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Year : 2017  |  Volume : 15  |  Issue : 2  |  Page : 153-155

Three knocks on my door

Madhipura Christian Hospital, Madhepura, Bihar, India

Date of Web Publication18-May-2017

Correspondence Address:
Pradeep Joseph Ninan
Madhipura Christian Hospital, Ward No 22, Bhirki, Mission Road, Madhepura - 852 113, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmi.cmi_29_17

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How to cite this article:
Ninan PJ. Three knocks on my door. Curr Med Issues 2017;15:153-5

How to cite this URL:
Ninan PJ. Three knocks on my door. Curr Med Issues [serial online] 2017 [cited 2022 May 24];15:153-5. Available from: https://www.cmijournal.org/text.asp?2017/15/2/153/206519

Those of us familiar with the story of Aunt Ida (Ida Scudder, the founder of Christian Medical College, Vellore, my alma mater) know of how her life was changed by three knocks on her door one night [Figure 1]. Confronted with the problem of three young women dying in childbirth because of the lack of trained women doctors, the young and reluctant Ida was convinced of the need to train in medicine and return to India as a medical missionary with a desire to train Indian women doctors.[1]
Figure 1: Three knocks on my door.

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A few years ago, I also had my own three knocks experience, when the stories of three patients changed the way I practice medicine. At the time, in 2007, I was working in a 120-bed mission hospital in rural Uttarakhand.

Patient A was an elderly male brought in with a perforated duodenal ulcer. He was very sick. His lungs were permanently damaged due to smoking, and he was now in shock because of the peritonitis. After we resuscitated him and operated, he was shifted to the Intensive Care Unit, where he was ventilated for 4 days. After a stormy postoperative period, he recovered well and was ready for discharge.

Before he left the hospital, his relatives came to talk to me in the outpatient department (OPD). After giving them the usual pep talk (about making sure he ate well and stopped smoking, and so on), I asked them whether they had paid the bill. They had. I was pleasantly surprised, because they looked quite poor, and I had been expecting them to ask for some concessions.

”How much was the bill,” I asked. “About ₹ 10, 000,” they said. They had paid ₹ 4000 as an advance and had now paid the remaining amount. Again, I was quite pleased. ₹ 10,000 was quite reasonable for such a major operation and hospitalization, especially for somebody who had been ventilated for 4 days. I felt quite proud of my hospital.

More out of a desire to make some light conversation before they left, I asked them how they had managed to pay the bill. They had taken a loan (Fair enough, I thought to myself, ruefully. Even I might need to take a loan if I require major surgery in the future! It's good to hear that even the poor are able to get loans when they need…).

”So, what type of loan is this,” I asked. They replied that they were going to be paying a 10% interest. For every ₹ 1000, they would have to pay ₹ 100 (Sounds quite reasonable, I thought).

Since we were making pleasant conversation, and they had already received some advice from me with good humor, I thought I would give them some more. “Make sure you pay the loan regularly and quickly,” I advised. “After a year, the amount would have increased to ₹ 11,000. And unless you plan well, you will be stuck with a large debt.”

My jaw dropped, as I realized that the family was, in fact, paying 10% per month as compound interest. A whopping 214% interest per year!

”No,” they corrected me. “The loan would be ₹ 11,000 by the following month. And it would increase by a further 10% the following month.”

My jaw dropped, as I realized that the family was, in fact, paying 10% per month as compound interest. I quickly did the math. The repayable amount, after 1 year, for the initial loan of ₹ 10,000 would be ₹ 31,386. A whopping 214% interest per year!

Horrified, I tried frantically to prove that my calculations were wrong. But no, the family assured me. Those were, in fact, the conditions of the loan.

However were they ever going to repay this, I asked, aghast. The family, now perhaps seeing how upset I was, tried to reassure me. “No problem, sir,” they said. “The money lender has said that we can work for him on his fields. He will not pay us any money but will give us food everyday. We can work for him until the loan is repaid. Nothing to worry!”

