The mid-2010s were a tumultuous time for the biomedical profession in India. A series of media reports suggested that incidents of physical assault against doctors, mostly by persons accompanying patients, were undergoing a sudden and worrying spike. While such physical assaults were not uncommon, doctors seemed to agree that the frequency and nature of attacks had worsened during that decade.
Many wrote detailed commentaries on how and why the medical profession had reached such a stage that the public was “losing trust” in doctors and often expressed their distrust and anger through violence. Through many such analyses, doctors and other commentators were arguing that at some point of time in the recent past (“a few decades ago”), a major break had occurred in how people in India looked at doctors: before the break, doctors were “highly respected” members of the society, and after, a “social disconnect” had crept in which made people approach them with “suspicion, distrust, and anger.”
Several reasons for these changes were cited, including the proliferation of private medical colleges and corporate hospitals in the 1980s-90s, which led to increased “commercialisation” of healthcare, as well as inadequate investments by the Indian State in improving public health facilities and healthcare in general.
Government action and inaction were also said to be fuelling commercialisation: the state’s insufficient support and budgetary allocation for the public healthcare system was thought to have left people generally dissatisfied with government doctors and health centres, ceding more space, power and even prestige to private, for-profit care providers and centres. As options to access care through public institutions diminished, increasingly larger numbers of people were opting to receive care from private providers who were themselves in competition with one another and engaged in monetary and other malpractices.
Thus, interspersed in the commentaries of doctors (and other experts) during this tumultuous time was a quasi-historical narrative of the changes in public attitudes toward the medical profession over the post-independence period, and of the role that government policies played in these changes.
As a medical student and practicing doctor in India during 2004-2014, I began to develop an interest in dissecting this received wisdom. After an immersive historical inquiry as part of my PhD during 2016-2022, I discovered that there are in fact large question marks on this received wisdom, including on the claims of a trustful patient-doctor relationship in the past.
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State-backed dominance of upper caste and class
Biomedicine (also known as ‘modern medicine’ or ‘allopathy’) came to be embraced by India’s anti-colonial, nationalist leaders as the most appropriate mode of healthcare for free India. A shared vision of progress through modernisation, combined with a shared past of privilege through tradition, together facilitated the choice by early Indian leaders to appoint biomedical doctors as the primary providers of state-directed healthcare. Doctors, however, also had personal visions of progress which often clashed with the state’s vision of development. This clash of interests was most visible in the state’s insistence that doctors serve in villages, and doctors’ consistent ambition to practice in urban areas.
Thus, in the early decades of independence, the state entrusted biomedical doctors with the task of providing healthcare to the nation and devoted considerable resources to building new medical colleges and hospitals, but was unable to convince most doctors to practice in villages where the majority of the Indian public lived. There was a contradictory asymmetry in the relationship between the state and doctors, in that despite possessing substantially more power than the profession, the state ended up conceding far more to doctors and failed in extracting any major concessions from them.
How did the state’s resolve to provide healthcare to the public through the agency of biomedical doctors manifest on the ground and within communities? In the early decades of independence, doctors remained an alien group for much of rural India: alien not only through their consistent absence from villages, but also in their occasional presence. A large number of villagers, especially those from underprivileged castes and communities, saw doctors primarily as representatives of caste-, governmental, and urban elites. Combined with the fact that the rural Indian landscape was liberally populated with many kinds of local, traditional healers and practitioners of medicine whom villagers continued to patronise, the alienness of doctors meant that they were rarely the trusted, first-line providers of care for a large majority of rural Indians.
In urban India, on the other hand, doctors were abundant, but there was a paucity of “human touch” in their interactions with many patients. Public hospitals, which commanded an overwhelming presence in cities and major towns, were simultaneously major providers of healthcare for underprivileged urban residents, and a major site of humiliation and exploitation. The behaviour of hospital staff, including of many doctors, was frequently characterised as rude, careless, and callous, with casteist and classist prejudices often influencing how doctors interacted with people. Such behaviour from the staff, coupled with the general overcrowding and insanitary conditions in public hospitals, meant that these hospitals were rarely the first choice of care for a large number of urban Indians, who frequently preferred—like their rural compatriots—local practitioners based in their communities.
Cities also housed a number of private clinics, nursing homes and hospitals, including private wards in public hospitals, all of which were primarily used by the urban elite who were also the class and caste equals of doctors. Doctors generally enjoyed a friendly relationship with them, and these elites frequently shared the same elite urban spaces, e.g., social clubs like the Rotary and Lions Clubs. Thus, the relationship of the medical profession with the privileged public was vastly different from that with underprivileged people: the extent of doctors’ camaraderie and courtesy in the former often matched the amount of indifference and disrespect in the latter.
