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Sunday, March 3, 2013

From the Hippocratic Pact To the Consumer Protection Act - A Medical Journey

 [This article was written for the souvenir brought out on the occasion of the diamond jubilee celebration of the Patna Medical College, formerly the Prince of Wales Medical College, Patna long time back.Later a severely edited version of this article appeared in The Economic Times,perhaps in 1992 or 93. A series of correspondence with an esteemed friend of mine on related issues  led me to reconstruct  this article from old papers and notes. The version that appears  here  may not be the same as it originally appeared in the Patna Medical College journal.]

In the B.B.C. comedy serial Yes Minister, as an instance of bureaucratic insensitivity extra long tubes for the existing stethoscopes are offered in response to demand for more of this item form a certain hospital. Humour apart, it can also be taken as a grim metaphor of the fact that in our avowedly compassionate society, doctors are forever receding form its sick and morbid members. The physical interface between the patient and his doctors, the detailed examination to question the dis tempered part, the protracted palpation is gradually giving way to a mechanical probe by means of vast and impersonal appurtenances of technology.

Every age has its own paradigm about what causes disease. The role of the doctor as well as the community’s expectations from him is closely aligned to it. In the earliest times, it was believed that sickness occurred as a result of the invasion by evil spirits. In a manner of speaking the shamans and exorcist could be said to be the earliest medical practitioners. Their therapeutic regimen consisted of a closely defined procedure, a technique of the incantation of the magic mantra to propitiate or exorcises the malevolent presence. When summoned to tend the sick the Tibetan Lama would, by reciting the cosmogynic myth, symbolically project his patient to the dawn of time. The whole subsequent temporal drama would be enacted step by step, by the recitation of the myth of illness, the myth of the first shaman and so on. The patient by this journey back would be restored to the primeval and essential condition of health from which he appeared to have strayed en route.

In primitive cultures, before scientific hubris overtook human civilization men trusted forces larger than themselves to mend things. The shaman could at best be a mediator, an agent, a medium through whom grace could flow. History records many such events where  prophets and saints have charmed away excruciating pain by mere touch and sometimes suffered the pain themselves in the bargain are trans historic and cross cultural models. The practitioners of the art of healing were public spirited men with a super abundant gift for affection and empathy. Even till sometime back, physicians are known to have tested dangerous poisons and their antidotes on themselves.

Over the years the paradigm of the causation of disease has undergone several changes.  A historian records that theories like autointoxication, disproportionality of Yin and Yang imbalance of the bodily humours, deviation from natural way of living, even excessive love of theatre as being responsible for disease held sway. The role of the doctors as well as the repertoire of medical strategies has undergone commensurate changes. The point that needs to be underlined is that the practice of medicine has always been a tripartite arrangement, between the doctor and his patient and the two taken together with the contemporary social cultural scientific milieu.

The concept of focal infection, of specific etiology, the medical equivalent of the reductionist, causal, deterministic world view has captivated the medical imagination for close to hundred years. The one to one relationship between the disease and the causative agent was spectacularly demonstrated by Louis Pasteur. Due to the efforts and under the influence of Robert Koch, Louis Pasteur, Paul Ehrlich and others a whole new demonology of pathogens – the disease causing agents- was complied with a countervailing pharmacopoeia of “magic bullets” and precision guided chemical munitions capable  of specifically engaging and destroying  the enemy.

In the beginning of the 20th century, Lord Kelvin in one of the headier moments declared that the task of physics was well nigh over. What remained to be done was to tie up the loose ends. The contemporary medical thinking was equally convinced that the only end of medical endeavour and research was  to isolate as many pathogens as possible and develop suitable drugs. Consequently a shift in the traditional role of the doctor took place. A large area of his activity was relegated to the microbiologists and the pharmacists. Separating the malady form the sick person became the  very raison d'etre of the practice of medicine.

Diseases like tuberculosis, measles, small pox, meningitis which swept through towns and villages like a visiting pestilence were tamed. But perhaps the newer ones, foremost among them cardiovascular diseases, cancer and AIDS have overshadowed the triumph.Therefore,when Rene Dubos describes their endeavours as creating a "mirage of health" or Ivan Illich insists that there are strict "limits to medicine" it does merit concern if not downright alarm.

