‘Quality and cost must be under government regulation’

(Over most of April and May, as the Covid-19 pandemic unfolded in India, growing from just a handful of cases to take region after region in its grasp, Dr T Jacob John, India’s foremost virologist, epidemiologist and researcher, spoke daily with Jagdish Rattanani, journalist and editor of Foundation of The Billion Press, to build what we call the COVID-19 diary.)

Here, Dr John talks about the uniqueness of Christian Medical College, Vellore, where he taught and practised for decades. The profit-seeking model for medical institutions, whether college or hospital, has failed in self-regulation. Dr John recommends the model of the truly not-for-profit private party institute, which will be governed and audited by proper government oversight.

 

Jagdish Rattanani: You have very high regard for Christian Medical College. Can you tell us more about it.

Dr Jacob John: I remember during a recent discussion on national television, there was a microbiologist from Cambridge or somewhere. She said something very interesting. She said there are private institutions like Christian Medical College that stand out. They are world class; their leaders are world class. But the television anchor did not react to that.

I say CMC is a national resource. All of India’s neurosurgeons were grandchildren, great-grandchildren, of CMC-trained people. The first-generation of them was trained in India and in CMC. Like-wise, the nephrologists and cardiothoracic surgeons. We have been pioneers in bringing in high-technology and in reaching it to the poorest of the poor.

That is CMCs philosophy. It is a Robin Hood philosophy. We literally overcharge the rich and subsidise the poor. Anyway, I'm positively biased by my institution.

This microbiologist also pointed to the private sector being kind of sidelined for so many things in this (Covid) fight.

JR: OK

Dr John: But then, the problem is, if you look at the private medical establishment in India, you can’t name many others of that (CMC) type in the private sector. I think we are stuck . . .  For that I blame the 1980s, whoever was in power, I think . . . Congress prime minister . . . whoever . . .

JR: Indira Gandhi.

Dr John: Indira Gandhi, Narasimha Rao, Manmohan Singh . . .  everybody. They wanted healthcare opened up for the public-private sector. Bright idea. The private sector would self-finance and give service to a huge number of people. Good idea. And the mistake was, they expected the private sector to be self-regulatory.

JR: That is right.

Dr John: This is India; and if you don’t curb . . . as to how much profit you can make, u don't curb how much you can charge people for healthcare . . . if you don't establish an auditing system so that quality is absolutely assured . . .  it is not good. Quality and cost must be under government regulation and under the watchful eye of government supervision. In this case, you give a free land to the private sector, you give concessions, you give excise duty exemption for procuring all the benefits that was given to the private sector. In the end, most cases—or many, if not most, cases—happen to be private money-making concerns.

The private sector would self-finance and give service to a huge number of people. Good idea. And the mistake was, they expected the private sector to be self-regulatory...So that was a tactical blunder made three decades ago. But whenever I get an opportunity, I say that there is a third model in India: the private sector, not-for-profit, high-volume and therefore low-cost model can be built in.

So that was a tactical blunder made three decades ago. But whenever I get an opportunity, I say that there is a third model in India: the private sector, not-for-profit, high-volume and therefore low-cost model can be built in.

JR: That is possible.

Dr John: So that's what CMC very much does. Now, when you look at the cost per medical test,

it may be comparable with that at other private hospitals. But if you look at the cost of testing per head, it will be only a fraction of what other people charge because we don't test unnecessarily. All tests are under one roof. To talk of high volume, when I had to have an MRI scan . . . I got my appointment at 2 a.m.

JR: 2 a.m.?

Dr John: Yes, because the machines are working continuously. So that means high volume.

Therefore, the cost is not high.

JR: But you being from CMC and a senior doctor there . . . they could have given you a better time, isnt it?

Dr John:  We treat everybody more or less equal. So, if that is a time slot they have, that’s the time slot I use. I will not go and tell the head of the department, ‘Sir, I can’t come at 2 a.m., give me another time.’ No, I don't do it. I don't think anybody there does it.

JR: OK.

Dr John: I did the better thing. I got admitted the previous evening, and I go for my scan from the hospital, go back to my bed and sleep. Then, next morning I'm more or less OK. The point is, the third model of the private sector hospital is not for profit. If they had encouraged this model it would have resulted in many, many NGOs creating non-for-profit hospitals and medical colleges.

The other thing is allowing capitation fee, that too partly because politicians and such people established medical colleges, and that is probably why capitation fee was charged. In Christian Medical College, there is no capitation fee, I said we are high volume, low margin

JR: But, you see, many of big five-star hospitals are formally registered as not for profit when actually there are anything but that.

Dr John: That is because there is no overseeing body from the government, because the government thought they will self-regulate.

JR: Correct.

