Dr Kamal Kumar Mahawar is a practicing medical doctor who has had the opportunity of reflecting on a range of ethical and systematic issues that plague health care in India. He writes regularly on subjects pertaining to Indian health care in India Medical Times.
Following his graduation from Calcutta Medical College and post-graduation from Postgraduate Institute of Medical Education and Research, Chandigarh, and University of Liverpool, Dr Mahawar has been working as Consultant General and Bariatric Surgeon with National Health Service (City Hospitals Sunderland NHS Trust), United Kingdom. He is actively involved with research and is the editor of several reputed scientific journals. Dr Mahawar is also the co-founder of science portal Webmed Central.
This interview was conducted over email.
Jhilmil Breckenridge (JB): I just finished reading your book and while I was aware of some of the issues of ethics, the level of detail with which you expose some of scams, because I cannot think of another term, is amazing. Please tell me about your journey and how this book came to be.
Dr. Kamal Kumar Mahawar (KKM): I have for a long term felt the need to give something back to Indian society. I understand how populist that sounds but that is the honest truth. I got a free medical education in India and when I was in a position to return something to the society that nurtured me, I moved to the wealthy West to live a comfortable life. The guilt has been playing on my mind for quite some time.
The overarching aim of this book is to improve the healthcare provisions for people in India. In this context, one recognizes that a number of unethical practices have engulfed the practice of medicine in this country. Patients are suffering and the majority of doctors are sucked into it, against their will. I hence felt that a superficial analysis that just ends up exhorting doctors to be more ethical wasn’t going to be successful. Somebody had to put together the myriad of reasons underlying the behaviour of doctors and we need to debate the whole situation in its totality in our society.
JB: Tell me some of your personal experiences with some of the issues you have raised in this book.
KKM: This is a difficult one, as you can never talk about yourself without inadvertently bringing others connected to you into it. Besides, that is the not the aim of this book. This book is not about me; it is not my story. This book is the story of a sick healthcare system that needs fixing for a billion and a quarter people. I just desperately wanted to play my part in fixing it. I will tell you a couple of things, though. In February 2002 I was earning 25,000 working in India and I could barely afford to live and take care of my responsibilities. In February 2003 in the United Kingdom, I was earning approximately GBP 5,000 per month. Similarly, I was licensed to practice surgery in December 2000 after my MS in General Surgery from one of the most reputed institutions (Postgraduate Institute of Medical Education and Research, Chandigarh) when I did not myself ready for it. In the United Kingdom, I would be required to work and train as a "junior Doctor for another 8 years before being appointed as a consultant surgeon (an independent practitioner) in March 2011. During this time, I was remunerated adequately and trained in adequate facilities.
JB: Where did you grow up? You alluded to a middle-class childhood in India. When did you move to the UK?
KKM: I grew up in Kolkata and did my entire school education there. Thereafter I went on to obtain graduation from the Calcutta Medical College and post-graduation from PGIMER, Chandigarh. I moved to the United Kingdom in January 2003.
JB: Please tell me a bit about WebmedCentral. What was your idea behind setting it up? Is it fulfilling what you set out to do? I know you have discussed peer review in the early part of your book, but please tell me more.
KKM: Systematic mechanisms that prevent developing countries from rising have long bothered me. In the world of science, which you could argue also determines the output of a lot of other human endeavours, once again there are systems that Western institutions use to thrive and develop while countries like India cannot even begin to make an inroad. Peer review or more accurately pre-publication peer review is known for a number of biases, including biases against the developing countries. The WebmedCentral is a unique model in academic publishing where all scientific publishing happens in an environment of peer review after publication and not before it. However, there are other systematic issues, controlled by Western countries that prevent wider adoption of such platforms. It is indeed disheartening that we in India do not think of these systematic issues while addressing any serious problem and our scientific output is one such.
JB: Please compare the ethics of the medical world in India and the UK.
