Sunday, February 19, 2017

Three Knocks on my door

Those of us familiar with the story of Aunt Ida (Ida Scudder, the founder of Christian Medical College, Vellore, my alma mater) know of how her life was changed by three knocks on her door one night. Confronted with the problem of three young women dying in childbirth because of the lack of trained women doctors, the young and reluctant Ida was convinced of the need to train in medicine, and return to India as a medical missionary with a desire to train Indian women doctors.

(If you are not familiar with this story, you could listen to a recording of Aunt Ida speaking of the Three Knocks here)

A few years ago, I also had my own Three Knocks experience, when the stories of three patients changed the way I practise medicine. At the time, in 2007, I was working in a 120-bed mission hospital in rural Uttarkhand.

Patient A was an elderly gentleman brought in with a perforated duodenal ulcer. He was very sick. His lungs were permanently damaged due to smoking, and he was now in shock because of the peritonitis. After we resuscitated him and operated, he was shifted to the ICU, where he was ventilated for 4 days. After a stormy post-operative period, he recovered well and was ready for discharge.

Before he left the hospital, his relatives came to talk to me in the OPD. After giving them the usual pep talk (about making sure he ate well and stopped smoking, and so on) I asked them whether they had paid the bill. They had. I was pleasantly surprised, because they looked quite poor, and I had been expecting them to ask for some concessions.

How much was the bill, I asked. About ₹ 10, 000, they said. They had paid ₹ 4000 as an advance, and had now paid the remaining amount. Again, I was quite pleased. ₹ 10,000 was quite reasonable for such a major operation and hospitalisation, and especially for somebody who had been ventilated for 4 days. I felt quite proud of my hospital.

More out of a desire to make some light conversation before they left, I asked them how they had managed to pay the bill. They had taken a loan. (Fair enough, I thought to myself, ruefully. Even I might need to take a loan if I require major surgery in the future! It’s good to hear that even the poor are able to get loans when they need…)

So, what type of loan is this, I asked. They replied that they were going to be paying a 10% interest. For every ₹ 1000, they would have to pay ₹ 100. (Sounds quite reasonable, I thought)

Since we were making pleasant conversation, and they had already received some advice from me with good humour, I thought I would give them some more. “Make sure you pay the loan regularly and quickly”, I advised. “After a year, the amount would have increased to ₹ 11,000. And unless you plan well, you will be stuck with a large debt.”

No, they corrected me. The loan would be ₹ 11,000 by the following month. And it would increase by a further 10 percent the following month.

My jaw dropped, as I realised that the family was, in fact, paying 10% per month as compound interest. I quickly did the math. The repayable amount, after 1 year, for the initial loan of ₹ 10,000 would be ₹ 31,386. A whopping 214 percent interest per year!

Horrified, I tried frantically to prove that my calculations were wrong. But no, the family assured me. Those were, in fact, the conditions of the loan.

However were they ever going to repay this, I asked, aghast. The family, now perhaps seeing how upset I was, tried to reassure me. “No problem, sir”, they said. “The money lender has said that we can work for him on his fields. He will not pay us any money, but give us food every day. We can work for him until the loan is repaid. Nothing to worry!”

Slowly, the realisation of what had happened sunk in. My Du perforation surgery had pushed a family into bonded labour. My colleagues and I scrambled to arrange money to give to this family as a gift, so that they could go and settle this loan quickly.

A few days later, the story was repeated. Patient B. Also admitted for Du perforation surgery and ventilated post-operatively. This time, we asked the questions before the bill was paid, but found the family had already taken the loan. Another ₹ 10,000 loan, being repaid at 214 percent interest. Another generous offer from the money lender that the family could work on his land as bonded labourers. But this story had another twist. The money lender had promised them that if they did not report for work anytime, he would send his goondas to tear down the small tin-shack in which they lived. They were going to be living under the perpetual threat of violence. Again, we tried to put together funds to help this family out of their debt.

A few weeks later, I had the third knock on my door. This time, it was the wife of Patient C, a middle-aged gentleman admitted with acute pancreatitis secondary to chronic alcohol abuse. He was now ready for discharge, and the family was asking for a reduction on the discharge bill. The bill was ₹ 1200, and they wanted ₹ 400 to be reduced.

At that time, I had a clear and firm policy on alcoholic pancreatitis. No reduction in bills allowed. My reasoning was simple: If they had enough money to buy alcohol and drink every day, it was safe to assume they had enough money for the hospital bill! I explained this policy to the wife.