Dr John: For quality especially, and of course for charges. They thought everyone knows we have doctors, who have a reputation for being just, fair and ethical and scientific.

But then I'm told by some people that a doctor is paid four lakhs per month salary, and the doctor must bring at least five lakhs per month in income, and for that the doctor will have to make ‘adjustments’. That is where the rot begins.

JR: Yes. A very, very serious problem.

Dr John: The other thing is allowing capitation fee, that too partly because politicians and such people established medical colleges, and that is probably why capitation fee was charged. In Christian Medical College, there is no capitation fee, I said we are high volume, low margin; our margin per patient is low, but we have high volume and we exist as a hospital only because of the college. So, this is a teaching institution.

JR: How many seats do you have?

Dr John: 100. You know what the annual tuition fee is? You take a guess.

JR: About two lakh rupees?

Dr John: 3000 rupees per annum, 3000 rupees per annum!

JR: Oh!

Dr John: You know why? Because the hospital exists on behalf of the college. So, the college actually is the owner of the hospital. So the hospital's high-volume, low-margin income is more than enough to subsidise medical education. Now, one of the ways by which we do it is, the anatomy professor and the neurosurgeon have the same salary. The salary is fixed by lecturer, assistant professor, associate professor, professor.

You are created by society and you owe everything to society. That is a philosophy that we teach and that is what the students see and learn, because the teachers practise the same simple living. There is not much luxury, but very comfortable living;

So, therefore, the anatomy professor can hold his head high and be in the institution. People ask, why do you keep this 3000-rupee fee for years together? The answer is very simple, we want medical students to know that they are being educated by the patient whom they serve. Not by your father's income, your bank loan or your intended dowry that comes when you get your degree, none of that. You are created by society and you owe everything to society. That is a philosophy that we teach and that is what the students see and learn, because the teachers practise the same simple living. There is not much luxury, but very comfortable living; it is a gurukul system because we are all on the campus when practising too.

Moreover, every student has a faculty member as a foster parent. So, we have been foster parents to many, many students . . . to generations of children. They come home any time. Okay, we have had a person who was very disturbed psychologically, was far away from home, and my wife handled him very well and he came out of trouble. They call us uncle and auntie, they don't call us sir. They come home, they share meals with us. They talk about their family. They play with our children. So, these are certain bond-making practices, which are of prominent value . . .

JR: Really, very true.                                                                                                  

Dr John: Recently, Mr Ram of the Hindu wrote to me, he said one of my students is in Mayo Clinic and he gave me his email id. I looked him up, he was from the 1984 batch, I think . . .

He is a big shot there, in Mayo Clinic. I contacted him and he told me, ‘Sir, don't you remember me? One day I was eating lunch at the same restaurant opposite CMC where you eat regularly. I sat next to you, and we were chatting, and I asked you a question . . . and you said something to me, which I never ever forget. The question you ask must be very clear in your mind. So, you must articulate your question so that the listener should understand the spirit of your question.’ He seemed to be quite taken by the freedom with which I talked and my gentle nudging to put him in the right direction for communication. And he says he still remembers that was so thankful that the idea was put into his mind in that way. What I'm trying to say is, at CMC is truly a gurukula.

Another time, I was teaching virology, talking about the shape of the virus being geometrical . . .

JR: Always?

Dr John: Not always, Coronavirus is not of a geometrical shape. It's pleomorphic, but poliovirus, adenovirus, measles virus . . . many viruses are geometric in shape. So, I am teaching about the geometrical shape, they are all electro-microscopic. So, at a big medical conference, a big shot from a vaccine manufacturing company who is in charge of the quality control division—and that is a big designation . . . the vaccine has to be of high quality—well, he came up to me and said sir, do you remember me? I had difficulty in remembering him, but he told me a story:

‘Sir, one day you asked in the class, the football is round, but it made up of pieces, each of a particular shape . . . what is the shape?’                                                                                        

Apparently, one student said it is a pentagon, five-sided. So I began drawing the five shapes on the board. Next one, next one, next one, next one. Then he said I turned around, and said, hey there I have a problem . . . this is not beginning to go around, it is growing sideways, it is expanding only in one dimension, two dimensions . . . One guy from the back row stood up and said they are mixed with hexagons in between. The whole class laughed as it looked like a stupid answer; using hexagons and pentagons appeared a stupid answer . . . When the laughter died out, I apparently told him his name doesn’t matter, nor the whole world laughing at him. The world laughs at people who are correct. You are absolutely correct.