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Changing worldview of State, elite
It is in this larger context of the biomedical encounter, during the mid-to-late 1960s, that the Indian state’s approach toward doctors (and healthcare in general) began to undergo major shifts: the earlier contradictory asymmetry of power gave way to the state’s increasing disregard for the medical profession’s inputs in health policymaking. In response to the continued reluctance of doctors to provide meaningful care in rural India, the state began to look beyond both biomedicine and doctors, with some of the major Indian indigenous systems of medicine (particularly Ayurveda), in addition to homeopathy, receiving increasing patronage at the federal level in the 1960s and 1970s (and continuing to this day).
The state also invested in commissioning a large cadre of community health workers for rural India, who began to be deployed beginning in 1977. All these changes were vehemently opposed by doctors, though they enthusiastically supported the state in its simultaneous preoccupation with the “population problem.” Doctors conceptualised, organised, participated in, and generally supported several “family planning” policies and activities, many of which were coercive.
Throughout India, the state-led family planning programme came to be looked at with suspicion and anger by especially the underprivileged public who bore the brunt of its coercive adverse effects.
Parallel developments emerged in the 1970s and 1980s that primarily impacted the relationship of doctors with the elite public. This period was characterised by a substantial increase in the number of medical graduates in India: mainly a result of the Indian state’s continued patronage of and investments in medical colleges and hospitals since 1947, aided by a gradual rise in the number of private medical colleges. The majority of new graduates, like their predecessors, chose to engage in private practice in urban areas, further saturating the urban medical marketplace. The privileged urban public, including those from the so-called “middle-class,” began to increasingly complain about unnecessary tests and procedures by doctors, their “depersonalised” demeanour, their “business-like” attitudes.
However, even as doctors’ paid attention to the elite public’s dissatisfaction with the depersonalisation of medical practice, the profession continued to ignore the disrespect, neglect, and dehumanisation, which marked many doctors’ interactions with underprivileged patients.
By the 1980s, the “negligent doctor” became an increasingly common topic of discussion in the elite-dominated print and popular media, with the elite beginning to discuss medical negligence both in terms of personal experiences and in the form of narratives on negligence and exploitation faced by the underprivileged in government hospitals. At the same time, the ethical integrity of the profession and its leaders came under severe attack with reports of sex-selective abortions, kidney trading, and other forms of malpractice perpetrated by doctors. Public discourse in India now began to increasingly register the sentiment of “loss of trust” in doctors, and by the late 1980s and early 1990s, disillusioned patients were increasingly suing doctors for medical negligence under a new law (the Consumer Protection Act).
However, the ability to express disillusionment with doctors in mainstream public forums, and take to court those who had potentially done harm, were accessible mostly to people with at least some socioeconomic privilege. In such a scenario, the everyday forms of elitism, casteism, patriarchy, and exploitation in the biomedical encounter experienced by people from underprivileged communities, remained largely unaddressed.
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How did doctors’ react?
The increasing numbers of lawsuits against doctors in the early 1990s catalysed tremendous rhetoric and action, including a legal challenge against the Consumer Protection Act’s oversight on doctors, filed by the Indian Medical Association (IMA) in the Supreme Court of India. Doctors wrote and spoke prolifically, and generated a large number of narratives about the history of public trust in doctors.
In these commentaries, the rise in medical malpractice and the loss of people’s trust in doctors were said to result from the rise in the number of private medical colleges and corporate hospitals, as well as a rise in the number of patients who acted as “doubting Thomases.” The narratives ignored and left unacknowledged the longstanding presence of profiteering and malpractice in the Indian medical profession. The occasional reluctant acknowledgment of the existence of corrupt and unethical practices was almost invariably accompanied by the caveat that these were uncommon and were the work of “a few black sheep.”
Elements from these narratives continued to be employed in the late 1990s and the 2000s, with a significant addition being the Indian state’s economic liberalisation policies and the consequent privatisation of healthcare services as major reasons for the “deteriorating” patient-doctor relationship. But even during these decades of massive changes, analysis, and rhetoric, there was little discussion on the dominance of the privileged castes in the profession and its leadership, and on how caste-based privilege shaped and coloured doctors’ worldview and narratives as well as their attitudes toward a large majority of patients. As in the past, the routine dehumanisation of underprivileged patients in biomedical encounters remained, and continues to remain, a rarely mentioned topic.
Kiran Sambhaji Kumbhar is a medical doctor, health policy graduate, and PhD in History of Science. He tweets @kikumbhar.
This is an edited extract from Kiran Sambhaji Kumbhar’s doctoral dissertation ‘Healing and Harming: The “Noble Profession” of Medicine in Post-Independence India, 1947-2015,’ published by Harvard University Graduate School of Arts and Sciences. Read the full paper here.