Slowly, the realization of what had happened sunk in. My duodenal ulcer perforation surgery had pushed a family into bonded labor. My colleagues and I scrambled to arrange money to give to this family as a gift so that they could go and settle this loan quickly.

A few days later, the story was repeated. Patient B also admitted for duodenal ulcer perforation surgery and ventilated postoperatively. This time, we asked the questions before the bill was paid but found that the family had already taken the loan. Another ₹ 10,000 loan was being repaid at 214% interest. Another generous offer from the money lender that the family could work on his land as bonded laborers. However, this story had another twist. The money lender had promised them that if they did not report for work anytime, he would send his goondas to tear down the small tin shack in which they lived. They were going to be living under the perpetual threat of violence. Again, we tried to put together funds to help this family out of their debt.

Slowly, the realization of what had happened sunk in. My duodenal ulcer perforation surgery had pushed a family into bonded labor.

A few weeks later, I had the third knock on my door. This time, it was the wife of Patient C, a middle-aged male admitted with acute pancreatitis secondary to chronic alcohol abuse. He was now ready for discharge, and the family was asking for a reduction on the discharge bill. The bill was ₹ 1200, and they wanted ₹ 400 to be reduced. At that time, I had a clear and firm policy on alcoholic pancreatitis. No reduction in bills allowed. My reasoning was simple: if they had enough money to buy alcohol and drink everyday, it was safe to assume they had enough money for the hospital bill! I explained this policy to the wife.

A couple of hours later, a nurse came to my OPD. The patient's wife had been asking the relatives of other patients for a loan of ₹ 400. She was offering that they could have her 6-year-old daughter until she arranged enough money to redeem her back. I felt like crying. My treatment of alcoholic pancreatitis was pushing this family into human trafficking, possibly even sexual trafficking. We promptly wrote off the ₹ 400 and allowed the family to leave.

Thirty-nine million Indians every year are pushed below the poverty line directly as a consequence of emergency health.care related expenses.

I was very shaken by these three knocks on my door. As I read more about the problem of emergency out-of-pocket spending for hospital expenses, I came across this disturbing statistic.

Thirty-nine million Indians every year are pushed below the poverty line (BPL) directly as a consequence of emergency health-care related expenses.[2]

Over the years, I have often remembered these three patients who changed my life. They have taught me some valuable lessons:

  • Even the poorest patients sometimes pay their bills without asking for concessions. They do so, however, at horrific personal costs. In our hospitals, we need to look out for these patients, and actively ask the questions about how finances are being arranged, and sometimes write off costs even when patients do not ask for reductions
  • Even the highly subsidized treatment available at our charitable, not-for-profit hospitals can push poor patients BPL and even into human trafficking and bonded labor
  • While health insurance does seem like the obvious answer to this problem (of out-of-pocket emergency healthcare spending, with its devastating effects on poor families), the insurance schemes available at present (even those offered by the government to BPL families) somehow often seem to benefit the rich and middle-class families, who are aware of their rights, and of available options and schemes. The poorest are often left out of the very schemes designed to benefit them
  • The public health system in India has been designed to provide free and high-quality healthcare to India's poorest citizens. Unfortunately, due to a number of factors (poor governance, corruption, apathy, and poorly trained staff, to name a few), our public health system is in shambles. I am convinced that it is our duty, as responsible health-care providers, to do whatever we can to ensure that the public health system in India is strengthened and equipped to fulfill its role.

Finally, a word to my professional colleagues.

The World Health Organization, in 1948, defined “Health” as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” When 39 million Indians are pushed BPL every year as a result of healthcare expenses, it is well past the time for us to ask ourselves some disturbing questions. Are we truly promoting health? Or is this itself a symptom that the healthcare 'industry' is desperately sick and in need of healing?

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Conflicts of interest

There are no conflicts of interest.

  References Top

Wilson DC. Dr. Ida: The Story of Dr. Ida Scudder of Vellore. London: Hodder and Stoughton; 1959.  Back to cited text no. 1
Balarajan Y, Selvaraj S, Subramanian SV. Health care and equity in India. Lancet 2011;377:505-15.  Back to cited text no. 2


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