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The corrupt doctor

Following the arrest of the president of the Medical Council of India for accepting a bribe to recognise a substandard medical college, Sandhya Srinivasan points out that when money can buy medical seats, college accreditation, and degrees, we’re talking about multiple investments that must earn their returns. Those returns are being earned at the expense of consumers and patients

So the president of the Medical Council of India has been arrested for accepting bribes to certify medical colleges that were unfit to teach. The MCI has been disbanded and replaced by a governing council. A “re-inspection drive” has started of all medical colleges that received clearance within a specified period, since some if not many of these colleges may have bribed their way to a certificate.

The government’s actions, whatever their motivation, confirm our fears of widespread corruption in the medical profession. They only confirm, because reports of corrupt doctors are no longer news. Such corruption, the circumstances in which it is bred, and the response of professional organisations to the problem – all have implications for the general public. They have a bearing on the availability, appropriateness, quality and cost of the care that we receive. Such revelations – welcome as the actions are – also deepen the public’s distrust of all encounters with the healthcare system.

The April 22, 2010 arrest of Ketan Desai, president of the MCI, on charges of corruption came as a surprise to the medical profession – not because of the charges against him, but because he finally got arrested for what was apparently an open secret, and which he had been getting away with for years.  

Desai was charged with accepting a bribe of Rs 2 crore, allegedly to grant recognition to a medical college though it did not meet standards of faculty, infrastructure, equipment or other essential facilities. This was apparently a long-standing extortion racket; the standard practice during MCI inspections was to identify deficiencies and then negotiate a rate to clear them in a second inspection.

Desai’s arrest seems to have unleashed a pent-up anger among some sections of the medical profession long aware of his dealings but, for whatever reason, unable to do anything about them. The ‘Remedy MCI’ campaign was joined by doctors from all over the country who demanded that Desai’s name be taken off the Indian Medical Register pending completion of the CBI inquiry, and possibly permanently if the charges are proved.  There was even talk of calling for the MCI’s dissolution, but this demand proved unnecessary.

On May 15, the central government issued an ordinance superseding the MCI for a period of one year. A governing council of seven persons “of unimpeachable integrity in the fields of medicine and medical education” was chosen by the central government, and asked to consider and decide on applications for new colleges, or new courses, or expanded admission capacity. The CBI called for the registration of grievances regarding the MCI’s functioning and received some 150 complaints which it will investigate. Inspections are expected in some 90 medical colleges – that’s one-third of all medical colleges in the country.  As part of its promise of transparency, the government has asked the governing council to post the results of each inspection on the MCI website along with statements of verification by the college’s board of governors and faculty members. The last “on-site assessment process for the purpose of establishment of new medical colleges/ renewal of permission” was scheduled to be completed on June 26.

On June 22, Desai was released on bail and immediately rearrested for possession of unaccounted assets amounting to Rs 24 crore.

“Arranged gifts” and “accommodation transactions”

This was not the first time Desai was charged with accepting a bribe. In 2000, an income tax raid turned up demand drafts in the names of Desai and his family members, totalling Rs 65 lakh, which the tax authorities concluded were “arranged gifts” or “accommodation transactions” to launder and transfer into his account cash received for dubious services rendered. At that time, too, he was president of the MCI. The Delhi High Court judged the evidence strong enough to order a CBI investigation and to force him to step down from the presidency of the MCI. But the CBI eventually issued Desai a clean chit; apparently investigations had revealed that Desai had been gifted the money in order to “earn his goodwill” because he was “an influential person in medical circles”.

If paying an influential person Rs 65 lakh to earn his “goodwill” is not a bribe, what is? Did Desai’s powerful friends have anything to do with the CBI’s report?

Friends in high places

Desai’s resume (posted on the website of the World Medical Association, of which he is president-elect) gives an idea of the breadth of his influence. Some of these positions he acquired while the 2001 corruption charge was being investigated.