KKM: As I mentioned before, doctors (and indeed members of the rest of the society) need to be enabled to work honestly and ethically and then by all means monitored and disciplined if need be. We in India have failed at all levels. We have failed to create a 21st-century healthcare system that can train and employ our own medical and nursing force. As a result, professionals are forced to emigrate to earn a livelihood and those that choose to stay have to survive in an environment of cut-throat competition and dishonesty. What options do these doctors have left to them? In the United Kingdom a General Practitioner (Family doctor) earns as much as (if not more than) a consultant transplant surgeon working in the most state of the art hospital and all doctors are generally paid wages that respect their talent, devotion, and hard work. In contrast, in India, most general practitioners can never hope to earn as much as a consultant surgeon in a private hospital working entirely honestly. How do they then feel? What will then they do? They, after all, control the flow of patients in any healthcare system.
Moreover, if you look at the General Medical Council, the regulatory body in the UK, it is a strong body with significant resources at its disposal. In India, MCI like many other state institutions is inadequately funded and have completely failed in its duties to the society, the patients, and the medical profession. I know there is some talk of replacing MCI with a new body etc. I just hope that we cease this momentum for some real change and truly address some of these profound issues. A superficial band-aid treatment will not work.
JB: In the recommendations chapter, you call AYUSH practitioners practicing modern medicine quacks? What is your opinion of yoga and ayurvedic therapies and ayurvedic doctors and medicine?
KKM: Please allow me to clarify. This book is about modern system of medicine that is now recognised in all parts of the world. There is only one criterion for any medicine to be included in this system; it should work and should have been shown to work in scientific studies. In that sense, any treatment, if it is scientifically proven to work, becomes a part of modern medicine. Usually, it also means identifying the actual active ingredient within the traditional remedies.
This clarification aside, I do not know enough about Ayurvedic medicine or Yoga to have a view when it comes to the healthcare provisions for people of India. We should be proud of our heritage but my personal belief is that we should test them scientifically and prove them to the world rather than blindly follow them just because they are a part of our heritage. With such proofs, they will automatically be inducted into the armamentarium of modern medicine.
Anybody practicing things they are not trained for is fooling the gullible public. This could be AYUSH doctors prescribing modern medicine that they haven't been trained to prescribe or even some MBBS doctors prescribing Ayurvedic medicines (yes that happens too).
JB: Your book is a breath of fresh air, easy to read both by members of the medical fraternity, patients, change makers. Who did you write this book for and are you happy with the way it has shaped up?
KKM: Thank you. This book was primarily intended for those outside the medical profession – the patients, the media, and the policy makers. I firmly believe that Indian healthcare cannot now be fixed by doctors alone. It needs a concerted effort by all the stakeholders in the society if India has to develop healthcare provisions that we can all be proud of. I am happy with the initial reaction to the book but naturally, I would like it to rise to the national agenda for any real change to happen. We are a long way off it, yet.
JB: Tell me about your writing process, how you get your ideas, how you make time to write, and any advice to any aspiring writers.
KKM: These issues have been playing on my mind for a long time. In that sense, perhaps the book has been brewing in my head for decades.
With regards to the actual time for writing it, I have to say a lot of the credit goes to my wife. She ensures that everything in my life is completely taken care of so that I can devote my time to writing. I am also reasonably active with academic writing in the field of obesity management and bariatric surgery, my main focus of work.
JB: What is on your nightstand right now? What are you reading? Who is (are) your favourite author(s)?
KKM: I love reading Hindi as well as English literature. Maithili Sharan Gupta, Ramdhari Singh Dinkar, Shakespeare, and Emily Bronte are my all-time favourites. I am currently reading Atul Gawande’s “The Checklist Manifesto”.
JB: What motivates you to keep writing?
KKM: I like to play my part. If I see a problem, I feel compelled to take a stand. In that sense, I strongly feel that as a human being my net contribution to the society should be a positive one. If we all just keep taking from society and give nothing back in return, India's hopes of becoming a developed country will take that much longer, I believe.
JB: What is your daily routine?
KKM: I wake up between 06:30 – 07:00 AM. Most days, I am at work between 08:00 – 09:00 AM and come home between 05: 00 – 06:00 PM. Evenings are spent with family, reading, writing, and exercising twice or thrice a week. Sometimes we watch TV or a movie. Weekends are usually spent with family and friends, once again with a large time spent on writing for medical journals and other platforms.
JB: What makes you smile?
KKM: I had to think about this one. I love family holidays as and when we can manage them. But nothing can beat a good joke on WhatsApp these days!