Doctors as selfless gods? Urban elite created this myth, especially movies, says Dr Kiran Kumbhar

Dr Kiran Kumbhar, a doctor from Maharashtra currently doing research on the history of medicine in India in Harvard University’s department of history of science, upends the popular narrative of the medical profession being “noble” with meticulous research showing how such a narrative was constructed and had/has little connection with reality. Kumbhar’s research shows that a tiny sliver of upper castes and class dominating the medical profession has meant a lack of understanding of and empathy with the lives and circumstances of most of the population.He talks to Rema Nagarajan about the consequences of this in the medical profession and in health policy making.

It is a myth in the sense that it is considered a universal experience. The narrative says there was a time in the early post-independence years (1950s to 1970s) when all patients considered doctors to be Gods and that almost all trusted the treatment and advice doctors gave. That needs to be taken with a pinch of salt. For the underprivileged in a city, who constituted 70-80% of the population, hospitals were most often the only way to access a doctor. They could not go to their private practice. We have evidence that a lot of people were dissatisfied not just with individual doctors but with the whole experience of being in cramped insanitary wards, long queues for outpatient consultation and doctors with little time to spare. We see from the archives words like rude and disrespectful being used to describe the behaviour of doctors with these patients. There were some good doctors, but stories of such doctors have an element of exceptionalism to them, which makes it clear that this was not the norm. In rural areas, there were hardly any doctors though 80-90% of the population lived there. A majority of the Indian population never had any first-hand experience with doctors at all. So, how can we say that most people in India respected doctors and had a trustful relationship with them when they mostly had no relationship at all?

Most doctors did private practice in the 1950s and ’60s and their clients were mostly the urban elites such as business people, bureaucrats, managers, engineers, professors, and of course, filmmakers. It is they who created and controlled the public discourse and created the golden age gloss to the patient-doctor relationship during this period, especially through cinema — the trope of the doctor selflessly serving the poor, contributing to nation building. Biographies of that period mentioned this doctor who was almost like a family member. It is true only for a small minority of the Indian public whether in the 1960s or even now. We have so many movies in which we see doctors coming and being a part of family functions and even participating in discussions on marriage and all of that. This was not the experience of most people in India, but of a small circle of people in which the doctor moved.

This narrative was created mostly in the 1990s in response to the medical profession being heavily criticised. The 1980s were a period of several scandals, scams and corruption in the medical world in India — private medical colleges taking capitation fees, female foeticide, kidney rackets, deaths in a hospital due to a drug being traced to a nexus between pharma and doctors and medical negligence cases. All this took a lot of sheen off the profession. Even the elite, who were generally the collaborators of doctors through the 1950s, ’60s and ’70s, were talking about these unethical practices, malpractices and negligence. And then the Consumer Protection Act (CPA)was passed in 1986. Though the CPA was not meant to be used against doctors and hospitals, within a few months people were suing doctors under this new Act. That is when the medical profession started taking the public outrage seriously because now there were consequences to face. Before that, there were just people writing to newspapers and saying bad things but little that was actually going to affect them. Several articles appeared in medical journals and newspapers where doctors were analysing what was happening around them. That’s when this narrative was created: “Look what is happening now and think of how we used to be so well respected in the past.”

Through my research I was trying to find out the true origin of public anger and mistrust of doctors, which led to increasing incidents of violence against doctors and vandalism in hospitals in recent decades. And I would say liberalisation is just one of the factors.
Power asymmetry plays an important role in how doctors interact with patients. We know that a lot of times doctors yell and scream at patients. There have been so many studies on that, especially on obstetric violence. All these studies show that this is almost exclusively meted out to underprivileged people. It is hard to imagine that it can happen to a Brahmin woman or a woman from other locally dominant castes even in a government hospital. The attack on commercialisation and liberalisation, while it is important, will not help to remedy this sort of ingrained caste-based violence. But the kind of reform needed to address caste domination and hierarchical mindset is not being discussed with as much enthusiasm, passion and commitment as the reform of commercialized medicine.
It is not just medical profession. Almost all white-collar, middle class professions are dominated by privileged communities. Mandal documents showed how even after 40 years of independence, a majority of bureaucrats and administrators belonged to the dominant castes. This brings in blind spots and unconscious biases which, unfortunately, have never been acknowledged. These blind spots affect how policy is created. A lot of our policies in healthcare and public health have been one thing after another which is similar and we have done more of the same. So, in the 1940s and ’50s, we were talking about bringing doctors to villages and building more medical colleges to produce more doctors and even in 2020 we are having the same kinds of conversations.

A lot of research has shown that, unfortunately, our policy is too doctor and hospital centric. And I think that is one of the main problems with how we think about health care in India. We should have community-based healthcare, instead of a centralized, hospital-based one. It doesn’t mean hospitals are not important, it just means that there’s a lot more to health care and public health than just hospitals and doctors. We have policymakers with this urban upper caste bias and one of the main manifestations of that is the neglect of community health which holds the answer to a lot of problems (not all of the problems) that people in India face. The other way in which this bias is working is that there is just no focus on the idea of public health, which has proven to be effective all over the world, like providing clean drinking water, adequate housing etc. Millions, probably hundreds of millions of people in India don’t have access to these very basic materials necessary for promoting health. These are some of the ways in which the policy making bias keeps rearing its head, in the way these issues are neglected while we pursue fancy ideas like digital health ID, and of course family planning or population control.
The medical community itself is dominated by upper castes and so they never start these conversations. Because of this dominance, when we talk of caste the only thing that comes to mind is reservation, but not the effect of inequality on health outcomes of communities or of reducing poverty or caste equalities as a way to have better health outcomes.