He has been president of the Indian Medical Association (2001-2); member, institute body of the Post Graduate Institute of Medical Science and Research, Chandigarh (1995-2000); member, institute body of the All India Institute of Medical Sciences (1999-2001); chairman, academic committee of AIIMS (1999); chairman, standing selection committee, AIIMS (2001); member, Drug Technical Advisory Board (2000-1); member, governing body, Indian Council of Medical Research (1996-1999); member, governing body, National Board of Examinations (1996-2001 and 2009 until date); dean, faculty of medicine, Gujarat University (1991-7); member, board of management, Baba Farid University of Health Sciences, Punjab (1998-2003); chairman, clinical board of studies, Gujarat University (1991-2009); member, board of studies (clinical), Sardar Patel University (1992-5); and member, Employees State Insurance Corporation (2003-6). He has also been president of the Medical Council of India (1996-2001 and again since March 2009) and member of the MCI’s executive committee (2007-9), before he regained the presidency in 2009.

He has been president of the Gujarat Medical Council since 1993, member of the executive council of Gujarat University since 1992, member, clinical board of studies, Gujarat University, since 1991 and court member, Gujarat University since 1989.

When Desai was forced to step down from the MCI presidency in 2001, he got another person to keep his seat warm until the charges were dismissed, and is reported to have operated the MCI by remote control. In March 2009, after the CBI cleared him, and the Supreme Court gave the go-ahead for elections, Desai was elected MCI president, unopposed.  And in October 2009, at the annual general meeting of the World Medical Association in Delhi, he was elected president of the WMA, again unopposed.

Assault on the “independence of a medical education regulatory system”

There is some speculation about the circumstances of Desai’s most recent arrest. One theory has it that he got into trouble with the pharmaceutical industry for pushing through an amendment in the MCI’s code of conduct which banned doctors from accepting gifts from drug companies. But while the amendment seems to be a bold attack on the doctor-drug company nexus, it has its loopholes. For one, while individual doctors may not receive gifts, medical associations are permitted to take money.  And of course there is the question of implementing the code – the MCI has done a pretty poor job so far, of enforcing the code. Still, it is possible that Desai is being punished for disturbing more powerful interests than those which have supported him all these years. Of course, this does not mean that the charges against him are false – only that there is no honour among those accused of theft.

Another theory is that Desai’s arrest, and the government’s order dissolving the Medical Council of India, is part of a campaign against the autonomy of associations of medical professionals and their right to regulate the actions of their members. Indeed, the medical profession has always fought against external regulation, and in 2005, when a bill was introduced that would curtail the powers of the MCI and give more powers to the government, the Indian Medical Association led the campaign against this move.

This is the stand taken by the World Medical Association, where Desai is set to take over as president this coming October: The WMA held an emergency meeting in Geneva in May immediately after the MCI was dissolved, but the discussions at this meeting have not been made public. However, the WMA’s secretary general, Otmar Kloiber, has stated that the association stands by Desai: he is innocent until proven guilty in a court of law. Unless he becomes unable to fulfil his duties as president – if, for example, he is in prison or not permitted to leave the country – he will take over as president at the October 2010 annual general meeting.

Otmar Kloiber also stated that before Desai’s candidacy was accepted, the CBI report was shown to WMA officials and it cleared Desai of all charges.  Further, WMA officials saw that Desai was on very good terms with the health minister and the prime minister, evidence to them that he was well-respected and clean. Other sources at the WMA have stated that the association had no choice: since Desai had been cleared by the CBI in the 2001 case, there were no grounds to veto his candidature.

Incidentally, Desai’s resume on the WMA website continues to list him as president of the MCI.

In any case, the WMA is made up of national medical associations which represent the profession’s interests. We know what those interests are in the case of the Indian member association. None of the IMA’s representatives on the WMA committees inspires confidence or respect. Their accomplishments seem to consist of organising health camps and attending international conferences.

The only campaigns that the IMA has taken up seriously are against threats to its independence and its control over the profession. Two prominent campaigns taken up by the IMA or its committee members are against the government’s bid to take over the MCI in 2005 and, more recently, a proposal for a special cadre of doctors for healthcare in rural areas.

