This story is part of a partnership between MedPage Today and VICE News.
Everything about 33-year-old Vishal Chand pointed to a heart attack when he presented to Tata Main Hospital in Jamshedpur, India, with chest pain.
His heart activity was so erratic that his electrocardiogram (EKG) would have looked "abnormal even to a layman," one doctor later testified. But instead of admitting Chand, the emergency physician at Tata Main sent him home with drugs for pain, heartburn, and anxiety. Chand died the next day.
Medical errors happen everywhere. But in the world's largest democracy, stories of doctors being drunk, using rusty instruments or bicycle pumps during surgery, or ordering unjustified procedures are increasingly common.
Now hard data is emerging that show how dismal medical care is for many in India, with providers routinely failing to diagnose common diseases and frequently prescribing useless and hazardous drugs.
In North India, for example, the chances of getting a helpful prescription at the doctor's office are no better than a coin toss, while "you have about an 80 percent chance of getting stuff you don't need," estimates Jishnu Das, PhD, a lead economist at the World Bank in Washington, DC, who has been studying India's healthcare sector for years.
Consider heart attacks — a major killer in India. Using actors trained to fake chest pain and other classic symptoms, Das and his colleagues found doctors at public health centers completed less than a fifth of essential questions and exams.
They got the diagnosis right only 8 percent of the time, when they made one at all, and prescribed helpful drugs to just 3 percent of patients. Meanwhile, more than two-thirds got unnecessary or harmful medicine, according to a report published in June by the World Bank.
The results come from a representative sample of 88 country doctors who ran private clinics in addition to their public posts in the state of Madhya Pradesh. They did better when seeing patients privately, but still prescribed appropriate treatment to fewer than a third.
In fact, Das and his colleagues found, physicians often performed no better than "quacks" without a medical degree, who are such a common source of healthcare in India that the Indian Medical Association has an anti-quackery unit.
While qualified doctors did prescribe more effective drugs on average, they also were quicker to administer unnecessary antibiotics that could have side effects and breed resistance.
The scenario is no better in nearby Bihar state, which has India's highest infant mortality rate. According to a report last April in JAMA Pediatrics, not one of 178 rural health providers offered correct therapy to a father pretending to seek treatment for a toddler with diarrhea.
In Delhi, the capital, Das's data suggest patients get only slightly better care than in the villages, despite the fact that more urban providers have medical degrees.
It's not clear if the findings apply to South India, or how they compare internationally. But they square with widely held perceptions in India. While the country has some excellent physicians, the incompetent ones are so common that they have earned their own moniker in the medical community: "qualified quacks."
Compared with an unqualified health provider, "a qualified quack actually has the ability to do more harm because he or she would tend to have a smattering of knowledge of a larger number" of drugs that they might prescribe, says Dr. Amit Sengupta, a public health expert with People's Health Movement in Delhi.
The human and economic toll of low-quality healthcare is hard to quantify but likely huge. Child deaths remain more common in India than in Bangladesh and Nepal, where the average income is lower.
Poor people may be hit harder because they are more likely to go to the free government clinics, where doctors use particularly little effort, according to Das and his colleagues.
In a 2008 report in the Journal of Economic Perspectives, they note that private doctors in Delhi, one of India's richest regions, were spending just under four minutes per patient — less than in a low-income country such as Tanzania.
At public clinics, which tend to be understaffed and underfunded, the situation was worse. Doctors asked one question on average — "What's wrong with you?" — and spent less than two minutes per patient. Many didn't check the temperature of patients who claimed to have a fever.
In one of Das's studies, a pretend patient at a public clinic found the doctor outside in his underwear, looking drunk. He told the patient, who was feigning a heart attack, to go away.
"That's what I mean by low effort," Das said.
Ashish Jha, MD, MPH, from the Harvard School of Public Health, who is helping to develop a quality agenda for Indian government hospitals, says the country's hundreds of millions of poor sometimes go hungry to afford medical care.
If that care is "really bad quality, there is an incredible disservice to that," Jha told MedPage Today/VICE News.
Yet the Indian Medical Association's honorary secretary general, Krishan Kumar Aggarwal, MD, doesn't think his profession is to blame.
"The clinical skills of doctors in India are the best in the world," he told MedPage Today/VICE News, adding that there may be quality problems "because of lack of infrastructure in rural areas."
Wild West for Drugs
Experts say India's drug market, estimated at more than $14 billion by research firm IMS Health, is full of untested and dangerous products. As recently as May, researchers reported in the journal PLOS Medicine that "large numbers of unapproved formulations are available" in India and "should be banned immediately."
