A gateway to health

The Madras Medical Mission, Chennai. - S. THANTHONI

In terms of the availability of a large number of well-equipped hospitals, dedicated doctors and treatment expertise of international standards, all at a relatively low cost, Chennai is the place to be for dependable medical care.

THE Chennai Central railway station's passenger concourse has a large back-lit display listing the city's major hospitals. This is no routine public announcement but constitutes information that is crucial to thousands of people who come to Chennai seeking medical help. In fact, elsewhere in the concourse functions a telemedicine facility, which also has ECG equipment to provide emergency diagnosis in the case of passengers with heart ailments.

With its numerous multi- and super-speciality hospitals that provide diagnostic, technical and treatment expertise of international standards, Chennai is a virtual gateway to health. Patients come from all over the world, in some cases with medical conditions that are considered elsewhere to be too complicated for treatment or too risky for surgery. Of course, for the thousands of people who come from outside the country the relatively low cost is an added attraction.

Some nine lakh patients are admitted every year to the nearly 500 hospitals and nursing homes in Chennai. More than five lakh patients come from outside Tamil Nadu. The majority of the patients from outside Tamil Nadu come to the corporate and multi-speciality hospitals such as Apollo, Malar and Devaki or to the multi-speciality trust hospitals such as Sri Ramachandra Medical College and Research Institute (SRMCRI), Vijaya and Sundaram Medical Foundation.

The other major centres are: Sankara Nethralaya, the Agarwal Eye Hospital, the Eye Research Foundation and the Rajan Eye Care Hospital, the M.V. Hospital for Diabetes and Diabetes Research Centre and the M.V. Diabetes Speciality Centre; the Cancer Institute; the Madras ENT Research Foundation and the KKR ENT Hospital and Research Institute; the MIOT Hospitals and the Bone and Joint Clinic; the Kanchi Kamakoti Childs Trust Hospital... . and the Institute of Cardiovascular Diseases (Madras Medical Mission), the Heart Insitute (at the Vijaya Health Centre) and the Heart Foundation (at the Vijaya Hospital).

There are also several trust and charitable multi-speciality hospitals including the Hindu Mission Hospital, the Public Health Centre, the E.V. Kalyani Multispeciality Hospital and the Voluntary Health Services that cater to patients of average means.

Among the oldest multi-speciality hospitals set up by Christian missionaries in the country are Chennai's St. Isabel's Hospital and the CSI Rainy Hospital which provide advanced treatment at a reasonable cost.

The hospitals that offer modern techniques such as liposuction (to remove fat from certain parts of the body using metal tubular instruments connected to a suction machine), hair transplantation (using the follicular micro-grafting technique), infertility clinics and cosmetic surgery (to alter the shape of facial parts such as the nose) are Hande Hospital, Apollo, SRMCRI, G.G. Hospital and the Madras Medical Mission.

Offering a range of facilities, hospitals in Chennai have done much pioneering work. They have to their credit several firsts in Asia. Among these are trans-myocardial revascularisation laser surgery (1994), magnetopexy (a surgical procedure using magnets to treat giant retinal detachments: 1988) and the Batista operation to improve the performance of the ventricle (of the heart) by reducing its size on a two year old, the youngest person in the world to undergo this type of surgery. Chennai has the only hospital in Asia where giant aneurysms are operated upon.

The city is justifiably proud of several medical firsts. Among them are the setting up of the country's first nuclear medical oncology department (1956), employing lymphangiography in the diagnosis of lymphoid tumours (1960); using mammography to diagnose occult breast tumours (1965), using therapeutic endoscopy (1975), introducing hyperbaric oxygen therapy (1978), hyperthermia (1984), and the use of intra-operative electron therapy (1992) in the treatment of cancer.

Chennai's list of other firsts include the country's first cryo-surgery for the eye (1966), successful kidney transplant (1985), successful heart and heart lung transplant (1995), successful lung transplant; 1997), successful umbilical cord blood transplant (which involves the use of blood in the placental or umbilical cord which contains the life-saving progressive tissue needed in bone marrow transplants (1997), steriotactic radio surgery (a non-invasive technique to deliver radiation doses accurately to the affected part of the brain), and an arterial switch operation on a 10-hour-old infant.

ALL this has happened in the private sector, though the foundation for quality medical care in Chennai was laid over time by government hospitals, of which there are 24 in the city, including multi-speciality and super-speciality hospitals. Most of these now have state-of-the-art diagnostic and treatment facilities, but are short of funds to maintain them. While the Union and State governments are responsible for providing universal access to health care, their resources are limited.

In a paper, "Healthcare Budgets in a Changing Political Economy" published in the Economic and Political Weekly, health researcher Ravi Duggal says that the government's revenue expenditure on health in Tamil Nadu declined from 7.7 per cent of the total revenue expenditure in the mid-1980s to 5.7 per cent in the mid-1990s. According to the paper, the percentage of expenditure on medicare of the total health expenditure came down from 41 to 36 in the same period.

