The most tragic thing in the world is a sick doctor

One day, more than ten years ago, I saw three blind men assaulting a man outside the Fort Railway Station.  They were screaming at the victim. Apparently the three men were lottery sellers retailing dreams at the station.  The ‘victim’ had robbed one of them.  The robbed had recognised robber, several months later, by footstep, or so we were told. The ‘victim’, silently took the mauling. The robbed were trying gouge his eyes out.  The police intervened; bundled them all into a vehicle and took them away.

Petty theft. Petty assault.  Not the first. Not the last. And not the only type of crime.  There’s pickpocketing. Pimping. Prostitution. Verbal abuse. Physical abuse. Character assassination.  Small. Crimes, yes, but petty, not for victim but when viewed against the canvass of major crimes.  There are down-and-dirty crimes.  Hands-get-dirty crimes.  And then there’s clean crime. Sanitized crime.  Loophole-knowing crime. Politically-protected crime. Ladies-and-Gentlemen crime. 

White-Collar Crime.  That’s Allowed-Crime.  It is the kind of crime that you will not associate with people who have ‘names’ like Malu Nihal, Baddegane Sanjeewa, Kuru Noor, Kristoper (of Kelaniya University fame), Bada Mahinda etc etc.  It is more likely that they will have aristocratic-sounding names and are propertied to the maximum.  Much of it happens under the radar of the law, naturally. If, as Lenin said, the law is the will of the ruling class, then the political reality is that the ruling class will if necessary bend its own laws to protect itself or at least its champions. 

White-collar crime refers, technically, to theft, fraud, embezzlement or some other non-violent lawbreaking act perpetrated by a salaried employee or senior manager of a company or organization. There’s no eye-gouging or Tyson-like ear-chewing.  Clean-cut. That’s the signature of such crimes. The term, which has no legal significance, was first popularized by the American criminologist Edwin H. Sutherland in his classic paper “White-Collar Criminality” (1940), I learned.  He pointed out that there’s a ‘significant sociological difference between conventional crimes such as burglary and murder, which are defined without reference to the social status or occupation of the perpetrator, and white-collar crimes such as fraud, embezzlement, price-fixing, antitrust violations, income-tax evasion, misuse of public funds, and abuse of political and legal powers’.

He adds, ‘in general, the latter are committed by persons of relatively high social status, are intimately connected with the socially approved occupation of the perpetrator, and are treated by the authorities more leniently and inconsistently than are conventional crimes.’  The crimes, then, are clean-handed and so too the (rare) punishment, typically nothing more than loss of professional license (where applicable) or levying of fines.  There is of course some fallout by way of loss of face, but that’s not something a court can order and anyway, we all know, popularity can dip and swing back, especially if enough bucks are thrown into it.  The film ‘God Father III’ showed how it is done and anyway, if we look around, we will see enough examples of those who recovered face or rather, purchased face back, after getting ‘sooted’ in public.  Most importantly, white-collar criminals, for the most part get away without having to serve jail-terms. 

There have been scandals.  Why ‘scandal’? Is that a word used for ladies-gentlemen-crime?  Pickpocketing is not ‘scandal’, embezzlement is.  It’s about status isn’t it? Anyway, we had some scandals recently.  Big-name people making big bucks by lying to people.  Big-name people taking people for a ride, doing a Ponzi.  The amounts pilfered were so huge that pickpockets and would-be eye-gougers suddenly appeared to be respectable and considerate.  My friend R. Manamendra committed suicide after being short-changed of all his savings in the Golden Key scandal (read ‘daylight robbery’).   I am yet to hear of someone hanging him/herself on account of being pickpocketed.  Depositors are still to be compensated. 

Ponzi schemes are not the only kind of white-collar crime, though.  I am thinking of the kinds of crimes engaged in by medical professionals. Again, these are ‘ladies’ and ‘gentlemen’ we are talking about.  Clean-hands people.  You wouldn’t think that Opthalmologists and Cardiologists would rob would you?  They are not pickpocketing types, surely?  Right.  They are not.  Pick a pocket and you get a handful of bucks; well, a couple of thousands which in these inflationary times amount to peanuts.  Let me relate some stories.

First the Ophthalmologists.  We are talking about cataract surgeries. The glass lens that is suitable in 95% of the cases costs just Rs. 700.  Almost all Government Ophthalmologists discourage the purchase of these lenses.  There is however one Ophthalmologist at the Vijaya Kumaratunga hospital, Seeduwa, who is perfectly happy with this lens type and performs 80-100 surgeries a day on average.  Now, is he stupid? Should he lose his license for incompetence? Is he a ‘quack’?  No, he’s just doing things differently.  He doesn’t have to, but doing things this way means that cataract operations become affordable to a larger number of people.

