In my younger days as a journalist I was blessed to have the friendship of several dedicated young doctors who after passing out in distinguished ways from some of the top medical colleges had decided to devote themselves to serving the poor in remote villages or working class colonies. Another category of medical friends whose friendship I cherished were those who were devoted to exposing the various malpractices of a medical system which was increasingly going towards getting dominated by high profit orientation.
Over the years the number of new doctors and other medical personnel coming up to take up the call of duty in difficult conditions appeared to decrease, while the grip of big business interests over the medical system tightened further. A sad reality that has been increasingly seen, and was even more obvious during the recent pandemic, is that profit-driven health and medical systems are unable to respond effectively to the real needs of people and to such crisis situations. People tell many instances when they felt very disturbed and cheated due to their experiences but their grievances do not impact the system much because many such distortions have been ‘normalized’ in the system. It is important to recognize this as a systems problem and not just as sporadic happenings.
Another important aspect is that if such a distorted system exists in a very rich country, some of its ill-effects can be checked because a lot of funds are available. However when some poorer countries try to copy parts of this system, or else pressures are exerted on them to do so, then these countries are unlikely to have the funds to check these ill effects. Hence much more harmful impacts may result.
The USA health system is regarded as a very important example of a profit-driven health system and some important and useful studies of the distortions that exist here have emerged in recent years. One such book discussed here is titled ‘Doctored – The Disillusionment of an American Physician’. This has been written by Dr. Sandeep Jauhar. Dr. Jauhar has been the Director of the Heart Failure Program at a leading US hospital and has also written regularly for the New York Times.
In this book Dr. Jauhar has portrayed a highly commercialized system in which doctors who want to be honest to their profession feel very helpless and hence are exposed to high levels of depression. In a survey of 12,000 physicians, only 6 per cent described their morale as positive! The majority of them said they did not have enough time to spend with their patients because of paperwork. In the USA, among professions, physicians have the highest suicide rate. One American doctor kills himself (or herself) every day.
One doctor said on Sermo, the online community of more than 1,25,000 physicians, “Working up patients in the ER these days involves short-gunning multiple unnecessary tests (everybody gets a CT!) despite the fact that we know they don’t need them, and becoming aware of the wastefulness of it all really sucks the love out of what you do. I feel like a pawn in a money-making game for hospital administrators.”
Another doctor quoted in this book says, “You’re doing things, and you’re doing them because you’ve got to be doing them, but you’ve thinking, why the hell am I doing this?”
One doctor regrets, “We allowed the insurance companies to come between us and our patients.”
Dr. Jauhar says, “Year after year, health care spending grew faster than the economy as a whole. Premiums for insurers like Blue Cross, whose reimbursement rates were determined by doctors, increased 25 to 50 per cent annually. Meanwhile reports of waste and fraud were rampant.”
A Congressional investigation found that surgeons performed 2.4 million unnecessary operations resulting in nearly 12,000 deaths.
The Institute of Medicine estimated that wasteful health spreading (that does not improve health outcomes) costs $750 billion in the USA every year.
A study published in the England Journal of Medicine found that one in five Medicare patients discharged from the hospital was readmitted within a month. One in three was readmitted within three months.
Dr. Donald Berwick and Dr. Allan Detsky wrote in the Journal of American Medical Association that inpatient care at teaching hospitals has become a relay race for physicians and consultants, and patients are the batons.
Researchers have found that a doctor who owns a nuclear scanner is seven times as likely as other doctors to call for a scan. Between 1987 and 2006 the exposure of Americans to radiation increased by seven times, primarily because of CT scans. The number of CT scans in the USA in one year is around 70 million.
Patients are overexposed to a battery of specialists, several of whom they do not need, while the doctor who knows a patient best is often not involved in her or his care at the time of hospitalization. Dr. Jauhar gives one example, “A fifty-year old patient of Oni’s was admitted to the hospital with shortness of breath. During his month-long stay, which probably cost upward of $200,000, he was seen by a hematologist; an endocrinologist; a kidney specialist; a podiatrist; two cardiologists, a cardiac electro-physiologist; an infectious-diseases specialist; a pulmonologist; an ear, nose and throat specialist; a urologist; a gastroenterologist; a neurologist, a nutritionist; a general surgeon; a thoracic surgeon; and a pain specialist. The man underwent twelve procedures, including cardiac catheterization, a pacemaker implant, and a bone marrow biopsy (to work up mild chronic anemia). … When he was discharged (with only minimal improvement in his shortness of breath), follow-up visits were scheduled for him with seven specialists.”
