Shubhendu, the quint essential news junky, the man who loves science and politics in equal measure and offers the complete contrast to it by being a fan of urdu poetry as well.
In India, doctors are placed at par or next to God as it is their profession to treat people in pain, end their sufferings and also many save lives. On the other hand, doctors are often accused of callousness and self-infatuation for taking undue advantage of people's sufferings. In this process, the doctor oscillates like a pendulum at his work and becomes a tool in the hands of his patients and their families and others in society.
India is a developing economy. The nation's assets are shared unequally by 1.4 billion people. According to the latest government data: India's gross domestic product is estimated to have slowed to a five-year low of 5.8 per cent in the last quarter of fiscal ended March 2018–2019.
At the same time, the country's per capita income is estimated to have risen by 10 per cent to ₹10,534 a month during the financial year ended March 2019, government data on national income showed in June. In 2017–2018, the monthly per-capita income had stood at ₹9,580. This does not mean every adult Indian has ₹10,000 to spend every month.
Since the 1970s, India has progressed rapidly in healthcare indices, yet the anomalies are stupefying. The Maternal Mortality Rate has declined from 167 in 2011–2013 to 130 in 2014–2016 per 100,000 live births, according to a special health bulletin from the government in 2018. Still, about 44 children out of 1,000 live births die even today.
Yet, India has emerged as one of the top 10 medical tourism destinations in the world with more than four lakh people visiting India annually for low-cost healthcare that ranges from heart-transplant to knee surgery and Ayurveda, amounting to about 5 per cent of the total yearly tourism revenue – about ₹200,000 crore. And India is also where kidneys can be bought for a few lakh of rupees.
The poor in India, however, have no access to even basic healthcare, and certainly no access to dialysis or kidney transplants even in major government-run hospitals. What is low-cost for the world is unaffordable to the poor Indian.
The poor in India is deprived, uneducated and always in need of funds. They remain at the end of the economic supply chain, which includes basic housing, schooling and medicare and often gets nothing in her/his life.
Doctors fall in the high-income bracket, at the high end of the economic supply chain by virtue of being educated. This, however, does not decrease their 'irresistible desire' for more, nor does their swearing by the Hippocratic Oath make them any more ethical than the average medically untrained human being.
The healer and the poor are all caught in the web of a nation-wide trade in kidneys perpetuated by rich recipients, their families and middlemen – all five categories of people making up the innards of a runaway scam that no government in India can reign in.
The authorities, as well as civil society, acknowledge that the 'kidney rackets' need a final solution. But who is responsible for such ongoing rackets all over India? Believe it or not, the situation affects everyone, from the poor to the acclaimed and senior kidney physicians. A solution is needed and the doctors can neither wash off their hands by blaming bad hospital management nor can be meagre spectators without contributing to stemming the rot in the system.
As a specialist nephrologist, I have participated in the emergence of the much-needed kidney transplantation service in major hospitals in the country from its beginning in the early seventies to the present time and I have witnessed the various forces at work in this field of healthcare. In the '80s and '90s, our country was labelled as the 'Kidney Bazaar' of the world. But subsequently, with the enactment of The Transplantation of Human Organs Act, 1994 (THOA), this image and the practice of ethical kidney transplantation did improve immensely. This is, however, a case of too little, too late.
Even today, two decades into the 21st century, the fact remains that we keep hearing of such painful incidents from time to time. With technological advances, kidney scandals, scams and the trade of kidneys has gone out of the hand of governments, hospitals and civil society.
Are the various doctors engaged in transplantation squarely responsible for these malpractices? No!
The treatment and activity of kidney transplantation are done by well-trained, fairly well-to-do and senior persons in their profession. I cannot accept that one of us would participate in a racket, put his/ her life's reputation in the hands of others and then languish in jail.
The fact is that a kidney physician/surgeon remains vulnerable to the suffering, hardship and pressures of his patient who wishes to survive at any cost. That is where the whole story begins. The catchword is: Survive at any cost. Irrespective of what happens to anyone else. Irrespective of the right and wrong of it.
High-profile patients like 'NRIs, businessmen, politicians and bureaucrats' pressure the treating doctor, the specialist. India's laws don't help much either. The doctor/ surgeon is an expert in performing the kidney replacement operation. But they are not an expert in documentation and verification.
