TeaThat was a rough time for the biomedical profession in India in the mid-2010s. A series of media reports suggested that incidents of physical assault against doctors, mostly by persons accompanying patients, were undergoing a sudden and worrying increase. While such physical attacks were not uncommon, doctors agreed that the frequency and nature of attacks had worsened during that decade.
Many wrote detailed comments on the medical how and why The profession had reached such a state that the public was “losing faith” in doctors and often expressed their distrust and anger through violence. Through many such analyses, doctors and other commentators were arguing that in recent times (“a few decades ago”), there had been a major break in how people viewed doctors in India: before the break, doctors were “highly respected” members of society, and thereafter, there was a “social disconnect” in which people approached them with “doubt, distrust and anger”.
Several reasons were cited for these changes, including the proliferation of private medical colleges and corporate hospitals in the 1980s–90s, which led to an increase in the “commercialization” of healthcare, as well as public health facilities and health care. Inadequate investment was made by the Indian state to improve in general.
Government action and inaction were also said to promote commercialisation: inadequate state support and budgetary allocations for the public health system left people generally dissatisfied with government doctors and health centres, with more space, power and Even prestige left private. Beneficial Care Providers and Centers. As the options for care through public institutions became less frequent, a greater number of people were choosing to receive care from private providers who themselves were in competition with each other and engaged in monetary and other malpractices. Were.
Thus, the observations of doctors (and other experts) during this turbulent time had a quasi-historical narrative that changed public attitudes towards the medical profession in the post-independence period and a quasi-statement of the role played by government policies. Historical description. Change.
As a medical student and a doctor practicing in India during 2004-2014, I began to develop an interest in dissecting this gained knowledge. After an extensive historical investigation as part of my PhD during 2016-2022, I found that there are indeed large question marks over this gained knowledge, including over claims of a trustworthy patient-doctor relationship in the past.
state-backed dominance upper caste and class
Biomedicine (also known as ‘modern medicine’ or ‘allopathy’) was adopted by India’s anti-colonial, nationalist leaders as the most appropriate form of healthcare for independent India. A shared vision of progress through modernization, coupled with a shared past of privilege through tradition, facilitated the appointment of biomedical doctors as the primary providers of state-directed healthcare by early Indian leaders. However, the doctors also had personal visions of progress that often clashed with the state’s view of development. This conflict of interest was most visible in the state’s insistence that doctors serve in villages, and the persistent ambition of doctors to practice in urban areas.
Thus, in the early decades of independence, the state tasked biomedical doctors to provide healthcare to the nation and devoted considerable resources to building new medical colleges and hospitals, but unable to persuade most doctors to practice in villages. where most of the Indian population lived. There was a paradoxical asymmetry in the relationship between the state and doctors, in which, despite having significantly more power than the profession, the state accepted doctors far more and failed to make any major concessions from them.
How did the state’s resolve to provide healthcare to the public through the agency of biomedical doctors manifest itself on the ground and within communities? In the early decades of independence, doctors remained a foreign group for much of rural India: not only because of their frequent absence from villages, but foreigners as well. In His occasional presence. A large number of villagers, especially those from disadvantaged castes and communities, saw doctors primarily as representatives of the caste, government and urban elite. Along with the fact that the rural Indian landscape was liberally replete with a variety of local, traditional healers and practitioners of medicine whom the villagers continued to patronize, the isolation of doctors meant that they were rarely trusted, first-hand, of care. The line provider. large number of rural Indians.
On the other hand, in urban India, doctors were plentiful but lacking a “human touch” in their interactions with many patients. Public hospitals, which had a heavy presence in cities and major towns, were simultaneously a major provider of healthcare for disadvantaged urban dwellers, and a major site of humiliation and exploitation. The behavior of hospital staff, including many doctors, was often portrayed as rude, reckless and rude, with racist and classist prejudices often affecting how doctors interacted with people. Such staff behavior, as well as the general overcrowding and unhygienic conditions in public hospitals, meant that these hospitals were hardly the first choice for the care of large numbers of urban Indians, who often preferred – like their rural compatriots – Local physicians based in their community.
Cities also had many private clinics, nursing homes and hospitals, including private wards in public hospitals, all of which were primarily used by the urban elite, who were also equal in class and caste to doctors. Doctors generally enjoyed a friendly relationship with them, and these elites often shared the same elite urban space, for example, social clubs such as the Rotary and the Lions Club. Thus, the relationship of the medical profession with the privileged masses was quite different from that with the disadvantaged: the cordiality of doctors and the extent of etiquette in the former often matched the amount of indifference and disrespect of the latter.
