San Francisco Chronicle - July 20, 2008
Hannah Gardner, foreign@sfchronicle.com.

In a closet-size room on the outskirts of this capital city adorned with faded medical posters and pictures of Hindu gods, Lal listens to a patient's chest and measures blood pressure before scribbling a prescription on a graying note pad.

"I feel more comfortable with our local doctor," said Javid, a 31-year-old electrician who gave only his first name.

Lal, whose only medical training consists of working as a doctor's assistant for two years, is one of hundreds of thousands of unqualified doctors - commonly referred to as "quacks" - working across India. There are an estimated 40,000 in Delhi's teeming slums alone, according to the Delhi Medical Council, an association that registers doctors and monitors medical standards.

For years, the government has waged an unsuccessful war against quack doctors, but now a report compiled by the prominent All India Institute of Medical Sciences recommends training and incorporating them into the formal health care system, which suffers from a dearth of physicians and nurses.

Dr. Chandrakant Pandav, the chief researcher for the institute report, believes training quacks is a practical way to relieve pressure on a system struggling to provide health care to India's 1.1 billion people. He points out that they often prescribe the same drugs as their qualified counterparts.

"We need to recognize the reality that these people provide a service and devise a classification scheme for them," he said, "They are available, accessible, affordable and acceptable."

But Pandav may have a hard time persuading his colleagues.

"If there were no quacks, longevity in this country would increase, people would be diagnosed earlier and they would be treated for underlying problems, not just for the symptoms," said Dr. Girish Tyagi, secretary of the Delhi Medical Council.

Pandav acknowledges quacks don't always follow good medical practice. Mistakes include reusing disposable needles, writing prescriptions for banned or expired medicines, indiscriminate use of steroids, and prescribing two or three-day courses of antibiotics that are insufficient to kill an infection. The latter is the main cause of high levels of drug resistance in India, according to the Delhi Medical Council.

Critics also say some quacks claim to cure the HIV virus, charging huge sums for tablets whose only active ingredient is a steroid with a pick-me-up effect. And in February, a 4-month-old child bled to death after a quack performed surgery on the boy's tongue after his mother complained he wouldn't eat.

In response, police and the nation's chief medical officer's "anti-quack" team have also raided slums to shut down unauthorized clinics.

But since many quacks are known to spend more time with their patients and use simple language to explain medical questions in contrast to their qualified counterparts, they are often protected by the communities they serve, according to the institute report.

"Word travels fast and the community helps the doctors take down any signs. It's supply and demand: They are fulfilling a useful role," said Pandav.

In New Delhi, only a handful of government clinics operate in or near slums, despite the fact two-thirds of the city's 14 million people live in shantytowns. Health experts say the city can't keep up with the influx of poor rural dwellers seeking a better life in urban areas.

"We only go to the hospital if it's something really serious. You have to wait for hours, and it costs five times more to get there than to see our local doctor," said 47-year old Phoolmati, who lives in the same stench-filled alley as Lal's ramshackle clinic and refused to give her full name.

When seriously ill, Phoolmati and other slum residents go to Safdarjung Hospital in downtown Delhi. Built in 1944 to handle 500 patients a day, it now copes with 5,000 daily, according to the city health department.

Lal's clinic is open from 8 a.m. till 10 p.m. and the wait is never more than a few minutes. He charges about 23 cents per consultation.

"My fees are cheap and I have a good reputation," said Lal.

In the meantime, the Institute's Pandav is well aware that bringing quacks into the system will be a hard sell for the medical profession.

"They have a head-in-the-sand attitude," he said. "Our system, as it is, is not delivering."

India short on licensed doctors

Many Indian physicians move to the United States and Britain after finishing medical school, lured by better working conditions and salaries. Indian-trained doctors account for 5 percent of U.S. doctors, according to government statistics. And until recently, India's Medical Council refused to recognize medical degrees from Western universities earned by Indians studying abroad.

As a result, there are only 60 doctors per 100,000 people in India in contrast to 256 per 100,000 in the United States and 106 per 100,000 in China.

India's public health spending is among the lowest in the world - $4 annually per person, less than 1 percent of the nation's gross domestic product. In contrast, the United States spends $2,000 per person, or about 6 percent of GDP, according to the United Nations Development Program.

The shortage of doctors is most acutely felt in rural villages and urban slums in India's largest cities.

About 60 percent of physicians assigned to rural communities by the government go AWOL, according to a 2006 government study. Many find life in the villages dull, having grown up in towns and cities. Doctors with families often cite their children's need for a good education as a prime reason for leaving rural areas.

With more than two-thirds of Indians living in the countryside, at least one-third of the nation's inhabitants have no access to state health care, according to the last government census in 2001.

India's unlicensed physicians

Because of a dearth of physicians, millions of Indians are treated by hundreds of thousands of unlicensed doctors - known in India as quacks, jhola chap (Hindi for shoulder bag or medical salesman) or "Bengali doctors" (since many hail from that region).

The government estimates it needs 600,000 doctors and 1 million nurses to reach an acceptable level of health care for the nation's 1.1 billion citizens, according to a recent government report.

The United Nations estimates that 2.1 million Indian children die before reaching the age of 5 every year, mostly from preventable illnesses such as diarrhea, typhoid, malaria, measles and pneumonia.

Even though health care is free at state-run hospitals, many poor people prefer to spend between 12 and 70 cents to see an unlicensed doctor to avoid the long lines to see a qualified physician. Also, many cannot afford to miss four to five hours of work waiting to see a doctor. In some cases, patients have been known to pay bribes to be admitted to over-crowded wards, according to Transparency International, a nongovernmental organization that fights corruption.

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