This operating specialist is most often made to speak to unknown donors and their agents – presented to him as 'friends or relatives (cousins)' by the family of the prospective recipient. The doctors cannot distinguish/detect the impersonation, fictitious albeit genuine-looking relatives, and the relevant documents presented to the hospital or the State Authorisation Committees for approval. One specialist has many patients in any hospital or private clinic settings.
Fabricating fake documents is a huge industry in itself; this is a malady of high magnitude and nearly insurmountable at this stage. Hospitals do not have lie detectors or security-police scanners that can detect fake documents and lies. Nor do average authorisation committees have psychiatrists on panels, though this is legally mandatory. In an attempt to plug the loopholes, the Transplantation Act has been modified twice – in 2011 and 2014. However, ambiguities in the law continue to remain.
The present law permits transplantation from totally 'unrelated donor' source – after it is verified and authenticated by the duly-appointed 'hospital-based Authorisation Committee', of which the treating doctor is not a member.
Any committee member can be open to 'pressure' from political quarters, the rich and the famous, a peer group or hospital bosses.
Any member of such an 'authorisation committee' can just as well knowingly connive to okay fake documents and transplants based on these. They can duped by the assisting staff, hospital facilitators, and managers whom they trust blindly. The blame rarely reaches the 'authorisation committee' members and hospital managers and auxiliary staff.
Mostly, it is the care-taking doctor and operating surgeon who is named, hauled up, humiliated and his/her character assassinated.
For the doctor/surgeon, often there is a 'donor' on one table and a 'recipient' on the another. Both would have arrived at the operation theatre through the hospital system. He is not likely to guess that the donor-recipient are not related. Or that the documentation of the donor is false.
Even if they are not related, the matching of blood and tissue and the compatibility test is verified by the 'authorisation committee', supposed to be designated by the hospital and experts in their field. Look at the catch in the situation. The recipient is real. The donor is real. Only the papers of the donor are fudged.
Thus, the doctors who are supposed to be next to God in one moment have their 'face blackened' without any means of protesting or proving themselves innocent. He/She has committed the crime of harvesting a kidney from a donor who has 'sold' it to the recipient.
Quite often, these days, the doctor does everything in good faith but becomes a victim of his own doings. He remains under police surveillance as a 'criminal' and is bundled into a lockup without being allowed a whimper! What an irony!
The real culprits – the middlemen, touts, hospital staff involved and various others who have participated knowingly – put the medical profession in the dark.
In India, not only kidneys but heart, liver and skin are sold as well. A patient with low blood platelet count has accused a doctor at a speciality hospital of advising her to get her spleen removed! Whenever a case or scam comes under media glare, the police in various medical centres reap a rich harvest too.
They get paid by the recipient family not to pursue the investigation and not to file charges; they make money from the arrested to 'complicate' the case, to mishandle 'evidence'; they make money to let arrested culprits escape; they get publicity, promotions and ensure that the case proceeds in the court/s for an unlimited period, without any conviction and punishment. The humiliated doctor, his family and the cheated slum dwellers continue to suffer throughout their lives.
One is often forced to wonder why does the press wake up only when something sensational happens? Why cannot the media keep a continuous eye on the kidney/organ commerce in the country?
The solution to this problem is identifying the middleman who is the 'actual kingpin' warranting severe punishment. The relatives of kidney patients and the conniving hospital staff should also be punished. The so-called 'cousins' of a patient – the kidney-selling donor – and the kidney-buying recipient should also be brought under the purview of law with equal punishment. And these punishments should include a huge economic component because it is money that is driving the kidney trade today.
Our country tops in the world in road traffic accidents and in Delhi and the National Capital Region alone, about 6 to 7 people meet fatal accidents daily. Harvesting of kidneys from unfortunate accident victims is the only solution to the shortage of kidneys for transplantation in India.
We all need to urgently respond to this task both at the government level and with the amendment of available laws to remove organs from brain-dead victims, with the consent of the families. It is a gigantic task. The awareness of organ donation from cadaveric source is of paramount importance in this country.
My slogan has been and continues to be ONE LIFE SAVES FOUR LIVES. Two available kidneys save two persons' lives and in turn, they also vacate life-saving dialysis machines for two other patients. I do not want to see this final solution remain just a dream in my lifetime!
This is an excerpt from Kidney Transplants & Scams: India's Troublesome Legacy by Dr Ramesh Kumar, published by SAGE Publications India. He is a pioneer in the field of Nephrology (kidney diseases) in India and South East Asia. Nephrology has grown with him in the country.
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