In the Bonesetter's Waiting Room (12 page)

4

The Heart of the Matter

INDIA'S EQUIVALENT OF SILICON VALLEY
began life in a town called Electronic City. Conceived in the mid-1970s, it lies around twenty kilometres south of what was then Bangalore's city limits. Today, the main approach to the heart of Bangalore's immense technology park is via a seemingly endless highway named after the Hosur municipality, just over the state border with Tamil Nadu. Neither the Hosur Main Road's multiple lanes, lined with hotel chains and Indian and multinational electronics corporations, nor the elevated expressway above it do much to relieve the congestion in either direction along its length. So the Audis, Land Rovers, BMWs or Porsches bought from the highway's many showrooms have little prospect of picking up speed as they are driven away; and every journey to India's biggest tech hub is necessarily a slow and protracted one.

Interspersed with the corporate headquarters and luxury brands were towns with a slightly run-down, albeit genteel feel, and it was near one of these – away from the main drag down a side street lined with fruit stalls and small family-run hotels and restaurants – that I found the entrance to another enormous complex, this one dedicated not to electronics or cars but to health.

Screened by a wall of large and aptly named flamboyant trees with their fiery red canopies, its foyer was surrounded by a wide porch topped by a double pitched roof of red tile, built in the vernacular style typical of pre-independence south Indian architecture. Rising directly behind it was a seven-storey L-shaped tower block, topped with an immense sign bearing its name, Narayana Hrudayalaya. In the broad scheme captured by the term ‘Hinduism', Narayana is the member of the ‘holy trinity' who protects life (placed between the Brahma, the creator and Shiva, the destroyer); Hrudayalaya means ‘the temple of the heart'. Living up to its name, this world-renowned centre for cardiology (or Narayana Health, as it is more commonly known outside the subcontinent) is one of the world's largest heart hospitals and has, in the fourteen years since its founding, performed more successful paediatric heart surgeries than any other institution anywhere in the world. In addition to its staggeringly efficient output, the hospital has gained a reputation, fitting in every sense, as India's ‘healthcare provider with a heart', because for over fifteen years it has been making world-class healthcare available to people who would otherwise have been unable to afford it.

As I lingered in the entrance porch, a little early for my appointment with its creator, cardiologist Dr Devi Prasad Shetty, I noticed that patients and relatives were gathered in worship at the hospital shrine, which stood in a garden just inside the front gates. In my line of sight was a portrait of Guru Nanak and an elderly man in a Sikh turban, offering prayers, and just past him, through its open window, another man, in his twenties, wearing a Muslim topi cap and sitting on a wall under an Islamic arch. Confused, I realised that what I had assumed was a Sikh temple was actually loosely divided into four parts: as well as the gurudwara and the mosque, under a dome with moon and star, there was a church with a Romanesque facade and topped with a cross, in which a lady in a sari knelt; and a mandir whose elaborate dome was carved with Hindu gods. That mixture of grief, hope, resignation and fear familiar to families of the dangerously ill was clearly recognisable in the eyes or postures of those praying in each quadrant.

‘It is very important for the families, while their loved ones are being operated on, to have this shrine here,' Dr Asha Naik told me when she joined me in reception for a hospital tour. Asha, a former paediatrician, had been Dr Devi Shetty's principal administrator for the vast Bangalore health complex since it opened in 2000. Though she was pivotal to the running of a hospital that saw hundreds of patients and performed nearly forty heart surgeries a day on children alone, Asha was warm and almost languidly at ease. As we talked, she described the opening of the hospital, starting with just one building given to Dr Shetty to help him realise his dream of providing India with cheap affordable world-class healthcare. What had begun as a 225-bed heart hospital was now, just over a decade later, a 3,000-bed multi-speciality complex, including a general medical hospital with thirty departments and a separate dedicated, state-of-the-art cancer centre. The complex now covers twenty-six acres around Electronic City.