A couple of hours later, a nurse came to my OPD. The patient’s wife had been asking the relatives of other patients for a loan of ₹ 400. She was offering that they could have her 6-year-old daughter until she arranged enough money to redeem her back. I felt like crying. My treatment of alcoholic pancreatitis was pushing this family into human trafficking, possibly even sexual trafficking. We promptly wrote-off the Rs 400, and allowed the family to leave.

I was very shaken by these three knocks on my door. As I read more about the problem of emergency out-of-pocket spending for hospital expenses, I came across this disturbing statistic:

39 million Indians every year are pushed below the poverty line directly as a consequence of emergency health-care related expenses.
(See this Lancet article)

Over the years, I have often remembered these three patients who changed my life. They have taught me some valuable lessons:

1. Even the poorest patients sometimes pay their bills without asking for concessions. They do so, however, at horrific personal costs. In our hospitals, we need to look out for these patients, and actively ask the questions about how finances are being arranged, and sometimes write off costs even when patients do not ask for reductions.

2. Even the highly subsidised treatment available at our charitable, not-for-profit hospitals can push poor patients below the poverty line, and even into human trafficking and bonded labour.

3. While health insurance does seem like the obvious answer to this problem (of out-of-pocket emergency healthcare spending, with its devastating effects on poor families), the insurance schemes available at present, (even those offered by the government to BPL families) somehow often seem to benefit the rich and middle class families, who are aware of their rights, and of available options and schemes. The poorest are often left out of the very schemes designed to benefit them.

4. The public health system is India has been designed to provide free and high quality healthcare to India’s poorest citizens. Unfortunately, due to a number of factors, (poor governance, corruption, apathy, and poorly trained staff, to name a few) our public health system is in shambles. I am convinced that it is our duty, as responsible healthcare providers, to do whatever we can to ensure that the public health system in India is strengthened and equipped to fulfil its role.

Finally, a word to my professional colleagues.

The World Health Organisation, in 1948, defined “Health” as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. When 39 million Indians are pushed below the poverty line every year as a result of healthcare expenses, it is well past the time for us to ask ourselves some disturbing questions. Are we truly promoting health? Or is this itself a symptom that the healthcare ‘industry’ is desperately sick, and in need of healing?

If you liked this, you might also like:
1. Inasmuch as you have not done it to the least of these my brothers.......
2. A shout-out to India's Generalists
3. Uterus eradication Programme


  1. I agree with what you have written Sir. I have felt the same too. But, at the same time, those patients who are fully capable of paying the bill comfortably take the system for a ride. Stewardship of resources (including charitable funds) rests upon us. One measure which could probably be of use would be to find a group of dedicated social workers for an accurate socioeconomic assessment. Or maybe, accept alternative modes of payment - poultry, vegetables for the hospital canteen etc. - which can probably be tended to by the very people who give them as a means of livelihood. Other possible solutions may be health insurance at a young age for a low premium (health education). Would love to be a master of all trades but medicine is tough enough.

    1. Thanks, Aditya. Yes, I agree. We need to continuously keep coming up with innovative ways to make our hospitals more poor friendly

  2. A well written article Dr. Pradeep.I am touched. Now you have knocked me. I was completely shaken by your humanity and your article has prompted me to introspection regarding self. Once upon a time i was like you but dont know how and when did i change myself. Even i remember those three knocks at my door a long time back and i even woke to that. Now days i hear knocks but somehow remain deaf to these sound and hear only what my mind says ignoring my conscience. Hopefully from today this is the loudest knock from you on my conscience and will follow your footsteps.Thanks for waking me up.

  3. You could try what we did. The hospital can give interest free loan or collect the money in installment. I think Makunda also did it later

  4. Very moving but you are not the only one who have such experiences. You stand different as you get 'moved" and act !! Thank you for sharing

  5. Nicely written blog. I wish everyone one of us should get such knocks in our life.

  6. A good article which every public health professionals shoud read and try to find the knocks which we get in our day to day life. During my MSW i also found such knocks which taught me a lesson that these poor and vulnerable people are more happy than us though they have less resources but have a big heart. I was on my internship of community mental health at Assam where i realised what are the problems faced by the family members of a severe schizophrenic patient. There family were so caring to that 50 years old lady and were living happily.

  7. Poverty is a major cause of poor health and a barrier to accessing health care when needed. This relationship is bidirectional, the poor cannot afford better health services and the relationship is also related to other factors related to poverty, such as lack of information on appropriate health-promoting practices or lack of voice needed to make social services work for them.Thank you Sir for being a voice to them.
    Pooja Tripathi

  8. Thanks to people like you our country has some hope...
    Isn't there anyway we can make our national health system better?