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Dr. Zahir’s dilemma: money and morals in India’s private medical networks

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Abstract

Public health experts often describe care in India’s private sector as ‘chaotic,’ ‘substandard,’ ‘profit-driven,’ and ‘arbitrary.’ Discourse tends to focus on the ‘predatory behavior' of doctors who demand consultation fees and kickbacks for everything from medicine, to laboratory tests, to specialist referrals, and even hospital stays. These practices are ethnographically observable. However, this discourse does not take into account the multiple uncertainties, ethical complexity, and personal relationships involved in providing care in exchange for money in a setting of scarce personal and public resources. Situated at the very end of a value chain designed to make money from health, or the lack thereof, private physicians find themselves embroiled in moral peril. In this article, I engage what it means to make a livelihood in a context such as this by considering the economic, moral, and epistemic practices that physicians and their patients use to create and evaluate the value of pharmaceuticals in Mumbai’s slums. Based on over a year of clinic ethnography and interviews with family physicians, specialists, pharmacists, and pharmaceutical wholesalers, I trace how physicians manage the effects of a pharmaceutical value chain that produces profit by fulfilling patient’s health needs and desires.

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Notes

  1. All names are pseudonyms. Forthwith, I use physicians’ first and last names on first mention. In subsequent mentions, I use either their first name or last name depending on the convention among their patients and themselves.

  2. Most Mumbai and Delhi-based general physicians provide pharmaceuticals to patients as part of their fees. The law prohibits the sale of medicines by anyone but licensed pharmacists, so Dr. Zahir describes these pharmaceuticals as “gifts.”

  3. Slum is a contested category in Mumbai. In general slum refers to an unplanned settlement but also expands to planned settlements characterized by a lack in services and disorganized settlement patterns, encroachments, and crowding (Bjorkman 2014).

  4. Public health scholars describe the private medical sector as an aggregation of those medical services not located in a center run by local, state, or central government. Though these physicians are often accused of asking patients who visit their public sector practices to attend their private clinic, I saw only one instance of this action. On the contrary I observed several instances of these physicians referring patients from their private clinics to their public sector practices.

  5. Bachelor of Ayurveda, Medicine and Surgery, Bachelor of Homeopathy, Medicine and Surgery, and Bachelor of Unani, Medicine and Surgery are all government recognized degrees in alternative medicine. Though trained in alternative systems these practitioners in Mumbai commonly practice a combination of alternative and biomedicine or biomedicine exclusively (McDowell and Pai 2016a, b). They make up the majority of physicians in the city’s 12 high burden wards.

  6. Jhola Chhap, Hindi for “satchel mark” doctors, are named after their once itinerant lifestyle and clinic-in-a bag treatment paradigm. This is a common Hindi moniker for those practicing as physicians without formalized training in any system. Pinto calls them “ersatz” (2004) while Das calls them Bengali doctors (2015). I have written of them elsewhere as Bengali doctors (McDowell 2017).

  7. India is a global leader of pharmaceutical production, and factories producing generic drugs are common in Western India, as well as Himanchal Pradesh. ‘Local quality’ drugs, which physicians buy in bulk, are often produced in the slums of Mumbai in cottage industries and sold in plastic bags. Ahmedabad and Surat are also hubs of production.

  8. I present all quotations in my own translation. Though I understand Marathi well and can speak it when necessary, I have asked native speakers to double check any translations from Marathi provided here.

  9. This makes the two slums nearly five times more densely populated than Manhattan and 16 times more densely populated than Paris.

  10. All person and place names have been changed. A diversity of names has been used to reflect the diversity of actors involved.

  11. Rantac is a trade name for ranitidine a drug used for heartburn and indigestion sold in the US as Zantac®.

  12. Marathi for “What’s the problem?” “Do you have fever?”.

  13. Dexamethasone is a commonly used steroid.

  14. Available on youtube: https://www.youtube.com/watch?v=1Lg0kUtS8ic.

  15. Physicians distributed 4–6 different drugs in small sachets during the first few visits. These often include a pain killer, an antihistamine, a steroid, and bronchodilators among other things (McDowell and Pai 2016a, b; McDowell 2017).

  16. Seeberg (2012), Brhlikova et al. (2011), and Das (2015) have convincingly shown that pharmaceutical sales representatives are an important source of biomedical knowledge for general practitioners and have an effect not just on what physicians prescribe but how they think about disease.

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Acknowledgements

I owe debts of gratitude to innumerable Mumbaikars who by sharing informal chats in waiting rooms, at bus stops, and across pharmacy counters helped me learn more about medicine. I am deeply indebted to Prashant Kumbhar and M. Afzal Sheikh for introductions to their neighborhoods and the great kindness shown to me by physicians, pharmacists and all other kinds of medical practitioners. Without their insights and engagement, the paper would not have been possible. I am also grateful for Shibhu Vijayan, Ravdeep Gandhi, Rishabh Chopra, Jalpa Thakkar, K. Praveen, Vaishnavi Jondhale, Nilesh Dhotre, Varsha Nagwekar, Vaibhav Saria, Nambi Konar, Eunice Lobo, and Vrushal Walkar’s shared fieldwork and friendship. Puneet Diwan, Daksha Shah, Arun Bamne, Nerges Mistry, Madhukar Pai, Ursula Rao, Maya Unnithan, Sarah Pinto, and Jean-Paul Gaudilliere asked challenging questions of earlier iterations of this work and certainly made it stronger. Veena Das shaped this project. Without her subtle tending, it may never have grown. Adeline Masquelier, Allison Truitt, and Tara Dankel provided crucial eleventh-hour insights that helped zero in on value. Finally, I am indebted to the Foundation for Medical Research, Mumbai and Nerges Mistry for innumerable forms of support in Mumbai. Shortcomings are mine alone.

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McDowell, A. Dr. Zahir’s dilemma: money and morals in India’s private medical networks. BioSocieties 16, 363–386 (2021). https://doi.org/10.1057/s41292-020-00216-2

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