Three years ago a Parliamentary probe accused the country's main drug regulator, the Central Drugs Standard Control Organization, of colluding with pharmaceutical companies and medical experts to approve medicines without adequate scientific scrutiny.
State authorities too have licensed myriad combinations of individually approved drugs without proof that the new products are safe and effective.
'Training the doctors on rationality is like trying to straighten the tail of a street dog'
Lack of oversight puts patients at risk. The FDA withdrew US approval for the cough syrup Clistin Expectorant in 1982 after determining the formulation was "not … a rational combination" and lacked proven effectiveness. Later, one of the product's key ingredients, carbinoxamine, was linked to 21 baby deaths, and the FDA pulled other products containing carbinoxamine from the market.
But Johnson & Johnson continues to sell Clistin Expectorant freely in India, where — like most medications — it is available without a prescription.
In response to questions about this product, Johnson & Johnson told MedPage Today/VICE News by email that patient safety and well-being are its "No. 1 priority." A spokesman said Clistin Expectorant was approved in India in 2008 and not recommended for children under 2 years, and that the issue of rationality is decided by each country's authorities.
In 2011, an Indian government expert panel summed up the situation this way: "The market is flooded by irrational, nonessential, and even hazardous drugs that waste resources and compromise health."
India recently promised to beef up its regulatory efforts and has taken steps toward weeding out unproven drug combinations. But it's a tall order, because no one has an inventory of all the products being sold, according to Urmila Thatte, MD, PhD, of Seth GS Medical College in Mumbai, who has worked with the government on the issue.
Adding to the confusion, a single medication may be sold under hundreds of brand names, or different medications may carry the same name.
Physicians often don't know the active ingredients in the products they administer, experts say. One prescription reviewed by MedPage Today/VICE News contained two different brands of nimesulide, a controversial pain drug linked to severe liver damage. In this case, a pharmacist caught the error before the patient began double-dosing.
Gifts and other incentives from drug reps may increase the temptation to prescribe unwarranted treatment, says Pijus Sarkar, MD, PhD, a former drug regulator of the state of West Bengal and editor of an independent bulletin on rational medicine.
In Sarkar's view, cleaning up the drug market is a safer bet than changing the behavior of India's nearly one million medics. "Training the doctors on rationality is like trying to straighten the tail of a street dog," he says.
It had been half a year since Shishir Chand spread the ashes of his younger brother Vishal in the Ganges, India's holiest river. As his grief grew less intense, a lingering doubt came into focus.
Vishal had gone to the emergency room just 13 hours before he died from a heart attack, at age 33, and the doctor had sent him home with pills for heartburn and anxiety. It had never seemed quite right to Shishir. When he read a magazine article about medical negligence, in November 2011, it all came together in his mind.
He called Kunal Saha, MD, PhD, a U.S.-based physician whose wife had died on a vacation to India after doctors gave her an overdose of steroids. Saha's organization, People for Better Treatment India, had been helping victims of medical negligence since 2001.
The odds weren't great. It had taken Saha $2 million and a decade of legal wrangling to reach a guilty verdict, and he was a doctor himself, connected to international experts.
"It is almost impossible for an ordinary Indian citizen to win a case of medical negligence today," Saha says. "The doctors have virtually no accountability."
Under the best of circumstances, Saha told MedPage Today/VICE News, "there may be medical errors, errors in judgments, and a lot of medicine is in the gray area, so you can't blame the doctor." But, he added, "what is happening in India is not that. So many lives are being lost absolutely needlessly."
Research shows many doctors spend almost no time examining their patients, commonly miss diagnoses, and often prescribe useless or harmful medicines.
Missing the warning signs
It's not clear how thoroughly Vishal's physician, Dr. Atul Chhabra, probed his symptoms and background. Had he asked about family history — it figures nowhere in the medical records — he would have learned that Vishal's father suffered a fatal heart attack at 44.
Both Chhabra and his employer, Tata Main Hospital, as well as the latter's corporate parent, declined to comment on the case. But Vishal's experience may not be unusual. In a recent study by World Bank researchers, not one doctor asked about family history when actors posing as patients at public health centers in Madhya Pradesh complained of heart attack symptoms.
Vishal's doctor probably suspected acid reflux. Meanwhile, he ignored Vishal's risk factors for heart disease; he didn't follow standard protocol, which includes keeping patients under observation and doing a series of EKGs, or electrocardiograms, for suspected heart attack; and he misread the one EKG he did order.
At some medical schools in India, students can graduate without learning to decipher the electric signature of a brewing heart attack. Dr. Gairik Ghosh, a 40-year-old orthopedic surgeon who received his degree from a prestigious medical school in Kolkata, had to teach himself to read electrocardiograms during a fellowship in the U.K.
