In the Bonesetter's Waiting Room

by Aarathi Prasad

  Dhrudev himself had trained in biotechnology and microbiology and talked me through departments as we passed them. ‘The integrative model is the key,’ he explained, ‘we have facilities for ECGs, radiography, a pathology lab: haematology, serology, microbiology, immunology – when patients have diabetes, we still want to know what their blood sugar level is. Our inpatients stay three to thirteen days typically and they come from all over India, as well as abroad. People hear about us by word of mouth. Even so, we also get two and a half thousand walk-ins per month.’

  ‘So who comes here and with what conditions?’

  ‘People come from all walks of life, all religions come, all communities – we have different price plans and subsidies. People below the poverty line will have up to one hundred per cent of their treatment paid for. We also run health camps once a month in rural areas – that programme was endowed by Tata.’

  I had noticed that many innovative initiatives, hospital buildings and health programmes around India also bore evidence of the Tata Group’s philanthropy. The enterprise, best known in the West as a steel company but which owns a multitude of business ventures in India, from hotels to jewellery shops to instant coffee and also counts Jaguar Land Rover and Tetley tea among their brands, contributes significantly to the arts, education, culture and health in India.

  ‘You know, traditional practices have come into disrepute often because of bad practitioners, people who are self-proclaimed doctors. Other than rural areas, where folk healers are used possibly because they might be the most accessible, urban people will always preferentially go to allopathic doctors. So what you’ll find is we will have people coming here for physiotherapy, rehabilitation, palliative care; after road accidents, cancer, or stroke. When there’s nothing they [the allopaths] can do, we get a lot of those patients. We see many autistic kids. We also look after many patients presenting with stress or poor weight management; infertility, pre-conception, pregnancy.’

  Dhrudev took me to the first floor, where the smell of fresh paint announced their new maternity ward, still being finished. Inside, he showed me the rooms for giving birth without conventional intervention, as well as one fully equipped for surgery, should that become inevitable. ‘Because there has been a loss of traditional practice, people living in the city, away from their extended families – mothers, grandmothers – more women now don’t have that support and guidance. We are seeing a rapid increase in caesareans in India now. That is why we are building this unit, so women can have natural, healthy pregnancies and birth.

  ‘In this kind of integrated approach, there are a lot of good initiatives happening across India of late. There are some other places similar to what we are doing here, or there are some really top-of-the-range private allopathic clinics that have now integrated traditional medicine. There is a lot that Ayurveda can do.’

  While the integrated approach might be revolutionising patient care, it might also have wider implications for the medicine across the globe.

  ‘Over the years, India has indeed seen an increasing interest in its medical traditions,’ Dhrudev continued, ‘and in its sources of traditional medicines: plants and parts of plants, seeds and fruits for perfumes and pharmacy, Ayurvedic and Unani medicines sold in bulk and traditional medicines for retail.’ In the mid-1990s (when Indian law did not allow agricultural and medicinal products to be patented), there had been wranglings with the US Department of Agriculture, together with US multinationals – famously over products from Azadirachta indica, the neem tree, from which seventy products had been patented. The corporate monopoly this threatened meant that neem-related patents allowed the holders to make major financial gains, while levying huge cost increases for the tree’s traditional users. In India, neem had been used for millennia for medicine, toiletries, timber, contraception and fuel, and in agriculture as a pesticide and for the care of livestock. There were also legal challenges made over the genes of other plants, like nutmeg and camphor. Between then and 2003, the export of Ayurvedic and Unani products increased five per cent annually and exports to the US shot up from just ten per cent of total exports of these products in 1997 to an astounding sixty-five per cent.