In fact, a cadre of rural doctors, or community-oriented practitioners, is exactly what many government reports have called for. Such practitioners could serve the health needs of poor rural populations, unlike the doctors of today. The National Knowledge Commission’s working group on medical education notes, in a 2007 report, that graduates of the medical education industry do best in “urbanised, doctor-centred, technology-driven” systems.

The medical education business

Established in 1933, the MCI was given charge in 1956 of regulating the profession and maintaining standards of undergraduate medical education. Over the years, it acquired powers to certify new colleges, new courses and increased admissions, and regulate postgraduate education.

The MCI has used these powers to make a lot of money, and this has been well-documented. Certificates have been issued on the basis of falsified attendance registers and even salary slips in the names of doctors who had died or migrated. Certificates have been issued even when there is evidence of fraud, such as when the names of the same faculty appear in registers of different colleges or when it is clear that the faculty have been shipped in from other colleges for the duration of an inspection in order to show the required staff strength. Clearance has been given to colleges that do not have the necessary hospital beds per student, where there are no patients, and so on. Given such flagrant violations, it is understandable that Desai has no qualms about being on the board of medical colleges that he inspected and certified.

Medical education is a multi-crore-rupee business in India. Capitation fees are illegal, but no matter: students seeking admission in a private college will pay anything from Rs 20 lakh upwards for seats under the management quota. Those applying under the quota for non-resident Indians will pay even more. A postgraduate seat can cost Rs 2 crore.

This education is “directionless, unregulated and non-standardised” with few exceptions, according to the NKC report. There is no monitoring or implementation of standards by “any regulatory body”. 

At the same time, the medical education industry has more than doubled in size in the last 20 years. The number of medical colleges has gone from 152 in 1994-5 to 262 in 2006, according to the NKC report. The number of students admitted every year has gone from 12,249 to 28,349 in the same period. Not a small part of this growth was due to the boom in private medical education. In 1995, there were 47 private medical colleges and 109 government colleges. In 2006 there were 131 private and 131 government colleges.

More than 70% of healthworkers of all types in India work in urban areas, and in the private sector. Few doctors wish to work in rural areas – not only are living conditions difficult, those who’ve paid lakhs of rupees to get into medical college need to recoup their investments.

If any more proof is needed of the direction of the medical education system, a study of graduates from the All India Institute of Medical Sciences found that 54% of those who graduated between 1989 and 2000 had migrated abroad. Another study found that 59,523 of doctors educated in India live abroad, compared to 503,900 practising in India – almost 11% of medical graduates migrate.

The NKC states that private medical colleges have become “a source of political and financial power” with admissions mostly “based on the collection of large sums of money, usually in cash, as capitation fees, in addition to the sizeable tuition and other fees charged”.It even goes so far as to declare that “Those colleges not having the scientific and ethical infrastructure and expertise do not deserve to exist. Poor quality commercial training shops producing poor quality manpower cannot be left loose on a hapless trusting public.” The MCI does not inspire confidence. The commission notes: “...there is an urgent need for a monitoring agency that ensures accountability in the system.”

Medical corruption: An open secret

Corruption in medical education is naturally accompanied by corruption in medical practice. After all, the money spent on this education must be earned back. Every one of us has experienced the seamy side of commercial medical practice today. Whether it is surgeons demanding large cash payments before they will operate in an emergency, or paediatricians peddling unnecessary vaccines by playing on the fears of parents, or doctors writing prescriptions for unnecessary, irrational and even dangerous drugs, or expensive tests for the kickbacks they receive from drug companies, or diagnostic centres. The list goes on and on.

Desai’s arrest is no surprise because we have reached a state of affairs in which medical education is acknowledged to be a business investment and medical practice gives the returns, where patients have no faith in the profession’s responsibility to regulate itself – or in an external authority doing it instead.  

We as healthcare consumers need to think about the implications for us, as patients, of corruption in medical education. When money can buy medical seats, college accreditation, and degrees, we’re talking about multiple investments that must earn their returns. Those returns are being earned at our expense.

Infochange News & Features, June 2010