Medicine at Cross Roads

  • By Swami Brahameshananda
  • December 2007
  • 7401 views

Courtesy Prabuddha Bharata

Editor: “My mother gave up her body on 5/12/2007 at a leading hospital in Hyderabad. She was admitted for a knee replacement surgery but she never came home. About 7 hours after the surgery she complained of shivering and feeling cold, asked for coffee. Instead of getting the coffee or wrapping blankets round her they gave her a painkiller Faintinol. She collapsed and went into Coma never to come out of it. After being on the ventilator for three weeks she passed away. Every other doctor we spoke to was shocked to know the sequence of events leading to her death. Inspite of the Dr in charge of an ICU knowing we are well educated he tried to fool us with lame excuses, imagine how they treat the uneducated. We want to sue him personally and the hospital but will that bring our Mother back!”
    
Three professions can be considered the noblest: those of doctor, teacher, and monk, because in these three professions, three gifts are made:  arogya-dana, vidya-dana, and jnana-dana. Traditionally, in ancient India, all these gifts of health, learning, and spiritual knowledge were made freely, without a stipulated fee. However, doctors, teachers, and spiritual instructors would generally receive a dakshina from their beneficiaries------a voluntary gift which could vary from a paisa’s worth of fruit from a poor villager to a fortune from an emperor. There are interesting examples of such gifts, one of which I would like to mention here, since it reflects how a physician, a vaidya, by making a dakshina, influenced the whole course of a monastic community.

At the time of Bhagavan Buddha, there was a famous physician called Jivaka. Once he treated Buddha, who, being a monk, could give as dakshina nothing but his blessings. Soon after, Jivaka had to treat a king, and as dakshina received a very expensive robe. The large-hearted Jivaka thought that Budddha was the fit person to receive such a valuable gift. So he humbly offered it to Buddha. Being indebted to Jivaka, Buddha could not refuse the gift. But the result was far-reaching. Till then, it was a rule that the bhikkhus should wear only a kantha or robe prepared by stitching together rejected pieces of cloth. Buddha was forced to alter this rule and allow monks to wear unstitched, full-length robes.

This was in old times. Now the face of the medical profession has completely changed. These changes have been brought about by three conditions: globalization, technicalization, and commercialization. I shall take up these three briefly.

Globalization
Like all other aspects of life, medicine has also become globalized. Now, one need not go to the US for advanced, sophisticated surgery. In fact, people are coming to India instead------and that is called medical tourism, because the same consultation, diagnostic procedures, and therapeutic measures can be had here at much lower cost.

There has also been globalization of disease. Aids is a striking recent example. And having accepted the Western lifestyle, Indians are also getting lifestyle diseases. Incidentally, it might be mentioned that the state of health of Americans is not as good as one might imagine. Forty percent of people in the US are either without or with insufficient health insurance, and medical services are so expensive there that it is nearly impossible. Together with this there are lifestyle diseases plus serious psychological problems.

In this context I would like to refer to two articles: ‘Medicine in an Unjust World’ by M H. King, and ‘The Diseases of Gods: some Newer Threats to Health” by M H King and C M Elliott, appearing in the first and third editions respectively, of the Oxford Textbook of Medicine. The first article focuses on the differences and disparity in prevalent disease patterns and available medical services in poor and developing countries on the one hand, and affluent ones on the other. The article bitterly criticizes the tendency of developing countries to blindly accept the American model of health care and medicine. The disease patterns as well as financial structures of developing countries are different from those of developed countries, and accepting the health-care patterns of the latter in poor countries is bound to produce disparities in health-care access and also economic imbalance.

Unfortunately this is happening in India today. We have major unsolved community health problems which ought to have been solved twenty years ago. For example, malnutrition is persisting and maternal mortality is as high as it was twenty years ago. Undernourished women beget underweight babies who become stunted children, and two hundred million of such children who fail to reach the full potential of their growth belong to India.  According to the third National Family Health Survey, nearly half of Indian children are undernourished. India has also the lowest child immunization rates in South Asia.