  I thought back to something Annamma Spudich had mentioned, about the low success rates of random search methods used in biotechnological drug discovery, despite the vast amounts of money spent on it. From her role as visiting scientist at Genentech, a Californian biotech giant, and from her days in experimental science, she had explained to me the standard procedure used to identify a new molecule that might potentially be beneficial in the treatment of a disease. It required determining the chemistry of a disease, sifting through vast numbers of randomly generated molecules created in line with that chemistry and then looking to see whether any of those molecules had an accelerating or inhibiting effect. But that random approach had not been particularly successful. ‘A relatively small number of successful molecules have been found. It’s really staggering, the amount spent,’ she said.

  I recalled that Darshan Shankar, from his Ayurvedic research perspective had also flagged up a similar thought: ‘So it’s important to go back to old therapeutic methodologies to see if there are easier or more successful ways to find solutions. At this stage in the history of the world we’ve largely managed to conquer infectious disease, therefore, the real problem is how to deal with chronic diseases. Chronic conditions are treated with single-molecule drugs and people are living with the by-products of these.’

  In India, an enormous body of knowledge – centuries of records detailing what conditions these plant products are used for – are there for the taking. And now, with the comprehensive information on plants and medical traditions kept in databases like Darshan’s at the Foundation for the Revitalisation of Health Traditions and the collections at the Department of AYUSH’s Government Central Pharmacy, future foreign patent claims on the pharmacopoeia of India’s flora may be easier to quash. Like the battles over neem products and the ever-present legal challenges and bans of India’s production of generic pharmaceutical drugs, the dramas played out in courtrooms about medicines deriving from any part of the country’s healthcare system has the potential to affect an enormous number of lives – both in India and in the developing countries that depend on her for cheap, accessible medication.

  I had seen plenty of evidence of a concerted drive, backed by the Indian government, to capitalise on traditional medical innovations that biomedicine may have been blind to. If it bears fruit, it is possible that the types of Ayurvedic medicine which will increasingly be produced for use in India and abroad will be single-drug formulations, closer to the rapid-acting ‘magic bullets’ which are a feature of Western-style pharmaceuticals: easy to test and validate in the conventional ‘reductionist’ way, widely preferred by patients and targeted at chronic diseases. Perhaps also, like Ayurveda’s management of rheumatoid arthritis, there will be clinical studies more suited to the old ways, so that other traditional treatments can be tested and validated for adoption by both Western and Eastern worlds. And if these emerge, the integration of India’s rich variety of ways to manage health and the bringing together of the ancient knowledge of plants and modern scientific tools may go some way to informing the quest that all patients have – to manage their illness, or to cure it – affordably and with the fewest possible side effects.

  4

  The Heart of the Matter

  INDIA’S EQUIVALENT OF SILICON VALLEY began life in a town called Electronic City. Conceived in the mid-1970s, it lies around twenty kilometres south of what was then Bangalore’s city limits. Today, the main approach to the heart of Bangalore’s immense technology park is via a seemingly endless highway named after the Hosur municipality, just over the state border with Tamil Nadu. Neither the Hosur Main Road’s multiple lanes, lined with hotel chains and Indian and multinational electronics corporations, nor the elevated expressway above it do much to relieve the congestion in either direction along its length. So t
he Audis, Land Rovers, BMWs or Porsches bought from the highway’s many showrooms have little prospect of picking up speed as they are driven away; and every journey to India’s biggest tech hub is necessarily a slow and protracted one.

  Interspersed with the corporate headquarters and luxury brands were towns with a slightly run-down, albeit genteel feel, and it was near one of these – away from the main drag down a side street lined with fruit stalls and small family-run hotels and restaurants – that I found the entrance to another enormous complex, this one dedicated not to electronics or cars but to health.

