Dark days for medical profession in India

You know a profession is corrupt when its practitioners surprise the public more when they refuse bribes than when they accept them. Unfortunately, such is the case with the medical profession in India, says Dr. Subrata Chattopadhyay, a former Erasmus Mundas Master of Bioethics Fellow at Italy’s Università degli Studi di Padova.

“Corruption is endemic,” says Chattopadhyay, who now teaches at an Indian medical college. “If a doctor is corrupt, it doesn’t excite anybody.”

Whether or not it elicited excitement, the recent arrest of Dr. Ketan Desai, a prominent and powerful Indian physician, has certainly elicited change — the most notable being the dissolution of the Medical Council of India (MCI), a body created in 1933 to regulate education standards in the country’s medical colleges.

On Apr. 22, Desai and three colleagues were arrested by India’s Central Bureau of Investigation for their alleged roles in a 20-million-rupee ($440 000) bribery case. They are alleged to have accepted a bribe from a medical college that wanted to increase enrolment despite lacking capacity for more students. At the time of his arrest, Desai was the president of the MCI. He subsequently resigned both the presidency and his position as head of the urology department at the B.J. Medical College in Ahmedabad.

The government of India subsequently dissolved the MCI. On May 15, it ordered council members to vacate their offices immediately, and set up a seven-member board of governors to take over their duties. The situation will be reassessed after a year.

In October, Desai is scheduled to assume the presidency of the World Medical Association (WMA), now led by former CMA president Dr. Dana Hanson. In an email response to CMAJ inquiries, Nigel Duncan, the World Medical Association’s public relations consultant, wrote: “The WMA will not be making any comment while this matter is under investigation. Our understanding is that Dr. Desai is still being investigated and has not been charged. He is due to take over as President at the WMA’s annual General Assembly in Vancouver in October. Any decision on his Presidency rests with the Assembly.”

Medical professors in India often receive a portion of their pay under the table to avoid income tax.

The current scandal is not the first time Desai has been accused of corrupt practices. In 2001, the Delhi High Court removed him from the presidency of the MCI after income tax investigators noticed he had received 6.5 million rupees in unexplained gifts. In 2005, however, the case was successfully appealed and dismissed for lack of evidence. By 2009, Desai was again leading the medical council.

Desai’s alleged misconduct comes as no surprise to critics of the MCI, of which there are plenty, including a neurosurgeon who penned an article entitled the “Medical Council of India: the rot within,” which featured an entire section devoted to the history of controversies surrounding Desai (Indian J Med Ethics 2009;6:125–31)

“This essay provides data that may help the reader identify the rot within the Council,” wrote Dr. Sunil K. Pandya. “Permitted optimism, we may hope that this essay and similar observations by others will prompt a change for the better. At present such optimism is not justified.”

Medical education, in particular, lost its way in India when it became a big business, says Dr. Arun Bal, president of the Association for Consumers Action on Safety and Health, a nonprofit organization based in Mumbai.

“The issue of corruption raised its head when private medical colleges were allowed 25 years ago,” Bal writes in an email. “MCI started giving recognition to these colleges without proper infrastructure and teachers. When Ketan Desai became MCI president in the late nineties this increased sharply.”

Most of the private colleges were founded by politicians as profit-making entities, says Bal. Many lacked the infrastructure, equipment and expertise to properly train new doctors. Applicants often had to make substantial “donations” to get accepted. Some critics of private medical colleges say professors manipulated exams to allow marginal students to pass. As a result, the quality of medical care in India varies widely.

When inspectors from the MCI announce a visit to examine an ill-equipped medical college, the ensuing scramble to impress can sometimes veer toward farce. In a commentary — “Black money in white coats: whither medical ethics?” — Chattopadhyay described the typical pre-inspection action at a college seeking council approval: “busloads of patients are mobilised to fill up empty wards, carloads of doctors are paraded before the inspectors (also flown in from abroad), and even instruments are hired during the period to fool the MCI inspectors. Who is in charge of — and participant in — these elaborate set-ups? Doctors, of course.” (Indian J Med Ethics 2008;5:20–1)

Chattopadhyay also described the shady way in which medical professors are paid. During a job interview, he was told he could receive 25% of his salary in cash. He would therefore not have to pay income tax on this portion, which is known in India as “black money.” Many professors accept this arrangement, wrote Chattopadhyay, because the cash amount is not added to their legitimate pay cheques if they refuse: “Therefore, you have two options: ‘enjoy’ the black money and be a part of overwhelming majority of your colleagues, or lose out financially by being ‘honest and isolated’.”

Cleaning up India’s medical education system won’t be easy, says Chattopadhyay. Though there are medical professionals concerned about ethical misconduct, he says, they tend not to be the ones in the corridors of power. Furthermore, it is difficult to prove that corrupt educators are doing anything wrong because they keep their misconduct well hidden.

“It is difficult to prove unethical practices,” says Chattopadhyay. “We don’t see them in black and white, or in front of our eyes. We hear stories and rumours and whispers.”

One way to help bring integrity back to his tainted profession, says Chattopadhyay, is to teach medical ethics to students in medical colleges. In a recent paper, he noted that bioethics is virtually nonexistent in India. And though it is difficult to teach ethics in an unethical environment, there are some people who care enough about cleaning up medicine to make a difference, he wrote. “The humble but spirited efforts of these conscientious physicians and educators may gain momentum and may make a difference to the ethos of medicine” (Indian J Med Ethics 2009;6:93–6).

Chattopadhyay acknowledges that the effects of teaching students medical ethics may be slight, but says the effort would not be in vain. “Doing nothing will not help either. At least doing something may be helpful. If we teach students ethics, at least we can hope they will be better doctors.”

A task even more daunting than fixing the problems with medical education in India is cleaning up corruption in the medical profession as a whole. In his email, Bal makes several suggestions, including the creation of laws to ensure the majority of members of influential medical councils are elected rather than appointed by government. But he acknowledges that the challenge ahead is great. “We don’t expect any early, fast and effective resolution of this crisis.”