"What we practiced and what we learned was pretty primitive," Ghosh recalls of his student days in Kolkata. "And I wouldn't just blame the teachers, because they were also taught in the same environment."
Corruption from top to bottom
Many experts worry the situation will only get worse, in part because medical education is under constant pressure from corruption.
Over the past two decades the number of private medical schools in India has soared. Along with tuition, many charge illegal admission fees that run as high as $150,000, a crippling expense that students must recoup from patients after they graduate.
Sting operations show some schools hire fake faculty and fake patients to pass inspections. In a recent case reported in the Times of India, "ghost" faculty were running private beauty salons and hair transplant clinics instead of teaching medicine.
Indeed, the government body tasked with regulating medical education, the Medical Council of India (MCI), was dissolved in 2010 following charges that its president accepted bribes for certifying a medical school that did not meet basic standards.
The council has been reconstituted, but the criticism persists. During his half-year stint as health minister last year, Harsh Vardhan, now minister of science and technology, called the MCI a "big source of corruption" and the country's drug regulator a "snake pit of vested interests."
The Internet forum Quality of Medical Education, which includes about 10,000 health professionals from across the country, frequently echoes this sentiment.
"Corruption is engulfing everything," Mukesh Yadav, MD, MBA, LLB, who founded the forum, told MedPage Today/VICE News last year. "Obviously this is dangerous for patients."
A few months after the interview, Yadav was sacked from his post as professor and head of the department of forensic medicine and toxicology at Sharda University's School of Medical Sciences & Research, in Delhi, in what he sees as punishment for his outspokenness against corruption.
Others worry less about medical schools and more about what happens later. While doctors are supposed to keep current through continuing medical education, most don't bother as nobody is keeping score, experts say.
Instead, many get medical updates only from pharmaceutical salespeople who offer gifts in exchange for prescriptions, as shown by a 2012 Reuters investigation.
Unnecessary tests and treatments also arise as a result of kickbacks for referrals, says David Berger, an Australia-based physician who volunteered recently at a small hospital in the Himalayas.
While healthcare fraud is a global problem, in India "you have basically institutionalized corruption," he told MedPage Today/VICE News. "And to me that's the difference between India and the Western countries, where you can be corrupt, but it's your own choice."
More awareness, but no data
The general public may be waking up to the problems.
Local newspapers have been reporting on medical scandals — from poor women having their uteruses wrongfully removed in a scam to bilk insurance programs, to a pediatric hospital where more than 3,800 infants died over four years, to a sterilization clinic using bicycle pumps to inflate women's abdomens prior to surgery.
And Saha's case has made headlines for years. In October 2013, it was featured in the New York Times after India's Supreme Court awarded Saha an unprecedented compensation of 60 million rupees, or nearly $1 million.
Some Indians fear seeing a doctor when they get sick. "I have relatives who never go to the doctor," says Aditya Jayanthi, 24, from Rajahmundry in Andhra Pradesh. "People are losing their faith in medical science because of the doctors' negligence."
Yet systematic data on medical errors and malpractice are lacking, because nobody tracks the problem, the Times of India noted in a 2013 report entitled "Clean Slate for Doctors on Medical Negligence?"
'A full-time job'
Few patients have the resources to hold doctors accountable. Many wait years to hear back from medical boards, which in the end nearly always side with the doctor.
Because the Chands are relatively well off, Shishir could afford to leave his job at British Airways to prepare his brother's case.
"Getting a medical opinion, hiring a lawyer and then drafting a petition, it's a full-time job," he told MedPage Today/VICE News. "It's very difficult."
People for Better Treatment helped, in part by connecting Shishir with two of the expert witnesses who testified on the family's behalf. Today the organization has offices in several Indian cities, staffed by volunteers who themselves have experience with malpractice.
A year and a half ago, Shishir became the group's Delhi coordinator. His complaint about Vishal's doctor was dismissed by the state medical board, which cited, among other things, lack of a hospital discharge ticket. After an appeal, the MCI issued a warning to Chhabra "to be more careful" in the future.
Meanwhile the court case continues. Shishir has also filed criminal charges against Tata Main and says there may be more coming. He has a list of five other patients who died there recently due to alleged negligence; in three cases, angry mobs stormed the premises.
To Ghosh, the surgeon who had to teach himself to read EKGs, the take-home message is clear.
"You don't have to be a super doctor, you have to be a safe doctor," he says. "A safe doctor follows certain protocols, so that you don't miss things."