In the future we are going to have both types of diseases.  On the one hand there will be malaria, tuberculosis, Aids, malnutrition, and respiratory and gastro-intestinal disorders, and on the other, lifestyle diseases.

The second article warns against the grave ethical implications of a science-driven industrial economy which treats the global environment as an infinite source of resources and an infinite sink for pollutants which is destroying the concept of family and traditional community values, and triggering unprecedented population growth. This article, which is significantly included in a prestigious textbook of medicine, also points to the media as a disease agent which relentlessly promotes a high-resource consuming, excessively polluting lifestyle, encourages violence, and is steadily eroding the norms of traditional sexual behavior and family stability. The authors also take into consideration the phenomena of global warming and the greenhouse effect.  This will lead to changes in the patterns of rain, increase in communicable and vector-borne diseases, and increase in morbidity and mortality from heart disease, stroke, and heat stress in the aged and chronically ill.  Perhaps it will also increase the incidence of skin diseases, cancers, and cataracts.  We can also expect a high incidence of mental diseases like panic disorders, social phobias, anxiety and depressive disorders, impulsive and behavioral disorders, drug abuse and schizophrenia.

Technicalization
Warfare and medicine--these are two spheres in which technology has entered in a very big way. Technology has indeed brought some medical miracles and today medical science and diagnostic as well as therapeutic technology cannot be divorced.  Technology has come to stay.  But technology has also robbed clinical medicine of its beauty and art.  Earlier eminent physicians used to diagnose cases intuitively-----an ability which they had developed through decades of clinical practice. But technology has converted doctors into technicians who set right their patients, and reduced patients to machines gone out of order.  The social, economic and psychological facets of the patients are totally neglected.  Many years ago I saw a book titled Patients as People.  In it about twenty clinical cases were described, not as a doctor would describe a case history, but in their social setting.  I remember just two cases----one of phaeochromocytoma (adrenal-gland tumour) and the other of epilepsy.  It described, for example, how someone suddenly falls down on the street, how people gather around him, how he is brought home, how his family members react, and how his financial situation is affected----in the form of a real-life story.  Doctors need to remember that the patient is a socio-economic and psychological being and not merely a machine.

Medicine has moved from organism to organ, from organ to cell, and from cell to molecular level.  The discovery of the biological role of nucleic acids and the uncovering of the genetic code and its role in regulating life processes are marvelous discoveries of recent years. Medicine has acquired a vast body of knowledge and has become highly technical. It has developed the capability to directly intervene in and manipulate the activities, bodies, and minds of human beings through such techniques as genetic counseling, genetic engineering, prenatal diagnosis of sex and genetic diseases, in vitro fertilization, organ transplantation, blood dialysis, artificial joint and heart implantation, psychosurgery, and even (in the near future) cloning. The data show that modern medicine has entered a new evolutionary stage with the promise of continued improvements in medical capabilities, not only for solving problems of sickness, but perhaps even for enhancing life.

According to K Park, despite spectacular biomedical advances and massive expenditures, death rates and life expectancy in developed countries have remained unchanged.  Today, a great skepticism surrounds medical care.  Like so many other institutions in contemporary society medicine has come under heavy fire.  Medicine, as practised today, has begun to be questioned and criticized. Some critics have even described modern medicine as a threat to health. Their arguments have been based on certain facts such as these:

• With increased medical costs have not come increased benefits in terms of health.
• Despite spectacular advances in medicine, diseases like malaria, tuberculosis, schistosomiasis, leprosy, filarial, trypanosomiasis, and leishmaniasis have either not lessened or actually increased.
• Life-expectancy has remained low and infant and child mortality rates high in many developing countries, despite advances in medicine,
• Historical epidemiological studies have shown that significant improvement in longevity had been achieved through improved food supplies and sanitation long before the advent of modern drugs and high technology.
• There is no equity in the distribution of health services, resulting in limited access to health care for large segments of the world’s population.
• Modern medicine is also attacked for its elitist orientation even in health systems adapted to overcome social disparities.