How do others do it?  This is how. There are two operation lists.  One under ‘normal procedure’, i.e. 6 months of ‘waiting time’, and the other a ‘private list’ with specific instructions to buy the les from a particular optician.  The actual price of the lens is in the region of Rs. 6,000 but it is sold to the patient for amounts ranging from Rs. 12,000 to Rs. 15,000. This is the ‘price’ of the queue-breaking ticket.  Thirty days and you are seeing the world with new eyes. The operations are done as part of routine surgical lists, but the surgeon takes home a big fee.  Well, the surgeon doesn’t get one extra cent from the Ministry of Health, but it is hard to believe that a surgeon would recommend a lens that is almost 20 times the cost of one that would do the same job unless he/she is adequately compensated for by the lens merchant. 

Let’s assume that such a surgeon does 20 surgeries a day and gets, say a 50% ‘cut’ from lens-sale.  That would be a minimum of Rs. 3,000 multiplied by 20 or Rs. 60,000 a day.  Let’s take 10 working days (that’s me being ultra-generous).  A whopping 600,000 a month or 7.2 million a year.  What if the true ‘cut’ was 6,000 and not 3,000 rupees?  That would be 14.2 million a year.  And if it was Rs 9,000?  That’s Rs. 180,000 a day.  Let’s have a working month of 20 days and the monthly take would be Rs. 3.6 million a month.  Let’s get some perspective here. The demi-god at the Vijaya Kumaratunga hospital would be making between Rs. 240,000 and Rs. 900,000 a day depending on amount of ‘cut’ and number of surgeries!

One begins to wonder, now, why there are only a few eye surgeons being produced by the system; low supply, high demand and therefore choice-lack, producing high prices?

Let’s take the Cardiologists.  They decide sometimes that patients require stenting.  The patients are duly referred to businessmen/agents who are within the premises of the Cardiology Units to obtain the stent. The price? Well, let me put it this way. If all you want is to go from Thimbirigasyaya to Town Hall, you can take a three wheeler. You can cycle. You can walk there. You could take a bus.  If you insist on going by car, you can go in a Maruti-Suzuki, a Cherry QQ or a Rolls Royce.  What is recommended, folks, is a Rolls Royce Stent. The unsuspecting patient will not know that there are Cherry QQ or 3-wheeler stents that will do the job just as well. The un-frilled device they could get for less than Rs. 50,000 is never recommended. Instead, frilled versions, ranging from Rs. 150,000 to Rs. 300,000 are touted as the best (and sometimes the ‘only’) thing out there in the market.  Does the Cardiologist get a cut? 

Isn’t all this pointing us to the worst kind of (and still quite ‘classic’, I might add) private-public partnership there can be?  Isn’t this a win-win situation for supplier and surgeon and betrayal of the ordinary citizen who is caught, beaten and made to cough up his/her life-savings.

It wouldn’t happen if there was integrity. It wouldn’t happen if those responsible for ensuring that such schemes don’t undercut the objectives of ‘free healthcare’ did their job.  It might help to increase the number of skilled people in the country.  Did the former minister know about these unethical practices, these trust-violations and blatant fraud?  Is the present minister ready to look into these issues?

Does this also happen in Orthopedic procedures such as hip-replacements and knee-joint replacements?  Are patients required to purchase branded devices from surgeon-specified sources carrying trade-named when the hospitals carry them?  Is supply deliberately kept low or even at zero? 

I know enough ‘professionals’ who bark at police officers taking bribes from drivers who are guilty of minor offences.  They even point their fingers at politicians and howl with righteous anger about corruption, lack of respect for the rule of law etc.  My friends in the medical field have told me enough stories about doctors being thick as thieves with the pharmaceutical industry. 

We are not talking about that wonderful world of market economics here, i.e one where demand and supply curves play willy-nilly and according to some kind of internal logic. We are talking about price-fixing and about agreement among sellers. We are talking about corporate monopolies. About complicity on the part of relevant officials.  

Francois Marie Arouet, better known as Voltaire once said that doctors are the greatest deceivers and patients the greatest fools.  I don’t want to paint with such thick a brush.  I am not happy though.  George Bernard Shaw said, ‘the most tragic thing in the world is a sick doctor’.  With due apologies to all the wonderful doctors out there healing patients and being absolutely honourable and of unblemished character, I concur and note that Shaw didn’t say ‘the most tragic thing in the world is that all doctors are sick’. He qualified. I do too. 

We need a counter-corruption commission. Fast. An independent one.  Mr. President, you are known to have reservations about the efficacy of the 17^th Amendment. Fine.  How about an alternative that can do the job?  The citizens of this country all have eyes. They have hearts. Knees and hips.  Some of these will need replacement or some kind of prop sooner or later.  You too, Mr. President.  I am sure surgeon and supplier will do the honours free of charge.  I will not have that privilege, no. Neither would the vast majority of my fellow citizens.  Any thoughts, Mr. President? 

[This first appeared in 'The Daily Mirror', June 10, 2010]