too congested, and insist upon the house being well-lighted and well-ventilated. He believed that cleanliness is next to Vaishnavaite Godliness. His ashrams in Sevagram and Ahmedabad are examples of these beliefs. He would have been aghast at the urban sprawl of unhygienic and congested slums. Prioritising health over healthcare would mean providing proper housing and sanitation and not just good hospitals. In this context, the Prime Minister’s campaign for freeing India of open defecation can be considered a Gandhian initiative.
The second turn: From metros to towns and villages
As was mentioned in the beginning of this article, our health trajectory has been lop-sided. And although late in the day (a good 70 years after the Independence), it is never too late to make amends. Healthcare must move from the KEM hospitals in cities and metros to Kasturba Hospitals in towns and villages. It must move from the corporate Apollo Hospitals to modern public Sushrut or Dhanwantari hospitals. Why can we not imagine a reoriented healthcare system where people from metros go to towns and villages for getting their major surgeries done – and probably at a much lesser cost!
Gandhi’s statement, “The future of India lies in its villages,” still holds good, although it has been consistently neglected by the disproportionate growth of Indian cities and urban regions, whereas there isn’t as much growth being witnessed in the villages. This applies to the healthcare infrastructure too. Over the past 20 years, the only meaningful healthcare infrastructure that has been developed in rural areas is a spattering of unregulated nursing homes set up by private doctors. Needless to say that the care provided in most of them is not up to the mark, many times unscientific and expensive. The other health-related infrastructure to come up in rural settings across the country has been the hundreds of private medical colleges run by politicians, where ironically, urban students come and study. Most of these institutions have made a mockery of Gandhian values and medical ethics.
During his lifetime, Gandhi advised doctors to go to villages. And his interesting advice to them was: “He will not go out as a patron saint of the villages; he will have to go in humility with a broom-stick in his hand. There is a Trinity of evil – insanitation, poverty and idleness – that you will have to be faced with, and you will fight them with broom-sticks, quinine and castor oil, and if you will believe me, with the spinning-wheel.”
I believe that even today, the paucity of doctors wanting to go to the villages is because they do not want to go there with the humility as suggested by Gandhi. They do not see themselves as social workers, while being a doctor. This mentality has to change. This can only happen with a Gandhian mindset. And thus, Gandhian values need to be taught as a part of the medical curriculum in all medical colleges, as they hopefully still continue to do at Wardha’s MGIMS. I would also suggest putting a moratorium on new medical colleges in cities and metros.
The third turn: From specialists to generalists and paramedics, from tertiary care to primary care
Gandhi, while laying great emphasis on preventing diseases, also believed that the most common 42 diseases do not require a specialist doctor, and can be treated easily by a good nurse or a generalist doctor. Gandhi himself served as a nurse in Mission Hospitals and also during the Boer War in South Africa. In his descriptions of his illnesses during his lifetime, he describes how only after several basic therapies were tried, did he opt to go to a specialist doctor.
In India, with our lop-sided healthcare trajectory, we have sadly moved away from primary healthcare. The initial efforts and enthusiasm to develop primary healthcare centres (PHCs) did not last long, and many PHCs exist today as dilapidated structures without staff and equipment. We do not even offer a postgraduation course in general practice at most of our medical institutions. The lack of good, modern, well-equipped primary healthcare facilities has led to overcrowding and overburdening of bigger hospitals and tertiary centres. In this context, the efforts of the Aam Aadmi Party (AAP) in Delhi to rectify this anomaly by setting up a chain of modern Mohalla clinics have been exemplary, and must be emulated across the country.
The fourth turn: From a non-scientific to a scientific and research-minded approach
Gandhiji was always scientific in his approach towards health and healthcare. He was very critical of the fact that the indigenous systems of medicine had not kept abreast with modern methods of research. Regarding Ayurvedic doctors, he has written, “They impute to Ayurveda an omnipotence which it does not possess, and in so doing, they have made it a stagnant system, instead of a gloriously progressive science.” As I write this, it brings to my mind the recent tall claims made by an Ayurvedic consumer goods and medicines manufacturing company regarding their new drug which could cure coronavirus.
Gandhi praised western medicine for the “…brilliant array of discoveries and inventions which western physicians and surgeons boast.” Indian doctors and basic medical researchers have to go overseas to western centres to let their research flourish and bear fruit. We must facilitate our doctors and bio-researchers to be able to do meaningful research. Many of my surgeon-peers in Europe or USA spend a day every week in modern research labs attached to their hospitals and medical colleges. How many surgeons in India can do that?
The fifth turn: From private to public health and healthcare
The final Gandhian turn to take is to move away from the limitations of an overwhelmingly privatised, disintegrated and for-profit healthcare system, to a more egalitarian, modern and predominantly public healthcare delivery model. The limitations of our exceedingly privatised model have been more than exposed by this pandemic. A similarly over-privatised system exists in USA and we know the havoc the pandemic wreaked in that country too.
Gandhi was very clear in his views about the priorities of the medical profession. On February 13, 1921, on the occasion of opening of the Tibbia National Medical College, he said, “Lastly I shall hope that this college will inculcate among the students the belief that the profession of medicine is not intended for earning fat fees, but for alleviating pain and suffering”. Thus, he would have certainly been against a system which was largely for-profit.
In 1991, when we liberalised the economy, the state withdrew many economic restraints, but it has also withdrawn from many of its social responsibilities: health and education. The pandemic has revealed the tragic consequences of abdicating these state responsibilities. The recent spurt of many national and state insurance schemes for citizens to avail treatments in private, non-modern, mom-and-pop, stand-alone nursing homes (it’s difficult to call many of them modern hospitals) cannot be equated to being treated in well-equipped public, modern multispecialty hospitals and centres.
It is said, if you sweat in peace, you don’t bleed in the war. During this war against coronavirus, we are bleeding and bleeding much more than others because we did not sweat in peacetimes. We did not build the right health infrastructure. We did not prioritise the health of our people over healthcare. We left the health of our people to the mercy of the market forces. We allowed wealth to buy health. We disabled our citizens from even attempting to remain healthy by making them live in cramped and unhygienic conditions, where social distancing is an impossibility, and asking them to keep a 2-metre distances is a ridicule.
I hope that the bright warning light that the pandemic has shone on our failures is strong and scorching enough to be perceived even by our blind or Nelson-eyed politicians.
Let us not forget what Bapuji, the conscience-keeper of our nation, once said: “It is health that is real wealth and not pieces of gold and silver.”
(Dr Santosh Karmarkar is a consultant paediatric surgeon and paediatric urologist at Lilavati Hospital and Research Centre, Mumbai)