High-technology medicine seems to be getting out of hand and leading health systems in the wrong direction-----that is, away from health promotion for the many and towards expensive treatment for the few.  For example, in developing countries, the tendency has been to follow the Western models of medical education and to favour high-cost, low-coverage, elite-oriented health services.  Not only is there an increasing concern about the cost and allocation of health resources, but the efficacy of modern medicine is being fundamentally questioned from various points of view.  It has given rise to the notion that limits have been reached on the health impact of medical care and research. This has been labeled as a ‘failure of success’.

Technicalization has also undermined the doctor-patient relationship.  Sometimes patients are treated as ‘guinea pigs’. Patients too have become conscious of the boons of technology in diagnoses and treatment.

In an article entitled ‘Scientific Medicine----success or failure? In the second edition of the Oxford Textbook of medicine David F Horrobin, after describing the era of success of scientific medicine, comments that there is an astonishing increase in cost of medical care yet these escalating costs have not been accompanied by equivalent objective therapeutic successes or a rise in patient satisfaction. In the Western world, a reaction is building up against modern medicine. Scientific medicine---portrayed as cold, unfeeling, unsympathetic, rigidly concerned with facts, treating the patient as a case with a disease and unappreciative of the person as a whole, neglecting his or her psychological, economic, and social dimensions---has begun to be widely thought of as a villain.

Much of the escalating cost of medicine relates to the introduction of diagnostic tests. When these tests were few and it seemed that health care budgets were infinitely expandable, the cost of tests did not matter. But now, with the vast range of tests available and a limited purse, diagnostic procedures have great potential for harm simply by drawing money away from areas more directly relevant to patient care.

Another failure of so-called scientific medicine has been its continued introduction and use of procedures which have no value in objective terms. The aim of medicine should be ‘to cure sometimes, to relieve often, and to comfort always’. Many modern medical procedures do not fulfill this criterion. Coronary care units have not been convincingly shown to change the outcome of a heart attack, yet this has not stopped their vast proliferation. Except in restricted indications, coronary bypass surgery has not been shown to be better than conservative treatment, yet this has not stopped the development of a large industry. The list could go on.

The problem with modern medicine according to Horrobin, is not that it is scientific, but that it is not scientific enough. A truly scientific approach must prevent much of the escalation of medical costs and must focus on curing, relieving and comforting. To make the results of modern medical technology available at affordable cost to the poor is the challenge before us today, and will be so in the future.

Everything which we introduce into medicine should be measured against this sole criterion: Is the new investigation or diagnostic or therapeutic procedure better for the patient in terms of cure, relief, or comfort? Unfortunately, medical science has been dominated by commercial interests.

It must be remembered that medical science is not simply science, but applied science. Yet it has acquired much of the flavour of a pure science, and academic ‘glass bead game’ in which knowledge is sought without regard to therapeutic ends. We have generated knowledge without wisdom.

In this context I would like to mention the Grand challenges in Global Health Initiative, a major effort to achieve scientific breakthroughs against diseases that kill millions of people each year in the world’s poorest countries. The ultimate goal of the initiative is to create ‘deliverable technologies’----health tools that are not only effective, but also inexpensive to produce, easy to distribute and simple to use in developing countries. The initiative is supported by a $ 450 million commitment from the Bill & Melinda Gates Foundation to help apply innovation in science and technology to the greatest health problems of the developing world. Of the billions spent each year on research into life-saving medicines, only a small fraction is spent on discovering and developing new tools to fight the diseases that cure millions of deaths each year in developing countries. ‘It’s shocking how little research is directed toward the diseases of the world’s poorest countries’ said Bill Gates, co-founder of the foundation.