Dr. Jauhar comments, “Patients don’t always require specialists. Patients often have “overlap syndromes” (we used to call it aging), which cannot be compartmentalized into individual problems and are probably best managed by a good general physician. When specialists are called in, they are opt to view each problem through the lens of their specific organ expertise. Patents generally end up worse- I have seen it over and over again.”
Medicare imposed a requirement that antibiotics be administered to a pneumonia patient within 6 hours of arriving at the hospital. Doctors often cannot diagnose pneumonia so quickly, but because of Medicare requirement antibiotics were given despite all-too-evident dangers to patients.
Introduction of surgical report cards which rewarded lower mortality led to a strong tendency to avoid more serious patients. As a research report stated, “Mandatory reporting mechanism inevitably gives providers the incentive to decline to treat more difficult and complicated patients. …Observed mortality declined as a result of a shift in incidence of surgeries towards healthier patients.”
In New York state 63 per cent of cardiac surgeons acknowledged that because of report cards, they were accepting only relatively healthy patients for heart bypass surgery. 59 per cent of cardiologists said it had become harder to find a surgeon to operate on their most severely ill patients.
Despite very high spending on health the USA lags behind in health achievements. According to the Commonwealth Fund, a health care research group, the US ranks forty-fifth in life expectancy (behind Bosnia and Jordan). Among developed countries, it is almost at the bottom of the list when it comes to reducing infant mortality. Similarly it is near the last place in terms of health care quality access and efficiency.
What is more, as Dr. Jauhar tells us, “…within the USA, regions that spend the most on health care appear to have higher mortality rates than regions that spend the less, perhaps because of increasing hospitalization rates that result in more life-threatening errors and infections.”
Dr. Jauhar concludes, “I am convinced of one thing; the vast majority of doctors aren’t bad. It is the system that makes us bad, makes us make mistakes.” He says that more doctors are willing to stay till late and provide good care, but “they are struggling to do so in a system that is diseased.” The most disturbing part of what Dr. Jauhar says is that most doctors realize that the system is forcing them into a situation in which they cannot be honest to their profession, yet feel so trapped by the system that they can’t resist it enough to find the honest way out.
Several distortions of the medical system increased further during the recent pandemic. While questions have been raised regarding the response to Covid-19 in many parts of the world, it has been rare for a medical journal of international repute to take a strong stand on this issue. It is in this context that the publication of an editorial in the famous medical journal BMJ attracted a lot of attention. This editorial published on November 13 2020 titled ‘Covid-19—politicisation, ‘corruption’, and suppression’ is, as its title suggests, a strong indictment of the response to COVID-19 in Britain and is also suggestive of what may have gone seriously wrong in several other parts of the world.
What makes this editorial, written by the executive editor of BMJ Kamran Abbasi, even more compelling was the strong and supportive response it evoked from many well-informed readers, several of them eminent and experienced medical experts, suggesting that these strong feelings are shared by many concerned members of the medical community.
This editorial declares loud and clear—When good science is suppressed by the medical-political complex, people die. It goes on to say—Politicians and governments are suppressing science. Science is being suppressed for political and financial gains. Covid-19 has unleashed state corruption on a grand scale, and it is harmful to public health. Politicians and industry are responsible for this opportunistic embezzlement. So too are scientists and health experts. The pandemic has revealed how the medical-political complex can be manipulated in an emergency—at a time when it is even more important to safeguard science.
While lamenting the many problems in the selection of officially appointed experts for guiding policy in Britain, this editorial specifically refers to research published in the previous week in the same journal which found that the government procured an antibody test that in real world tests fell far short of performance claims made by manufacturers. Researchers from Public Health England and collaborating institutions, the editorial points out, sensibly pushed to publish their study findings before the government committed to buying a million of these tests but were blocked by the health department and the Prime Minister’s Office.
The UK’s pandemic response , this editorial regrets, relies too heavily on scientists and other government appointees with worrying competing interests, including shareholdings in companies that manufacture Covid-19 diagnostic tests, treatments and vaccines. Government appointees are able to ignore or cherry pick science—another form of misuse—and indulge in anti-competitive practices that favour their own products and those of friends and associates.
The editorial asserts—Suppressing science, whether by delaying publication, cherry picking favourable research, or gagging scientists is a danger to public health, causing death by exposing people to unsafe or ineffective interventions and preventing them from benefiting from better ones. When entangled with commercial decisions it is also maladministration of taxpayers’ money.
At a wider level the editorial regrets deeply—Politicisation was deployed by some of the history’s worst autocrats and dictators, and it is now regrettably commonplace in democracies. The medical political complex tends towards suppression of science to aggrandize and enrich those in power.