Increased specialization set in motion the process of dehumanization of the doctor.The reductionist world view diminished the doctor from restorer of health and wholeness to a mender of broken or distempered parts, while the patient is reduced to a registration number. From being a person, a unique organism with definite physical and psychosomatic boundaries he becomes an object of piece meal curiosity- probed by machines, seen trough x- rays bounced off him in a strange setting, shut off from his family with white masked, dispassionate observes from outer space, as it where as witnesses to the procedure. The dehumanizing almost dismembering aspect of technology is now part of our medical imaginary.

Given the ineluctable logic of consumerism, the hidden tenet of capitalist industrialist system, health care was, sooner or later, bound to become one of the greatest growth industries. The law of supply and demand ensured that the doctors flocked in disproportionately large numbers to urban centres, where the standard of public health and sanitation are already much better than the rural areas where the medical facilities are woefully, criminally inadequate. But these areas of deprivation do not have buyers and markets are not known to be moral agents. So the poor languish for want of basic health care, while the rich are spoilt for choice and tertiary care nursing homes exist side by side with death wards dubbed as primary health care systems.

But of late the practice of medicine has got inextricably linked with the interests of the pharmaceutical industry. Like a puppet jiggling on strings the medical practitioner has become an involuntary even unconscious agent of the drug industry. Peddling avoidable surgeries and needless invasive procedures with the persuasive skill of a salesman he also   prescribes new fangled drugs-chemically synthesized, materialized out of nowhere,re-engineered with a molecule displaced here or a carbon bond dislocated there, these drugs are sometime launched  with inadequate field trials, sometimes they are   potentially dangerous. But this has come to occupy the center stage of his activities and he must carry it on if he has to remain in business. However the doctor alone cannot be trusted to boost the sales to achieve projected profit levels of the profit hungry pharmaceutical companies. So the advertising industry, always at the beck and call of those who can pay to perpetrate their lies, complement its activities by plugging  the drugs directly to the people,  making them so  consumer friendly that they are ingested without medical supervision. Just as the General Motors or Toyota have to innovate constantly to give more rev to their engines to keep the consumer preference from getting jaded so more potent and more lethal antibiotics have to be made available at the drug store because the bacteria have become resistant due to the indiscriminate use of earlier generation, of antibiotics. If the T-model Ford represents progress when compared to the wheel cart, and a Ferrari is a progress compared to the T model ford shouldn't the human self that responds only to Ciprofloxacin represent progress when compared to the generation that was amenable to ineffectual, antiquated penicillin?

Ivan Illich, the Hashelmere group and a host of others have amassed such a wealth of data that the charge that doctors are pushers in the illicit drug trade can no longer be brushed aside as mere rhetorical jibe.  How ironic that the legal drug trade yields the same astronomical profit as the illicit one!

It is perhaps recognition of this sad fact that the society does not hold the doctor in that same spirit of trust and confidence; his Hippocratic Oath is no longer binding enough. He is made further answerable in the consumer protection act. Next time round he short sells people on health, healing or happiness, he will have to pay the equivalent in monetary terms. In our country, where the record of  the enforcement and adjudication  of the 3000 odd legislation has been less than awe inspiring there will be devil to pay on both sides, especially for the poor who would find medicare much more expensive without being able to secure the protection readily.

From healer to dispenser of drugs, from counselor to promoter of particular nostrums,   the doctor has traveled a long way indeed. Forced to choose between the myths of Hygeia (health is the natural order of thing provided we live prudently) and Asclepius (to abstract and treat disease  to repair any damage of distemper due to an encounter with outside causative agents or accident of birth), he chooses to pay obeisance to Mammon the universal god and benefactor of our time.

The word doctor says, Lewis Thomas, has been derived from the root word "leg” one of its meanings being" enchanter, speaker of magic words" Which is perhaps just as well! Even in the days of self confident scientific medicine he does not fail to invoke the hawk-headed god Horus whose amulet Rx he appends at the top of his prescription to set in motion the process of healing. Even in these cynical times the magic works if the faith of the patient and the intent of the physician act in unison. Try as he might then, the doctor cannot escape his inheritance and one fervently hopes his unique responsibility as a healer, as a mediator of grace as an "enchanter speaking magic words".