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Changing worldview of the state, aristocracy
From the mid to late 1960s, in this larger context of the biomedical encounter, major changes began to take place in the Indian state’s attitudes towards doctors (and health care in general): the previously paradoxical asymmetry of power gave way to the state. Growing disregard for the input of the medical profession in health policy making. In response to doctors’ continued reluctance to provide meaningful care in rural India, the state began to look beyond both biomedicine and doctors, with the addition of homeopathy, some of the major Indian indigenous systems of medicine (notably Ayurveda), receiving increasing patronage. Was doing. at the federal level in the 1960s and 1970s (and continues to this day).
The state also invested in commissioning a large cadre of community health workers for rural India, whose deployment began in 1977. All these changes were strongly opposed by the doctors, although they enthusiastically supported the “population problem” as well in the state. .” Doctors conceptualized, organized, participated in, and generally supported a number of “family planning” policies and activities, many of which were overwhelming.
Across India, the state-led family planning program was viewed with suspicion and anger, especially by the underprivileged, who bore the brunt of its tremendous adverse effects.
There were parallel developments in the 1970s and 1980s that mainly affected the relationship of doctors with the elite public. This period saw a significant increase in the number of medical graduates in India: mainly the result of continued patronage and investment in medical colleges and hospitals from 1947 by the Indian state, aided by a gradual increase in the number of private medical colleges. Most fresh graduates, like their predecessors, chose to engage in private practice in urban areas, further saturated the urban medical market. The privileged urban masses, including the so-called “middle class”, began to complain about unnecessary tests and procedures by doctors, their “impersonated” behavior, their “professional” attitude.
However, even as doctors noted the dissatisfaction of the elite public with the depersonalization of medical practice, the profession continued to disregard, neglect and dehumanize, which marked the interactions of many doctors with disadvantaged patients. .
By the 1980s, as “negligent physician” became a common topic of discussion in print and popular media dominated by the elite, the elite began to discuss medical negligence in the context of personal experiences and in the form of narratives on negligence and exploitation. done. The underprivileged have to face in government hospitals. At the same time, the ethical integrity of the profession and its leaders were under severe attack with reports of sex-selective abortion, the kidney trade, and other forms of misconduct by doctors. Public discourse in India now began to register a sense of “loss of trust” in doctors, and by the late 1980s and early 1990s, disillusioned patients were increasingly under a new law on doctors (the Consumer Protection Act). were sued for medical negligence under
However, the ability to express disenchantment with doctors in mainstream public forums, and to take those potentially harmed to court, was accessible to those with at least some socioeconomic privilege. In such a scenario, elitism, racism, patriarchy and everyday forms of exploitation remain largely unresolved in the biomedical encounter experienced by people from disadvantaged communities.
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How was the reaction of the doctors?
The increasing number of lawsuits against doctors in the early 1990s catalyzed tremendous rhetoric and action, including a legal challenge in the Supreme Court of India against the Consumer Protection Act’s oversight of doctors, filed by the Indian Medical Association (IMA). is included. Doctors wrote and spoke extensively, and created a great deal of narratives about the history of public trust in doctors.
In these comments, the rise in medical malpractice and the loss of people’s trust in doctors was said to result from an increase in the number of private medical colleges and corporate hospitals, as well as an increase in the number of patients working as “suspects”. . Thomas.” The stories long ignored and abandoned the existence of profiteering and malpractice in the Indian medical profession. The sometimes reluctant acceptance of the existence of corrupt and unethical practices was almost always accompanied by the caveat that these were unusual and “some black Sheep” work.
Elements of these narratives continued to be employed in the late 1990s and into the 2000s, including the Indian state’s economic liberalization policies and the resultant privatization of health services as major causes of “deteriorating” patient-doctor relations. went. But even during these decades of massive change, analysis and rhetoric, there has been much debate on the dominance of privileged castes in the profession and its leadership, and on how caste-based privilege has shaped and colored doctors’ worldviews and narratives. There was little discussion. His attitude towards most patients. As before, routine dehumanization of disadvantaged patients in biomedical encounters remains, and remains a rare subject.
Kiran Sambhaji Kumbhar is a medical doctor, a graduate of health policy and a PhD in history of science. He tweeted @kikumbhar.
This is an edited extract from Kiran Sambhaji Kumbhar’s doctoral dissertation.Healing and Harming: The “Noble Profession” of Medicine in Post-Independence India, 1947-2015,’ published by Harvard University Graduate School of Arts and Sciences. read full paper Here,