THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 13, NO.1, 2000

Letter from Chennai37

I was delighted to see an item in the Indian Express dated 3November 1999. The wife of a doctor in the Tamil Nadu MedicalService underwent high-dose chemotherapy with autologousstem cell transplantation at the Apollo Cancer Hospital in Chennai,and incurred a bill of Rs 6.18 lakh. The doctor asked that this bereimbursed, but the government sanctioned just Rs l lakh, Fortu-nately for him, he could cite the case of a former Director ofMedical Education (DME), who suffered from the same illnessand received treatment at the same hospital, and was reimbursedto the extent of Rs 15 lakh for his expenses. The doctor ap-proached the Madras High Court with the complaint that he hadbeen discriminated against. The government countered that thistreatment was available in its hospitals. If the petitioner chose togo elsewhere for his treatment, then under the Tamil NaduGovernment Employees' Health Fund Scheme, he was eligible tobe reimbursed for only 75% of his expenses subject to a maximumof Rs 1 lakh. The former DME had applied for permission inadvance, and the government had granted this as a special case.

The learned judge observed that if the treatment was availablein its hospitals, the government should have told the DME to usethe hospital and should not have sanctioned treatment elsewhere.While the petitioner did not apply in advance, there was no rulewhich required him to do so, and that could not be held againsthim. The government had no right to discriminate between two ofits employees who had treatment for the same disease in the samehospital. He directed the government to pass orders within sixweeks to settle the bills in full. .

Aldous Huxley said, 'That all men are equal is a proposition towhich, at ordinary times, no sane individual has ever given hisassent' . I wonder whether the judge gave thought to the possibleconsequences of his ruling. The government is the largest em-ployer in the country, and the number of its servants is everexpanding. I am aware of some senior officers who remain on longterm dialysis, a perquisite denied to lesser mortals. Many secretar-ies to the government seek treatment in private hospitals forconditions which could be, and are, routinely handled in govern-ment hospitals. As for ministers, the sky is the limit. Illness takesthem to hospitals in the USA or UK. If the court considersministers to be government servants (is it sacrilege to evensuggest that a minister is a servant to anyone and not a monarch ?),every government employee with renal failure could approach thecourt to have himself or herself dialysed in London. Universalapplication of the court's decision would send the governmentinto bankruptcy, and might at last compel the government to insiston what I have been advocating for years, that it should pay fortreatment only in government hospitals. Any employee who optsfor treatment in a private hospital should bear the expenses out ofhis/her own funds. If only this rule were introduced and followed,government hospitals would improve and rival five-star hospitalsof the private sector. The admission of a minister to a hospitalwould work wonders in toning up the system. Decades ago, whenI was an Assistant Professor of Medicine in the Madras MedicalCollege, the then Chief Minister, Mr M. Bhaktavatsalam, wasadmitted with a fracture. One of the lifts serving the operationtheatre block had been out of order for years. It was miraculouslyrepaired in a day, and, what was more, it even recei ved a coveringof linoleum for its floor!

Alas, whatever the judge had to say, the fact is that, as Orwell

put it, 'All animals are equal but some animals are more equal thanothers' .

The deemed university seems to be a peculiarly Indian concept. Icould not find the term in the Encyclopaedia Britannica or in theNew Shorter Oxford Dictionary, and a web search revealed onlyIndian information. A friend from the Madras Christian Collegewas kind enough to give me some background information. Ourvery own University Grants Commission (UGC) first introducedthe concept of autonomy for various colleges, giving them someacademic freedom. The next step was to sanction institutionsdeemed to be universities, which are not full-fledged multi-disciplinary universities, but have complete freedom in the sphereof higher education. The idea is to aim for a high level of academicexcellence which may not be possible in the massive universitieswhich exist in India. The Governor is the Chancellor, and thedeemed university has its own Vice-Chancellor, Senate, Syndi-cate and Academic Council. The UGC then washes its hands ofthe running. The deemed university receives no money from theUGC, and is expected to raise its own funds.

A deemed university should have proven achievements beforeit is granted the status. It should aim to achieve something whichit could not in its old position as a component of a largermultidisciplinary university. Viewed from that perspective, thepresent deemed universities have been dismal failures. Twoprominent ones are the Manipal Academy of Higher Educationand the Ramachandra Medical College, the latter just outsideChennai. What have they delivered that is superior to ordinaryuniversity-affiliated medical colleges? There seems to be nodifference in the quality of the products from these institutionsand other colleges in the country. Most teachers of medicine agreethat our present system of education and examination is not suitedto the needs of the country. We do not turn out competent generalpractitioners, but half-baked specialists, who take an examina-tion, not on the infections and malnutrition which plague thecountry, but on valvular heart disease, hemiplegias and paraplegias,and a few respiratory conditions. Teaching is geared to thisexamination and, therefore, does not prepare the graduate toefficiently treat common ailments endured by most Indians.Should not a deemed university, with its independence, aim toimprove the quality and content of its teaching programmes, andits system of examination? Why are our deemed universitiestamely producing more of the same?

