Corruption ruins the doctor-patient relationship in India.

“The corruption strangles everything, Sir. It’s like a cancer.” Accompanied by apologetic shrugs and half smiles, statements like this are commonly heard in India. I knew this was the case before I went to work as a volunteer physician in a small charitable hospital in the Himalayas, but what I didn’t realise was how far the corruption permeates the world of medicine and the corrosive effect it has on the doctor-patient relationship. Although the causes and effects of corruption are complex, a few strands can be teased out. The healthcare system itself is a model of inequity; it is one of the most privatised in the world, with out of pocket expenditure on healthcare at more than 70%, far higher even than in the United States. This phenomenon is at least partly the result of the neoliberal World Bank policies of the 1990s, which mandated a reduction in public financing of healthcare, fuelling growth of the private sector. The latest in technological medicine is available to people who can pay, albeit at a high price, but the vast underclass, 800 million people or more, has little or no access to healthcare, and what access it does have is mostly to limited substandard government care or to quacks, who seem to operate with near impunity. There is one leveller, however: corruption is rife at all levels, from the richest to the poorest. One day in the outpatient department I was writing a request for an exercise electrocardiogram at a private heart clinic when the devout young resident consulting beside me said, “Give me that. I have to sign it.” Perplexed, I handed it over, and the story unfolded: all investigations attract a 10-15% kickback to the referring doctor. One day, the marketing executive for this clinic had turned up at the hospital with an envelope full of cash—the commission for investigations ordered in the past few months. The senior doctor refused it and stipulated that in future the commission was to be paid back to patients, which is why the resident had to sign the form. The country’s doctors andmedical institutions live in an “unvirtuous circle” of referral and kickback that poisons their integrity and destroys any chance of a trusting relationship with their patients. Given these practices, it is no surprise that investigations and procedures are abused as a means of milking patients. I saw one patient with no apparent structural heart disease and uncomplicated essential hypertension who had been followed up by a city cardiologist with an echocardiogram every three months, a totally unnecessary investigation. A senior doctor in another hospital a couple of hours away was renowned for using ultrasonography as a profligate, revenue earning procedure, charging desperately poor people Rs1000 (£10; €12; $17) each time. Everyone who works in healthcare in India knows this kind of thing is widespread. There is also widespread corruption in the pharmaceutical industry, with doctors bribed to prescribe particular drugs. Tales are common of hospital directors being given top of the range cars and other inducements when their hospitals sign contracts to prescribe particular antibiotics preferentially. I met a former pharmaceutical sales executive who left the industry, sickened by the corrupt practices he was supposed to employ. Working for one of the largest drug companies in the country, he was expected to bribe doctors with money and luxury goods. The crunch came when a doctor demanded that the company fly him to Thailand for a holiday and then provide him with prostitutes at his home. When the company representative queried this, his manager told him to comply, and he felt he had no choice but to resign, protesting that he was “not a pimp.” It is no wonder, therefore, that a common complaint I heard from poor and middle class people is that they don’t trust their doctors. They don’t trust them to be competent or to be honest, and they live in fear of having to consult them, which results in high levels of doctor shopping. Lack of trust in doctors, and the costs associated with going to see them, mean many patients rely on pharmacists, who seem to have a similar lack of ethics, selling inappropriate drugs over the counter at exorbitant prices to people who often have to borrow the money to pay for them.