[This article was written for the souvenir brought out on the occasion of the diamond jubilee celebration of the Patna Medical College, formerly the Prince of Wales Medical College, Patna long time back.Later a severely edited version of this article appeared in The Economic Times,perhaps in 1992 or 93. A series of correspondence with an esteemed friend of mine on related issues led me to reconstruct this article from old papers and notes. The version that appears here may not be the same as it originally appeared in the Patna Medical College journal.]
In
the B.B.C. comedy serial Yes Minister, as an instance of bureaucratic insensitivity
extra long tubes for the existing stethoscopes are offered in response to
demand for more of this item form a certain hospital. Humour apart, it can also
be taken as a grim metaphor of the fact that in our avowedly compassionate society,
doctors are forever receding form its sick and morbid members. The physical
interface between the patient and his doctors, the detailed examination to
question the dis tempered part, the protracted palpation is gradually giving way
to a mechanical probe by means of vast and impersonal appurtenances of
technology.
Every
age has its own paradigm about what causes disease. The role of the doctor as
well as the community’s expectations from him is closely aligned to it. In the
earliest times, it was believed that sickness occurred as a result of the
invasion by evil spirits. In a manner of speaking the shamans and exorcist
could be said to be the earliest medical practitioners. Their therapeutic regimen
consisted of a closely defined procedure, a technique of the incantation of the
magic mantra to propitiate or exorcises the malevolent presence. When summoned
to tend the sick the Tibetan Lama would, by reciting the cosmogynic myth, symbolically
project his patient to the dawn of time. The whole subsequent temporal drama
would be enacted step by step, by the recitation of the myth of illness, the
myth of the first shaman and so on. The patient by this journey back would be
restored to the primeval and essential condition of health from which he
appeared to have strayed en route.
In
primitive cultures, before scientific hubris overtook human civilization men
trusted forces larger than themselves to mend things. The shaman could at best
be a mediator, an agent, a medium through whom grace could flow. History
records many such events where prophets
and saints have charmed away excruciating pain by mere touch and sometimes
suffered the pain themselves in the bargain are trans historic and cross
cultural models. The practitioners of the art of healing were public spirited
men with a super abundant gift for affection and empathy. Even till sometime
back, physicians are known to have tested dangerous poisons and their antidotes
on themselves.
Over
the years the paradigm of the causation of disease has undergone several changes.
A historian records that theories like autointoxication,
disproportionality of Yin and Yang imbalance of the bodily humours, deviation from
natural way of living, even excessive love of theatre as being responsible for disease
held sway. The role of the doctors as well as the repertoire of medical
strategies has undergone commensurate changes. The point that needs to be
underlined is that the practice of medicine has always been a tripartite arrangement,
between the doctor and his patient and the two taken together with the
contemporary social cultural scientific milieu.
The
concept of focal infection, of specific etiology, the medical equivalent of the
reductionist, causal, deterministic world view has captivated the medical imagination
for close to hundred years. The one to one relationship between the disease and
the causative agent was spectacularly demonstrated by Louis Pasteur. Due to the
efforts and under the influence of Robert Koch, Louis Pasteur, Paul Ehrlich and others a whole new demonology of pathogens – the disease causing agents-
was complied with a countervailing pharmacopoeia of “magic bullets” and
precision guided chemical munitions capable
of specifically engaging and destroying the enemy.
In the beginning of the 20th century, Lord Kelvin in
one of the headier moments declared that the task of physics was well nigh over.
What remained to be done was to tie up the loose ends. The contemporary
medical thinking was equally convinced that the only end of medical endeavour
and research was to isolate as many
pathogens as possible and develop suitable drugs. Consequently a shift in the
traditional role of the doctor took place. A large area of his activity was
relegated to the microbiologists and the pharmacists. Separating the malady
form the sick person became the very raison d'etre of the practice of medicine.
Diseases
like tuberculosis, measles, small pox, meningitis which swept through towns and
villages like a visiting pestilence were tamed. But perhaps the newer ones,
foremost among them cardiovascular diseases, cancer and AIDS have overshadowed
the triumph.Therefore,when Rene Dubos describes their endeavours as creating a
"mirage of health" or Ivan Illich insists that there are strict
"limits to medicine" it does merit concern if not downright alarm.