The first fourteen scientific challenges, selected from among more than one thousand suggestions from scientists and health experts around the world address the following goals:
• Developing improved childhood vaccines that do not requires refrigeration, needles or multiple doses, in order to improve immunization rates in developing countries, where each year twenty-seven million children do not receive basic immunizations
• Studying the immune system to guide the development of new vaccines, including vaccines to prevent malaria, tuberculosis, and Aids, which together kill more than five million people each year.
 Developing new ways of preventing insects from transmitting diseases, such as malaria, which infects 350-500 million people every year.
• Growing more nutritious staple crops to combat malnutrition, which affects more than two billion people worldwide.
• Discovering method to treat latent and chronic infections such as tuberculosis, which nearly a third of the world’s population harbour in their bodies.
• More accurately diagnosing and tracking disease in poor countries that do not havw sophisticated laboratories or reliable medical recordkeeping systems.

Commercialization
The third factor which has disfigured the face of the medical profession is commercialization. The medical profession is now looked upon not as the noblest profession, but as the most lucrative business. From high capitation fees for admission into medical colleges and exorbitant educational costs, to commissions for ordering investigations, five-star hospitals, and the pharmaceutical industry with its grip on prescribing doctors, commercialization has penetrated into the profession in various ways and at almost every level. It is a law that the nobler a profession, the mote vulnerable it is to degradation; this applies most aptly to the medical profession. It is no wonder that today doctors are mistrusted and looked upon by patients with suspicion, that the profession has come under the Consumer Protection Act, and that various types of malpractices like taking commission for referrals, unwanted investigations and surgery, and sponsorship of medical programs by pharmaceutical companies have come into vogue.

There is a tendency among doctors to congregate in cities. I have been meeting medicos coming to Chandigarh for entrance examinations for post graduate medical courses. I ask them, What will you do if you are not selected? (and most of them will not be ). They invariably say they will try again and again. From what they say it would appear that they have no alternative to going in for specialization and super-specialization. That means they can work only in specialty hospitals. I try to impress upon them through various examples that even with an MBBS degree they can do a lot of good work. Millions of poor Indians cannot get even the services of an MBBS DOCTOR.

Thus, the medical profession is facing great challenges. Doctors cannot keep their eyes closed to socio-economic and even political issues----as is evident from the recent government policy on reservations. One of the major challenges is to carry the results of modern research and technology to the doorstep of the poorest of the poor. In spite of all these problems and challenges, the medical profession continues to be one of the noblest ones. There are exemplary doctors today who testify that the profession is indeed noble. Let me conclude by quoting from the preface of the first edition of Harrison’s Textbook of Medicine:

No greater opportunity, responsibility or obligation can fall to the lot of a human being than to become a physician. In the care of the suffering he needs technical skill, scientific knowledge and human understanding. He who uses these with courage with humility and with wisdom will provide a unique service for his fellow man, and will build an enduring edifice of character within himself. The physician should ask of his destiny no more than this; he should be contents with no less.

It now depends upon doctors to resurrect their image of the profession and reclaim its lost glory.

Notes and References
1. I am using the term to mean excessive introduction of technology in the medical field.
2. The Tribune, Chandigarh, 21 February 2007,
3. A E Clark-Kennedy, patients as people (London: Faber & Faber, 1957).
4. K Park, Park’s Textbook of Preventive and Social Medicine (Jabalpur: Banarsidas Bhanot, 2002),8.
5. Ivan Illiach, Medical Nemesis: The Expropriation of Health ( London: Marian Boyars, 1976 ).
6. Thomas McKeown, The Modern Rise in Population ( New York: Academic, 1976)
7. Public Health Papers ( WHO, 1984 ).
8. See Thomas mcKeown, The Role of Medicine: Dream, Mirage or Nemesis ( London: Neffield Provincial Hospitals Trust, 1976 ); and Milbank Memorial Rund Quarterly, ed. J B McKinlay and S M McKinlay, 1977.
9. See Rick J Carlson, The End of Medicine ( New York: Wiley, 1975 ).
10. Attributed to Ambroise Pare ( 1510-90 ).
11. < http:/ / www.gcgh.org/ GrandChallengers>
12. < http:// www.gcgh.org/Newsevents / Media Center/ 43GroundbreakingProjects.htm>accessed IO October 2007.
13. T R Harrison, Harrison’s Principles of Internal Medicine ( New York: McGraw Hill, 1950 ), preface.

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