‘At that time, this waiting room was very crowded with people,' Asha motioned to a very large hall, where perhaps around fifty to eighty people sat, quietly, in neat rows, waiting to be called into one of the consulting rooms surrounding it. Knowing the extent of cardiovascular disease in India, I had no problem imagining the room packed solid. Worldwide, cardiovascular disease accounts for the largest number of deaths not caused by infections: 17.5 million people die annually because of it. That's more than those who die because of cancers (8.2 million), respiratory diseases (4 million) and diabetes (1.5 million) – another disease which has also become a particularly virulent scourge in India. South Asians are genetically more susceptible to heart conditions than others, and it is projected that by 2020 Indians and Indian diaspora populations alone will contribute close to fifty per cent of the entire global cardiovascular disease burden. Of course, lifestyle factors such as lack of exercise and an unhealthy diet affect everybody, but genetically, Indians appear especially prone to their adverse cardiovascular effects and they also develop them earlier.

Heart disease is no respecter of class, and increasing numbers of the affluent have had to seek heart surgery alongside their poorer compatriots. The difference, of course, is that they can afford to be ill in style. Asha indicated a staircase to the extreme left of the waiting hall. ‘The rich patients didn't want to come here because of the poorer crowds. We had to create a separate area upstairs for the wealthier people – the executive area. I'll show you later.' She smiled. ‘But down here there are eighteen consulting rooms now. Dr Shetty's aim was to provide affordable healthcare on a large scale.

The hospital's atrium was divided from the waiting area by an enormous stone carving of various incarnations of the eponymous hospital god. At its base, it was supported by a scene from the
Bhagavad Gita
, in which the Lord is portrayed dispensing wisdom and calm amidst a raging battle of epic proportions. In this spotless, marble-floored atrium through which hundreds of thousands of people have passed over the years were several reception counters: a travel desk for foreign visitors, a cash desk for taking payments, registration counters where patients were checked in and a dedicated ‘Bangladesh Information' desk. This was to assist international patients from India's closest eastern neighbour: a less densely populated country, but one in which the people who need healthcare most face obstacles to accessing it as seemingly insurmountable as those encountered by the poorest Indians.

As I waited for Dr Shetty to see me, I read a fact sheet one of his assistants had given me detailing the chain of health centres that had opened across the country in the wake of the Bangalore original. Apart from the 1,000 beds housed here, there were now a further 6,500 spread across twenty-eight sister institutions in seventeen Indian cities.

The scale of what Shetty had managed to achieve in such a brief time was remarkable. India doesn't have anywhere near enough trained professionals to maintain the health and serve the sick among its 1.45 billion population, but the heart of the matter – the reason why Devi Shetty's hospitals stand apart from the rest of India's gleaming hospital-metropolises – is that they were created with a policy to be open to all.

In India, as in many areas of the world, the cost of private medical treatment is prohibitive to many, but the distribution of drugs and implementation of its public health programmes are also faced with massive bureaucratic and logistical hurdles, from endemic corruption to contradictory government legislation, which can make public healthcare equally inaccessible to the poor. A recent
Times of India
report detailed how, ‘under the Central Government Health Scheme which covers central government employees, including serving and retired
babus
, current and ex-members of Parliament and the judiciary, the annual per capita expenditure is more than Rs5,000. In contrast, the National Rural Health Mission, which caters to the rural masses, spends just Rs180 per head.'

This is symptomatic of the inadequate regulation which sustains massive regional disparities and promotes commercial medical ventures while the public healthcare system festers through a lack of funding, the absence of compulsory health insurance, inefficiencies in governance and care, poor hygiene and low staffing. It's no surprise, then, that four out of five Indians choose the private sector, even when they can barely afford to do so. Shockingly, it is estimated that self-funded healthcare forces around 40 million people into poverty every year. Although the slick private centres are required by law to provide a certain amount of free care, in practice the legislation is often flouted.

Narayana Health seemed to offer a revolutionary new approach. As Devi Shetty put it: ‘Corporate hospitals are developed for the rich, but also take care of the poor. This is a hospital for the poor and we also take care of the rich. That is why we exist.' I was struck by how Narayana Health had not only recognised the scale of the problem facing India's healthcare system but had also taken radical steps to change it – an almost impossible challenge.