Finally, the widely discussed editorial asserts—When good science is suppressed, people die.
This editorial was soon followed by responses from eminent medical experts who appreciated the courage and merits of the editorial and congratulated the editors for saying what needed to be said but had not been said earlier in such clear terms in any reputed medical journal. Dr. Eshani M. King of Evidence Based Research in Immunology and Health pointed out in a detailed response titled ‘ Covid-19—Science, Conflict and the Elephant in the Room’ ( published on November 17 )– Public fear of Covid has been elevated to levels that are completely out of proportion to the real danger.
Dr. Eshani King writes—Although deaths are currently at normal levels, fear is being driven by inflation of Covid cases caused by inappropriate use of Polymerase Chain Reaction (PCR) test. This test is hypersensitive and highly susceptible to contamination, particularly when not processed with utmost rigour by properly trained staff. According to Prof. Brookes, a health data scientist from the University of Leicester, the UK’s official data shows no excess deaths due to respiratory infections this season.
Dr. Eshani King says—Instead excess total deaths have been driven by lack of treatment due to hospital closure/lockdowns and have occurred mostly at home. Hijacking of science by vested interests has resulted in immeasurable harm to society. Lockdowns meant to save lives but pushed by narratives that have little basis in science, have themselves caused loss of life, livelihood, dignity and humanity.
In another response dated November 15 Dr. Theodore F. Schrecker, Prof. of Global Health Policy , Newcastle University, commented about this editorial—Congratulations for this admirable ( and admirably well-documented ) critique of the rot at the core of the UK government response to the corona virus pandemic. The result of the lack of accountability mechanism is that people die not only from Covid-19 but also from other conditions as diagnosis and treatment have been disrupted by shambolic responses to the pandemic.
The final words of this Professor are—Mourn and resist.
In another response a retired senior doctor Andrew N. Bamji has lamented—Any counter-narrative from an informed individual or an academic department, has been seriously ignored. Dissenters have been quite efficiently no-platformed.
The wider crisis is that with the enormous wealth of medical multinational companies (particularly those making medicines and vaccines) and several billionaires working for their interests in the guise of philanthropy, at several levels the medical system has started operating as though it exists first and foremost for profits, control and dominance, while what happens to people and patients is far lower down the list of its aims and priorities. Here is what some distinguished medical experts have stated.
John Adamson, M.D., Harvard Medical School says—The first step is to give up the illusion that the primary purpose of modern medical research is to improve Americans’ health most effectively and efficiently. In our opinion, the primary purpose of commercially funded clinical research is to maximize financial return on investment, not health.
Arnold Seymour Relman, former Editor-in-Chief of the New England Journal of Medicine—The medical profession is being bought by the pharmaceutical industry, not only in terms of the practice of medicine, but also in terms of teaching and research. The academic institutions of this country (USA) are allowing themselves to be the paid agents of the pharmaceutical industry. I think it is disgraceful.
Marcia Angell, M.D., former Editor-in-Chief of the New England Journal of Medicine—Now primarily a marketing machine to sell drugs of dubious benefit this industry uses its wealth and power to co-opt every institution that might stand in its way, including the US Congress, the FDA, academic medical centers and the medical profession itself.
As a result of the all-pervasive influence of big business interests, danger is increasing that they can use this situation of dominance to market in a big ways drugs and vaccines which not only bring massive profits but in addition, due to less attention being paid to safety aspects in the hurry to earn big profits, can also harm the health of people exposed to them.
The pandemic not only led to such questions being raised in some countries but in addition there was disturbing debate about COVID-19 response being manipulated in such a way that in terms of the inevitable impact, billionaires in many lines of business (and not just vaccines and medicines) benefited the most, adding billions to their accounts, while millions and millions of ordinary and poor people had their life and livelihood disrupted in a very cruel way. Hence there was a massive transfer of wealth and income from the poor to the rich, leading to further huge widening of already high level of inequalities. This is one way in which those who dominate the medical system can use their enormous power to unleash very disruptive changes. In addition imposed lockdowns and related changes can also be used to clamp down heavily on democracy and gatherings of people, and to increase authoritarian trends.
It is due to the big business domination of the medical system being used in such highly disruptive ways that there is increasing and very urgent need for medical personnel to get together with citizen groups to challenge and check this big business domination of medical system before it is too late.
Bharat Dogra is Honorary Convener, Campaign to Save Earth Now. His latest books include Planet in Peril, Protecting Earth for Children, Man over Machine and a Day in 2071.
