The winner takes it all

During the first month of Covid, when I wrote in this column that an acquaintance had called to ask whether he could ‘prebook’ an ICU bed, I received incredulous responses. I don’t know whether the gentleman needed an ICU bed, but in a devious sort of way he was indeed far-sighted.

Sanjay Nagral
Sep 25, 2020, Mumbai Mirror

During the first month of Covid, when I wrote in this column that an acquaintance had called to ask whether he could ‘prebook’ an ICU bed, I received incredulous responses. Many suggested that the person was crazy. Some wondered whether I was making up a story. I don’t know whether the gentleman needed an ICU bed, but in a devious sort of way he was indeed far-sighted.

Last week, an online portal called ‘Local Circles’ conducted a survey to assess citizen experiences on procuring ICU beds during Covid. They received 17,000 responses from 211 districts. A staggering 78 per cent of respondents said they used ‘clout’ or ‘connections’ to get an ICU bed. Such surveys are of course part perception, part truth. And they largely reflect the middle class. The terms ‘clout’ and ‘connections’ are nebulous, but we know what they allude to. But if these figures surprise any of you, it would make me wonder whether you have just arrived in India or have been living in some kind of a social bubble. Isn’t this how we largely conduct our public life? Haven’t we all used the strategy when it comes to school admissions, licences, passports, loans and jobs?

In March 2020, I discussed ‘triage’ and its importance in dealing with the pandemic in India in my column. I described how countries effectively use it to treat the most deserving patients on priority even in normal times. I had suggested that given India’s dichotomous system and natural triaging based on the ability to pay, we needed strong state intervention to ensure that everyone got care. Of course, this was partly wishful thinking. In many Indian cities, the state did move in to take control of Covid beds in a common pool. Help lines to allot beds were created. Costs were capped. Guidelines about who should be admitted and who could be treated at home were issued.

Why does one then need ‘clout’ to get an ICU bed? First, because there is a shortage of genuine ICU beds.

Also because all facilities are not seen to be similar. Mumbai’s makeshift ICUs built by the MCGM are underutilised as per the Commissioner himself.

But another important reason to seek connections for a bed is because it actually works! Our lived experience has taught us that it has a high chance of being effective compared to the normal route. It’s unrealistic to expect that such a well-entrenched phenomenon will not be used to access health care. Even in routine times, they do a lot. Jumping OPD queues, accessing senior doctors, early surgery, more polite behaviour is all part of this package.

The practice of medicine in India is socially intertwined. After a consultation, patients often ask me which state I belong to. If they are from that state, they are visibly happy. They often drop names of my friends or family they know to establish ‘contact’. Doctors will tell you how they get calls from acquaintances enquiring about a patient. They say things like ‘just see him properly’. This is of course a result of a natural insecurity and apprehension when someone is undergoing treatment. But it also implies a certain lack of faith in the process. I am not sure whether to blame people for this feeling. In fact, healthcare which values neutrality should be worried about this perception.

So, when people have used clout and contacts for ICU beds, who is to blame? Given the scarcity and desperation, is it the citizen, who knows that it works? Hospitals who are open to such influence under pressure? Many hospitals in India are power centres for their owners. They have been started by business families, communities and medical entrepreneurs. They are part of social networks. One reason they have been built is to ensure access for their own. That’s perhaps why minorities often build hospitals. Hospitals are also dependent on state largesse for licences and permissions. So it’s difficult for them to stand up to pressures. Have you heard of a VIP not procuring a hospital bed during Covid?

We have a huge triage challenge coming up soon in the form of the Covid vaccine. There will of course be a scramble when it arrives. Priority-based distribution in its early phase when its relatively scarce will be needed. What should this vaccine triage be based on? And will that be respected by all? Can we insulate it from ‘clout’ and ‘connections’? We will soon need to square up to this.

Of course, many questions are somewhat rhetorical. The day hospital beds in India are allotted on severity alone, we would also be a very different society. In some ways genuinely modern. Authentic triage is challenging because it involves dismantling of privilege. It’s about those used to getting their way to be willing to stand aside for someone more deserving, though less powerful. It could mean the old and infirm giving up an ICU bed for the young. That’s a tremendous leap of solidarity. Even Covid will find it difficult to cut through this.

As they say the winner takes it all. They always have. Except that in disease, today’s winners could be another day’s losers.

The writer is a surgeon who, when not wielding a scalpel, wields a pen