  Screened by a wall of large and aptly named flamboyant trees with their fiery red canopies, its foyer was surrounded by a wide porch topped by a double pitched roof of red tile, built in the vernacular style typical of pre-independence south Indian architecture. Rising directly behind it was a seven-storey L-shaped tower block, topped with an immense sign bearing its name, Narayana Hrudayalaya. In the broad scheme captured by the term ‘Hinduism’, Narayana is the member of the ‘holy trinity’ who protects life (placed between the Brahma, the creator and Shiva, the destroyer); Hrudayalaya means ‘the temple of the heart’. Living up to its name, this world-renowned centre for cardiology (or Narayana Health, as it is more commonly known outside the subcontinent) is one of the world’s largest heart hospitals and has, in the fourteen years since its founding, performed more successful paediatric heart surgeries than any other institution anywhere in the world. In addition to its staggeringly efficient output, the hospital has gained a reputation, fitting in every sense, as India’s ‘healthcare provider with a heart’, because for over fifteen years it has been making world-class healthcare available to people who would otherwise have been unable to afford it.

  As I lingered in the entrance porch, a little early for my appointment with its creator, cardiologist Dr Devi Prasad Shetty, I noticed that patients and relatives were gathered in worship at the hospital shrine, which stood in a garden just inside the front gates. In my line of sight was a portrait of Guru Nanak and an elderly man in a Sikh turban, offering prayers, and just past him, through its open window, another man, in his twenties, wearing a Muslim topi cap and sitting on a wall under an Islamic arch. Confused, I realised that what I had assumed was a Sikh temple was actually loosely divided into four parts: as well as the gurudwara and the mosque, under a dome with moon and star, there was a church with a Romanesque facade and topped with a cross, in which a lady in a sari knelt; and a mandir whose elaborate dome was carved with Hindu gods. That mixture of grief, hope, resignation and fear familiar to families of the dangerously ill was clearly recognisable in the eyes or postures of those praying in each quadrant.

  ‘It is very important for the families, while their loved ones are being operated on, to have this shrine here,’ Dr Asha Naik told me when she joined me in reception for a hospital tour. Asha, a former paediatrician, had been Dr Devi Shetty’s principal administrator for the vast Bangalore health complex since it opened in 2000. Though she was pivotal to the running of a hospital that saw hundreds of patients and performed nearly forty heart surgeries a day on children alone, Asha was warm and almost languidly at ease. As we talked, she described the opening of the hospital, starting with just one building given to Dr Shetty to help him realise his dream of providing India with cheap affordable world-class healthcare. What had begun as a 225-bed heart hospital was now, just over a decade later, a 3,000-bed multi-speciality complex, including a general medical hospital with thirty departments and a separate dedicated, state-of-the-art cancer centre. The complex now covers twenty-six acres around Electronic City.

  ‘At that time, this waiting room was very crowded with people,’ Asha motioned to a very large hall, where perhaps around fifty to eighty people sat, quietly, in neat rows, waiting to be called into one of the consulting rooms surrounding it. Knowing the extent of cardiovascular disease in India, I had no problem imagining the room packed solid. Worldwide, cardiovascular disease accounts for the largest number of deaths not caused by infections: 17.5 million people die annually because of it. That’s more than those who die because of cancers (8.2 million), respiratory diseases (4 million) and diabetes (1.5 million) – another disease which has also become a particularly virulent scourge in India. South Asians are genetically more susceptible to heart conditions than others, and it is projected that by 2020 Indians and Indian diaspora populations alone will contribute close to fifty per cent of the entire global cardiovascular disease burden. Of course, lifestyle factors such as lack of exercise and an unhealthy diet affect everybody, but genetically, Indians appear especially prone to their adverse cardiovascular effects and they also develop them earlier.

  Heart disease is no respecter of class, and increasing numbers of the affluent have had to seek heart surgery alongside their poorer compatriots. The difference, of course, is that they can afford to be ill in style. Asha indicated a staircase to the extreme left of the waiting hall. ‘The rich patients didn’t want to come here because of the poorer crowds. We had to create a separate area upstairs for the wealthier people – the executive area. I’ll show you later.’ She smiled. ‘But down here there are eighteen consulting rooms now. Dr Shetty’s aim was to provide affordable healthcare on a large scale.

