Earlier this year the entire country was shaken up with the arrest of a quack in the Unnao district of Uttar Pradesh. Rajendra Yadav, the accused had been operating there for the last decade. He used the same syringe to inject multiple people which was said to be contributing to the spread of HIV infection in the area. By the time, media followed this story, about 58 people had been tested positive for the infection. If a more rigorous and active case finding was conducted, the number would be much higher.
This incident brought in the limelight yet again a cadre of unqualified doctors and healers that work silently, providing services to a large number of innocent and unsuspecting population, all in the name of treatment. Their presence is not limited to any region or state. Be it North, South, East, West, Urban, Rural or Semi-urban, they have established a footing everywhere.
In South Rajasthan where I work with Basic HealthCare Services, the situation is quite similar. This system runs parallel to the existing governmental services and can be broadly categorized into two sections – faith healers, and untrained people practicing medicine. The Unnao episode dug up a murky topic that became a nation-wide conversation. Many similar incidents are taking place in other rural and remote belts of the country but do not get reported.
A few months ago, during a routine community visit, our field team learnt of Manish*, a four year old boy who lives with his family in Pratapgarh district of Rajasthan. A kachcha road goes to his village on which two buses ply to and fro, in a day. Like every other village, this one also has a ‘Daaktar saab‘ who works out of a one-room clinic. This doctor is the only point to access healthcare for about 10 km. He can be reached through a phone call and even hops on to his motor bike to make a home visit when his patients cannot travel to him. At any given time, one can find at least one sick person on a cot in the courtyard of the clinic with an attached IV line. He is highly regarded among folks in the village.
When Manish had a high fever for two consecutive days, Bheru*, his father took him to the clinic. Manish’s temperature was checked and he was immediately administered an injection that proved to be life-changing. It turns out that the injection was wrongly given, and resulted in waist-down paralysis. Bheru recalls that time with remorse and a heavy heart. He says, “Had I known that the doctor had no medical degree, I would never have taken my son there. He had been giving us medicines for a few years now. No one suspected.”
Traditionally, medicine had always been a private enterprise. For time immemorial, any individual with necessary knowledge and skills would be deemed a ‘Healer’ or ‘Doctor’. This knowledge was often passed down from generation to generation. A governmental role in healthcare was only envisioned when the need for preventive healthcare was felt. Major epidemics had taken a large number of lives and individual providers would not have the agency or incentive to work on the preventive aspect of medicine.
At that time in India, in line with the Bhore Committee’s recommendations, a multi-tier health infrastructure was implemented. A system where primary care would be readily available for all, with more intensive care at secondary and tertiary centers, was in place by late 1980s. Everyone naturally assumed that all citizens of the country, and especially those in rural areas, now would have access to healthcare. Alas! that was not the case. It was only after certain common illnesses, for example diarrhea, that did not come up in the government records as much as it was expected, did anyone think to dig further in the matter.
What emerged from researches conducted from late 1980s to early 1990s was crucial and eye-opening evidence for the Public healthcare system. Private practitioners were providing a major chunk of primary care. The first point of contact in illness for most of the population was not the government doctor or nurse.
According to the 1991 census, India had around 1 million Rural Private Practitioners (RPP) as opposed to an alarmingly small number, just 3,00,000 qualified MBBS doctors. Only 25% of these RPPs were graduates and around 50% had no formal training whatsoever. Where does India stand in 2018? The situation seems far worse. According to a WHO report ‘Health Workforce in India‘ published in 2016, in rural India only 18.8% of allopathic doctors had a medical qualification.
During a Community meeting I attended to understand healthcare seeking behaviors, a large part of the conversation was around the attributes of a good doctor as per the community.
Bhulki, a community volunteer said, “We cannot afford to lose our daily wage. There is no time to spend waiting for the doctor at the government PHC, and then rest. This Bangali daaktar gives us fast-acting injections that cure the symptoms right away.”
A young mother added, “When my son cries uncontrollably from pain at night, Daaktar saab in the next village is my only respite because he provides home visits. My husband is away for work and I cannot leave my older children alone at home.”
The reasons of people going to these unqualified half-baked doctors haven’t changed much from 1990s. In a few hamlets, people felt that the ‘waiting time’ and the ‘attention time’ doctor gave at the government facility was disproportionate, while in other hamlets the public sub-centers opened merely once a month. The quacks are well-known in these communities because they spend a large portion of their time among families, building a connection and trust through regular contact.
The detrimental effects of the treatment they provide, can be both acute and long-term. On one hand, incidents like Manish’s are not rare, and on the other, over prescription of drugs, particularly steroids that they commonly dispense induce dependency. Wrong dosages of antibiotics contribute to antibiotic resistance as well. These long-term effects are already starting to show, and pose a risk for medicine in future. Going forward, we have some lessons to learn in the way the quacks operate and build their practice. There’s an urgent need for reform in public healthcare system to make it more responsive for people it is meant to serve.
*Names changed to protect identity
Reference: Rhode E, Viswanathan H, The Rural Private Practitioner, 1995