Increased specialization set in motion the process of dehumanization of the doctor.The reductionist world view diminished the
doctor from restorer of health and wholeness to a mender of broken or
distempered parts, while the patient is reduced to a registration number. From
being a person, a unique organism with definite physical and psychosomatic
boundaries he becomes an object of piece meal curiosity- probed by machines,
seen trough x- rays bounced off him in a strange setting, shut off from his
family with white masked, dispassionate observes from outer space, as it where
as witnesses to the procedure. The dehumanizing almost dismembering aspect of technology
is now part of our medical imaginary.
Given
the ineluctable logic of consumerism, the hidden tenet of capitalist
industrialist system, health care was, sooner or later, bound to become one of
the greatest growth industries. The law of supply and demand ensured that the
doctors flocked in disproportionately large numbers to urban centres, where the
standard of public health and sanitation are already much better than the rural
areas where the medical facilities are woefully, criminally inadequate. But these
areas of deprivation do not have buyers and markets are not known to be moral agents.
So the poor languish for want of basic health care, while the rich are spoilt
for choice and tertiary care nursing homes exist side by side with death wards
dubbed as primary health care systems.
But
of late the practice of medicine has got inextricably linked with the interests
of the pharmaceutical industry. Like a puppet jiggling on strings the medical
practitioner has become an involuntary even unconscious agent of the drug industry.
Peddling avoidable surgeries and needless invasive procedures with the
persuasive skill of a salesman he also prescribes new fangled drugs-chemically synthesized,
materialized out of nowhere,re-engineered with a molecule displaced here or a
carbon bond dislocated there, these drugs are sometime launched with inadequate field trials, sometimes they
are potentially dangerous. But this has come to
occupy the center stage of his activities and he must carry it on if he has to
remain in business. However the doctor alone cannot be trusted to boost the
sales to achieve projected profit levels of the profit hungry pharmaceutical
companies. So the advertising industry, always at the beck and call of those
who can pay to perpetrate their lies, complement its activities by plugging the drugs directly to the people, making them so consumer friendly that they are ingested
without medical supervision. Just as the General Motors or Toyota have to innovate
constantly to give more rev to their engines to keep the consumer preference
from getting jaded so more potent and more lethal antibiotics have to be made available
at the drug store because the bacteria have become resistant due to the
indiscriminate use of earlier generation, of antibiotics. If the T-model Ford
represents progress when compared to the wheel cart, and a Ferrari is a
progress compared to the T model ford shouldn't the human self that responds
only to Ciprofloxacin represent progress when compared to the generation that
was amenable to ineffectual, antiquated penicillin?
Ivan
Illich, the Hashelmere group and a host of others have amassed such a wealth of
data that the charge that doctors are pushers in the illicit drug trade can no longer
be brushed aside as mere rhetorical jibe.
How ironic that the legal drug trade yields the same astronomical profit
as the illicit one!
It
is perhaps recognition of this sad fact that the society does not hold the doctor
in that same spirit of trust and confidence; his Hippocratic Oath is no longer binding
enough. He is made further answerable in the consumer protection act. Next time
round he short sells people on health, healing or happiness, he will have to
pay the equivalent in monetary terms. In our country, where the record of the enforcement and adjudication of the 3000 odd legislation has been less
than awe inspiring there will be devil to pay on both sides, especially for the
poor who would find medicare much more expensive without being able to secure
the protection readily.
From
healer to dispenser of drugs, from counselor to promoter of particular nostrums,
the doctor has traveled a long way indeed.
Forced to choose between the myths of Hygeia (health is the natural order of
thing provided we live prudently) and Asclepius (to abstract and treat disease
to repair any damage of distemper due to an encounter with outside causative
agents or accident of birth), he chooses to pay obeisance to Mammon the universal
god and benefactor of our time.
The
word doctor says, Lewis Thomas, has been derived from the root word "leg”
one of its meanings being" enchanter, speaker of magic words" Which
is perhaps just as well! Even in the days of self confident scientific medicine
he does not fail to invoke the hawk-headed god Horus whose amulet Rx he appends
at the top of his prescription to set in motion the process of healing. Even in
these cynical times the magic works if the faith of the patient and the intent
of the physician act in unison. Try as he might then, the doctor cannot escape
his inheritance and one fervently hopes his unique responsibility as a healer,
as a mediator of grace as an "enchanter speaking magic words".