Shetty had worked at London's Guy's Hospital twenty-five years previously and then returned to work in Calcutta as a cardiologist in a private hospital, seeing hundreds of patients a day but performing very few surgeries, simply because hardly any of the people who needed the operations could afford them. The experience spurred him to find a new way of working, in which efficiency, professionalism and skill would combine with sound economics to create a system in which those who could pay the market rate would do so and those who couldn't would be subsidised. Some criticised him for working outside the government health system rather than trying to improve it from within, but he was driven solely by an ambition to put world-class surgical care within the reach of people who needed it the most, and he felt that was a goal that would not be achieved via running the gauntlet of the state system.

‘In India there are 1.9 million people not getting heart surgery; we produce the largest numbers of young widows in the world,' he said. Added to this, an estimated 78,000 infants born with congenital heart disease in India die every year because of inadequate healthcare facilities. This was a tragic waste of life from a reparable condition that was proving debilitating to the nation but whose treatment was out of reach to most who desperately needed it. In Shetty's view, if a solution is not affordable, then it is not a solution.

Built on land donated by his father-in-law, his hospital shortly thereafter began working closely with the state to provide financial assistance to poor patients through various means. A combination of government subsidies, fees from private patients and gifts from donors meant that everyone was charged what they could afford, even if they could afford nothing and irrespective of nationality. In India, it is not uncommon for families to refuse to pay for a baby girl's treatment, so these fees too were often waived. Those who are either subsidised or who are not required to pay, now constitute fifty per cent of the Narayana's intake.

With India's majority rural population in mind, Devi Shetty also created the Yeshasvini Cooperative Farmers Health Care Scheme, an inclusive micro-insurance scheme, now adopted by state government, in which poor farmers and low earners pay just over £2 a year to cover their family. Membership now numbers in the millions, though it is as yet only offered in Bangalore's home state, Karnataka. In the bureaucratic minefield of Indian officialdom, it must have been a formidable task to see the scheme implemented. When I asked Asha how they got the Karnataka government on board for these subsidies, she replied simply, ‘Dr Shetty has great capacity of convincing.'

As well as the usual medical emergencies, some of the conditions eligible for treatment include dog bite, snake bite, drowning, injury from agricultural machinery, bull goring and electric shock, as well as labour and delivery, neonatal care and angioplasties. The Yeshasvini scheme has its critics, however, since it covers only surgical procedures and not general medical needs. There is a long list of exclusions – from burns and chemotherapy to spectacles and dental treatment – which, as the programme's metrics suggest, do deter a significant number of potential subscribers concerned about their more basic healthcare needs. Still, the small sum that millions of people now pay gives them access to approved, high-quality surgery (heart, brain and transplant surgery included) up to 1,000 times the value of their annual subscription as well as all-inclusive care while hospitalised.

One result of all this is that, in his home country, Shetty is now as close as it gets to being a rock star of medicine, adulation for whom, it seems, knows no bounds – in internet comment streams the words ‘god' and ‘sent by god' come up again and again. It made me think of the blurring of the spiritual and the physical I had seen in Dharavi. Certainly, to patients for whom any complex healthcare might have been previously out of bounds he must seem heaven sent.

As I knocked on his door, marked simply
Devi Shetty (FRCS, England)
, I wanted to ask him both how he had achieved so much, and why he thought other countries hadn't followed suit. I stepped into a large office where Dr Shetty sat behind his desk on a Herman Miller chair, wearing blue scrubs, a surgical cap and a stethoscope. As he fielded the various queries and phone calls that interrupted our interview, he radiated the sense of a man with a deep and peaceful centre, unflappable under pressure. At sixty-one, he looked ten years younger. Still, perhaps the wisdom of his years helped create the peaceful atmosphere at the heart of his hospital – its soundtrack was a steady, centring drone of a mantra, ‘Om Namo Narayanaya' (literally, ‘I bow to Narayana'); on the walls of his office were photos of Mother Theresa (to whom he had been first cardiologist and then personal physician) and Sai Baba; there were statues of Buddha and Mahaveera Jaina and a sofa for patients' families placed in front of a glass wall that gave Shetty a direct eyeline onto a lush balcony garden and brought its calming greenery into the room.