  The hospital’s atrium was divided from the waiting area by an enormous stone carving of various incarnations of the eponymous hospital god. At its base, it was supported by a scene from the Bhagavad Gita, in which the Lord is portrayed dispensing wisdom and calm amidst a raging battle of epic proportions. In this spotless, marble-floored atrium through which hundreds of thousands of people have passed over the years were several reception counters: a travel desk for foreign visitors, a cash desk for taking payments, registration counters where patients were checked in and a dedicated ‘Bangladesh Information’ desk. This was to assist international patients from India’s closest eastern neighbour: a less densely populated country, but one in which the people who need healthcare most face obstacles to accessing it as seemingly insurmountable as those encountered by the poorest Indians.

  As I waited for Dr Shetty to see me, I read a fact sheet one of his assistants had given me detailing the chain of health centres that had opened across the country in the wake of the Bangalore original. Apart from the 1,000 beds housed here, there were now a further 6,500 spread across twenty-eight sister institutions in seventeen Indian cities.

  The scale of what Shetty had managed to achieve in such a brief time was remarkable. India doesn’t have anywhere near enough trained professionals to maintain the health and serve the sick among its 1.45 billion population, but the heart of the matter – the reason why Devi Shetty’s hospitals stand apart from the rest of India’s gleaming hospital-metropolises – is that they were created with a policy to be open to all.

  In India, as in many areas of the world, the cost of private medical treatment is prohibitive to many, but the distribution of drugs and implementation of its public health programmes are also faced with massive bureaucratic and logistical hurdles, from endemic corruption to contradictory government legislation, which can make public healthcare equally inaccessible to the poor. A recent Times of India report detailed how, ‘under the Central Government Health Scheme which covers central government employees, including serving and retired babus, current and ex-members of Parliament and the judiciary, the annual per capita expenditure is more than Rs5,000. In contrast, the National Rural Health Mission, which caters to the rural masses, spends just Rs180 per head.’

  This is symptomatic of the inadequate regulation which sustains massive regional disparities and promotes commercial medical ventures while the public healthcare system festers through a lack of funding, the absence of compulsory health insurance, inefficiencies in governance and care, poor hygiene and low staffing. It’s no surprise, then, that four out of five Indians choose the private sector, even when they can barely afford to do so. Shockingly, it is estimated that self-funded healthcare forces around 40 million people into pove
rty every year. Although the slick private centres are required by law to provide a certain amount of free care, in practice the legislation is often flouted.

  Narayana Health seemed to offer a revolutionary new approach. As Devi Shetty put it: ‘Corporate hospitals are developed for the rich, but also take care of the poor. This is a hospital for the poor and we also take care of the rich. That is why we exist.’ I was struck by how Narayana Health had not only recognised the scale of the problem facing India’s healthcare system but had also taken radical steps to change it – an almost impossible challenge.

  Shetty had worked at London’s Guy’s Hospital twenty-five years previously and then returned to work in Calcutta as a cardiologist in a private hospital, seeing hundreds of patients a day but performing very few surgeries, simply because hardly any of the people who needed the operations could afford them. The experience spurred him to find a new way of working, in which efficiency, professionalism and skill would combine with sound economics to create a system in which those who could pay the market rate would do so and those who couldn’t would be subsidised. Some criticised him for working outside the government health system rather than trying to improve it from within, but he was driven solely by an ambition to put world-class surgical care within the reach of people who needed it the most, and he felt that was a goal that would not be achieved via running the gauntlet of the state system.

  ‘In India there are 1.9 million people not getting heart surgery; we produce the largest numbers of young widows in the world,’ he said. Added to this, an estimated 78,000 infants born with congenital heart disease in India die every year because of inadequate healthcare facilities. This was a tragic waste of life from a reparable condition that was proving debilitating to the nation but whose treatment was out of reach to most who desperately needed it. In Shetty’s view, if a solution is not affordable, then it is not a solution.