According to another paper, "From Philanthropy to Human Right - A Perspective for Activism in the Field of Health Care," presented by Dr. Amar Jesani at a seminar organised by the Mumbai-based Indira Gandhi Institute for Development Research, the government spent Rs.64 per head in 1991 (including expenditure on water supply), while the people spent Rs.200-250 per capita. The out-of-pocket expenditure on medical care incurred by people today is around Rs.450 per person a year, while government spending has declined.

Government hospitals frequently face a shortage of emergency drugs, IV (intravenous) fluids and even needles and cotton. Water supply is inadequate and of poor quality.

There is a chronic shortage of medical and non-medical staff. For instance, more than 8,000 out-patients and 2,000 in-patients are treated at Chennai's Government General Hospital every day, but its staff strength is not adequate to cater to even a fourth of these numbers. This leads to problems of corruption and harassment. Although treatment is free for patients with a monthly income of less than Rs.500, poor patients going to government hospitals complain of harassment by sections of the staff at various stages, starting with the income level assessment counters. Yet, with all the problems, the government hospitals, including multi-speciality hospitals such as the General Hospital, the Kilpauk Medical College Hospital and the Stanley Hospital and super-speciality hospitals such as the Kasturba Gandhi Hospital for Women and Children, the Government Ophthalmic Hospital and the Institute of Mental Health, play a crucial role, catering as they do to the overwhelming majority of the poor.

Seeing an opportunity the private sector stepped in, and thanks to the abundant talent available, has reached commanding heights today. Perhaps aware of its own limitations and the need to attract more investments in the medical field, the State government offered subsidies, soft loans, duty exemption and so on to private investors. The requirement of governmental sanction or approval to start a hospital was withdrawn. Thus private sector investment in the medical field, which was marginal until the mid-1970s, grew rapidly. Today some 50 per cent of hospital beds and 40 per cent of doctors are in the private sector in Chennai, compared to 21 per cent and 29 per cent respectively in Tamil Nadu as a whole and 35 per cent and 30 per cent respectively in the country. While most of the private hospitals have their own investigative facilities with the latest equipment and modern laboratories, there are also a number of exclusive laboratories, blood banks and scanning centres that offer high-quality, reliable diagnostic facilities.

Besides hospitals and diagnostic facilities, Chennai has a number of non-profit, service-oriented private facilities such as Sneha (a suicide prevention centre), the T.T. Ranganathan Clinical Research Foundation (working on substance abuse rehabilitation), and Banyan (a home for mentally ill women) to offer help to the depressed and the mentally-ill; Saraswati Kendra, the Kaleidoscope Learning Centre and the Madras Dyslexia Association to help children with development and learning disabilities; the Spastics Society of Tamil Nadu and the Schizophrenia Research Foundation (to care for and treat people with mental disability); CanStop of Sundaram Medical Foundation and Sanctuary of the Cancer Institute (to provide emotional support and counsel cancer patients) and YRGCare. There are a number of non-governmental organisations that offer treatment, care and support to HIV/AIDS patients.

While all this was possible because hospitals and diagnostic units could be set up with relative ease, the trend has a flip side too. Tamil Nadu Governor P. Ramamohan Rao, recently observed that "medicine has become commercialised". Says Dr. C.V. Krishna Rao, a gastro-enterologist: "All one needs to set up a hospital is a couple of beds, nothing more." This, according to the Federation of Consumer Organisations in Tamil Nadu, has led to unethical practices and a proliferation of quacks. Several nursing homes do not even have sterile operation theatres. Many do not have the facility to match blood sources from blood banks. There is, according to R. Desikan of the Federation of Consumer Organisations a need for the government to monitor healthcare services closely.

Several private organisations that provide high-quality services fault the government for the poor infrastructure. Says Dr. K.M. Cherian, Director, Madras Medical Mission: "With the money I spend just to get clean water to the hospital at least five heart operations can be performed free of cost every year." Dr. D. Rout, neurologist at the SRMCRI, wants an efficient system to be put in place to rush trauma patients to hospital. Even if it does not become possible to save a victim, this, according to Dr. R. Ravichandran, Director, Madras Institute of Nephrology, Vijaya Hospital, can save a number of lives indirectly by facilitating the harvesting of organs for transplantation.

But where all the facilities are available, medical care becomes expensive and beyond the reach of the poor and the middle-class, except in cases where employers meet medical expenses or there is a medical insurance facility. But health insurance comes at a price that is beyond the reach of many people. According to Desikan, it is important to cover the medical expenses of the poor and the needy under some scheme or the other. Chennai has shown the way in this. The Voluntary Health Services was started in the 1970s to reach medical care to the poor living in the peripheral areas of Chennai by means of an insurance scheme with affordable premia. This, according to Desikan, has benefited thousands of poor in and around Chennai and is worth replicating.

Chennai's healthcare facilities may have some problems that are common to any city in India, but undoubtedly these are some of the best in Asia. Much of its strength is derived from the vision, dedication, hard work and enterprise of a large number of doctors.