Then I made the whole class make a paper model, with hexagones in between the pentagons and that pulled the whole structure into the required shape. He told me, ‘Sir, that comment from you has made me self-confident. And I insist when I know I'm right, even to the owner of the company, I tell him that this is right. There is a reason why it is right.’ And he can stand up to any opposition. Once he is sure he is correct, then he defends himself without any problem. He says that self-confidence came to him with that one comment, when the whole class laughed at him.  

JR: Yes, that can be a turning moment. Absolutely.  

Dr John: Yes, and about two and a half decades later, he is coming and telling you this. The point I am making is, a teacher has to be careful.

JR: Absolutely true. A teacher can both break a person and make a person.

Dr John:  You don't ridicule anybody for a mistake, you don’t unfairly judge someone. With misdemeanour too, one has to be extremely non judgmental is an understanding anyway. I am describing CMC’s culture.

JR: Very, very interesting. I did not know anything at all about all this. How old is CMC now?

Dr John: In 2018-19, we celebrated hundred years of medical education. Originally, it was a women's medical college, starting with a diploma, then converted into MBBS, and only for women at the beginning. Then men joined, I think in 1947 men were allowed.

You don't ridicule anybody for a mistake, you don’t unfairly judge someone. With misdemeanour too, one has to be extremely non judgmental is an understanding anyway. I am describing CMC’s culture.

JR: It would be run by a trust, right?

Dr John: Society, not a trust. A charitable society, a charitable education society.

JR: Is it owned by Christian missionaries . . . ?

Dr John: The society has membership,  and membership paths are mainly by the Christian

denomination churches in India. They actually technically own the institutions run by an executive body, the college council. All the bodies are represented and the executive committee is elected by a council of key individuals. That is how it runs.

JR: Does it give its own degrees?

Dr John: Madras University, now it is MGR Medical University. We never wanted to be an independent university. Because it's extremely, highly nationalistic, not in the bad sense, but very patriotic. So we don't look for any extra advantage for CMC. We join the national stream . . . We obeyed all the laws when it came to NEET. We said, look, NEET sounds fair and just. But it is not fair and just. There are problems, so we went to the Supreme Court . . . I mean, we're not objecting to NEET, but in Tamil Nadu, rural students have a bad deal with the NEET. Because they are taught in Tamil, but they are good students. The Tamil Nadu model was for every district to have a medical college within at least a hundred feet of it. So, they were making medical colleges in every district. That is when NEET came, so Tamil students then don't have any advantage.

JR: What you have said to me about CMC has been very eye opening. It's amazing. The question that comes to my mind is, why are there not 100 CMCs in the country? Why couldn't your own CMC do 99 others?        

We are here to train medical students and then send them out. But train them not only in the biomedical field, but also in the field of humanity; they should understand the ethics and they should also see how rural people live. And so, faculty members take them, and groups of students live in the villages, interact with villagers and come back.                            

Dr John: We exist on a certain model; we are not the saviours of the whole population. We are here to train medical students and then send them out. But train them not only in the biomedical field, but also in the field of humanity; they should understand the ethics and they should also see how rural people live. And so, faculty members take them, and groups of students live in the villages, interact with villagers and come back. They are converted into saying, look, we have now seen the real India and they are good, kind-hearted intelligent people. The only thing is they don't have the opportunities that we have got. Their attitude towards the poor or disadvantaged is completely transformed.               

JR: Amazing. But have you been taking students to rural settings from the beginning or is it a recent thing?

Dr John: In the beginning, there were doctors going to rural areas in a mobile van, stopping under a tree or something and treating people with ulcers and those kind of things. If they needed admission—very few would need admission—they were come and get admitted, but the majority of the people have some injury or some skin disease or some tooth problem or those kind of things. This token reach-out programme was original thing. Then later on, in the community health department, some of us established what is called a COP; community orientation programme. In the beginning it was based in hostels; students visit during the day and return. Then one of the heads of the departments, he decided to make them stay in the villages. That needs to be planned very carefully.

JR: This happens during the first year, second year?

Dr John: This is in the second and third year, when they get their community health posting.

JR: When did you begin this?

Dr John: Maybe 40 years ago? Originally the students would stay in the hostels, but later they lived in the villages where there were simple makeshift stays for boys in one place, girls in another. Their toilets, water, food everything is arranged. The faculty stay with them. The students make their own projects and submit them after approval. They apply the projects in the community and report it in the general group, that is, back home after they return.

JR: How long would they stay?

Dr John: I think it is one week. Long enough to see the rural life, short enough to take time off the medical course. They have to come back and write their reports on Sundays and often senior faculty are called to see their presentations.                                                                                    

JR: Amazing,

Dr John: And so, they not only learn about the community, they also learn how to prepare a project, how to make a report, how to present it. The whole thing is a very holistic way of doing it, and students also love it. 

JR: You have given me some good insight into CMC.