Almost two years ago, the premier institution of Tamil Nadu,the Madras Medical College (MMC), was declared to be a deemeduniversity. The significant activity of the university seems to havebeen to attempt to eat its cake and have it too. The teachers are notready to sacrifice their private practice though they would gladlyaccept UGC pay scales, which are much higher than what theGovernment of Tamil Nadu offers its employees. On the otherhand, they are not ready to move from the MMC to other collegeswhich remain in the Tamil Nadu Medical Service and will allowthem to continue with their practice. Teachers now in the MMCwish to follow the UGC norm of age of retirement, which is 60,instead of the Tamil Nadu pattern, which is 58. A number ofprofessors who should have retired went to the Madras HighCourt and obtained a stay order, and thereby continue to servebeyond the retirement age of the government. Meanwhile, the

38 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 13, NO.1, 2000

Tamil Nadu Government Doctors' Association demanded that theprofessors retire, since their extension in service would hold upthe promotion of several other doctors. Confusion reigns.

It remains a mystery why these institutions have been chosenfor this exalted status, and what they will achieve by it. It appearsthe change of name is just to make the public believe thatsomething has been done to improve the MMC. As Shakespeareput it, 'What's in a name? That which we call a rose by any othername would smell as sweet.' Or, in this case, the olfactoryopposite.

A young man from a small town in Andhra Pradesh was referredto me for severe hypertension. When he stripped for examination,I found that he was muscular beyond the average athlete, andasked him whether he practised exercises to build his muscles.'No', he said, 'just last year I was in college, and I was a memberof the college weight-lifting team.' I cautioned him to avoidweight-lifting, springs, and other isometric exercises hereafter.They could raise the blood pressure precipitously. He seemeddisappointed, but I had opened a door to some reminiscences, andhe wanted to tell me more, with pride in his achievements. He andmany of his team-mates had won prizes in the university sportsmeet. His coach, he confided in me, was particular that the collegeshould sweep the board, and had injected them with steroids. I didnot believe my ears, and made him repeat himself. A small townin Andhra Pradesh, one of those station names that flash past asone goes elsewhere, never itself a destination! And the coach ofthe local college team was injecting his wards with steroids!

Sports Illustrated is not one of the magazines I care to read, oreven glance through. Its editor and correspondents have neverheard of cricket. However, some months ago in a waiting room inthe US I found no other reading matter, and one article interestedme. It stated that 90% of professional athletes have at some timetaken some form of illegal performance-enhancing drugs. Arecent item in our newspapers, datelined Berlin, reported thatthree former East German swimming officials were convicted ofcausing bodily harm to 70 under-age girls under their supervisionby distributing anabolic steroids to them. The three, all of whomadmitted responsibility for the charges, were sentenced to oneyear's probation and ordered to pay $ 2600 each to a charity forwomen in Berlin.

They failed to inform the girls or their parents of harmful side-effects, such as hormonal disturbances and the development ofmale characteristics. In some cases, women administered thesteroids have had long term menstrual and gynaecological prob-lems. I could believe that of Germany and the US, but not of India,and especially hot of college athletes. But here was this youngman telling me that his coach, not his doctor, had injected himwith steroids. 'Don't you know that is illegal?' I asked. 'Of

course,' he said, 'but we have to win medals. Everyone does it,and how can we win if we alone do not?'

How many proud parents of college athletes are aware of thisdanger? I do not know whether the practice is indeed as prevalentas this young man said, but surely someone should look into it. Mypharmacology book gives a long list of potential ill-effects ofanabolic steroids, but I am more worried about the idea of acollege coach injecting the stuff into a large number of youngpeople. What does he know about sterilization and HIV?

Tamil Nadu and especially the city of Chennai, has done betterthan the rest of the country in the introduction of cadaveric organtransplantation. More renal and cardiac transplants have beendone here than anywhere else in the country, but we cannot reston our laurels. The fact is that the number is pitifully small, bothtowards fulfilling the need for organs and as a proportion of thenumber of potential donors available. Our achievements havebeen due to the efforts of a few keen doctors, and not to a public-spirited citizenry. It is hard for nephrologists to canvass organdonation, since we are regarded as a group with vested interests.Fortunately, members of the public have responded to the need,both in Bangalore and Chennai.

The team in Bangalore took the lead with the formation ofFORTE (Foundation for Organ Retrieval and Transplant Educa-tion), but recently Chennai's MOHAN Foundation (Multi OrganHarvesting Aid Network) has begun work in the field.

At a meeting in Chennai on 13 December, the MOHANFoundation decided to set up an Initiative for Organ Sharing (IOS)Group, with doctors from hospitals which have done most of thetransplants, and some representatives from the Foundation itself.One each of a donor's kidney would go to the retrieving hospitaland the other to a common pool. A core committee is to be formed,which should devise a point system to allocate these organs towaiting patients. The IOS group would maintain a registry of allprospective recipients.

We need to make people realize the Biblical exhortation:freelyye have received,freely give. No donation is easier, none costs lessthan the gift of something we were going to discard (or bum, orbury) anyway. de La Fontaine said, 'People must help oneanother; it is nature's law.' I am afraid this law is just one more forus to break at will. The initiative should come from the medicalprofession, for who knows better the plight of patients with end-stage disease of the heart, liver or kidneys? We doctors shouldpledge our own organs, and donate those of our kith and kin whopredecease us. May the efforts of the 10S group bear fruit, andmay Indians live longer, healthier lives, and pass their organs onto the needy when they die.

M. K. MANl