of the doctors and other health staff, while they found the use of the govefnment hospitals helplessly

unavoidable for the sarne reason mentioned in the case of Birbhum, i.e. public hospitals are comparatively less expensive than private ones. As the maioity of our respondents were poor villagers, in most casesthey found themselves unable to afford the high cost irrvolved in hospitalisation (and also, in some cases,felt helpless because of the long distance to the nearest hospital), despite having the urgent need to admit a patient to hospital. Also in some cases,as fespondents in both the districts reported, authorities of the public hospitals refused to admit the suffering patients with the excuse of non-availability of beds (or space in the public hospitals anyone can see patients lying on the floor). A patient ftom a village in Dumka district was taken to the Sadar Hospital with a lot of difficulty. The patient was suffering from cerebral malaia and he had to be carried on a duli (a cot) to the bus stand, seven kilometres from the village. The hospital authoriry refused admission. What the patient received as "c fe" was a prescription for medicines to be bought from the market. His relatives brought him back with two days' medicines, as they did not have any money to get him admitted to a private nursing home. The patient died within a day. D MrnrcRt- ABUSFSFATAL tSoRDERS : If the non-availability of medical treatment from the public health delivery system imposes aheavy economic burden on the suffering people and their families (as they have to depend upon the market to buy medical assistance),unethical and corrupt medical practices by different medical practitioners make things worse, As we have seen eadier in this section, the unqualified medical practitioners (quacks) who form the backbone of the health services, particulady in Dumka, operate without sufficient medical education. In almost all the study villages (and also in some other villages) the quacks were seen to c rry saline water botdes with them, which are used as the most common medicine for any sort of disease.The first thing they were seen to do was to administer saline water evefl before doing a physical check-up, let alone trying other modes of treatment. According to a Block PHC incharge in Dumka, "These illiterates without knowing the consequences of administering saline kill many patients. There is very litde scope for using saline water in casesof malana; rather, it generally proves counterproductive if administered during fever. The only motive behind such ill-ptactices is to squeeze as much money as possible from the poor ignorant patients." In fact, one of our research team members witnessed a malaia patient dying in such a condition. His field note reads: I)una Soren. Caught a fer.'er 3 da,vsback. First he did not take it seriouslv - he a thought it r.r.as colrilnon fever and u'ill come dorvn shi:rd1i That rvas not t{} he. His n-rother put e lot of r;rgs On the second night he srarted shir.ering hear.il-i'. and clothes on him. Yet the sirivering colltinued. In thc morning his m<tther had ro call "X" ilfnnda| a quack living in a nearb,rtvillage. {It utas a rovo*rnemi:er

househ<ild. F{is father died of TB tt'o ycars back. llis sistet clieci of cliardroea last vear). i\'londal uras remarkably clruck to come. As a raere coincidence, w-e encounteted A{onclal ncat Duna's hosse, Sorae other per.rplev,ere alsc:there anri we lvent to his house. He r.vasstili sldverinq. L{onclai quickly took out a bot{e of saline rorzter'and auangetl to ac{minister it. He ciid not note the temperature. Nor ciicl he rl:, anY check up. Shii'ering gleui ancl the bov fi'equentlv sprang up ancl rlorvn. \{iithin haif an hour he rlietl. "Bhaga,an baja lfua . Asdni k;Ta ne kar .rakta hai? {{}od has summo,neclhim, s,ha1 can u,e mortds do?)" ,fondal saiciphilosaf:hicallri lVhen asked about the reason firr not grving anv n-redicinero lourer the temlleratr:re ijrst he rengrily said,,,Aap da/<"tor bajn ki huyr haiti fWho is the d<lc1'or* vou or rnei)" IIe also said that at this stage <lnlrrsaline could sal'e life. "Saline"" he emphasised, "is dre most irnportant 'meilicine' frrr treatin{ all kilds of ailmenrs!" What can be more pathetic than the fact that the most unscientific mode of medical treatrnent still exists in a country rrhere medical scientists in 6th century B.C stood "in defence of the- intrinsic efficacy of medical science" and courageously ignored adrsta and karma?9 $7e came across some quacks who cannot even read the names of medicines on the foils. one was seen to have bought medicines from a pharmacist,s shop at Dumka where the shopkeeper matked the bunch of foils or bottles of liquid medicine by labelling them w"ith their particular usage, viz. ,for diarrhoea,, ,for mala1;1a,, 'for fever'and so on. we saw a quack in Birbhum use a single syringe for administering injections to many patients vrithout stedlising it. Some of the quacks were also reported to have sexually abused female patients. In a Dumka village we were told: "\with one unmarried woman, the quack said he had fotgotten to bring his stethoscope and fondled the breasts of the patient pretending to do a check-up. Flowever, not all villagers \il/ereas ignorant as this paticu_ 'tlhterate lar patient and some of the young men of the village beat him black and blue as punishment..." Not only the quacks, there is evidence of severe medical abuse even by qualified private practitioners. Suna Hembram was suffering from general weakness. He visited a highiy qualified medical practitioner at Dumka town who aside from government service and private medical practice owns a medicine shop, a pathological labotatory and a nursing home. After checking up the patient he prescribed three med_ icines (all in tablet and capsule form) and advised aMalarira Parasite test. Flis assistant (called a compounder) took him to the nursing home, administered a saline and then took him to the laboratory for aMaialira Parasite test and also for an X-ray! No paper or bill or receipt was given. when Hembram asked for the accounts, he was given a piece of scrap packaging paper ftom a medicine bottle charging Rs 900. Hembram had only Rs 500 with him. His wife borrowed the rest from arelative living at Karharbil on the outskirts of Dumka town and got her husband released. Hembram, however, did not come round. After 15 days he saw a physician at Deoghar, who is known to be sympathetic towards poor patients, who diagnosed

that Hembram had low blood pressure! This time he had to spend only Rs 75, which included his bus fare. Nflhile private practitioners are accused of medical abuse which they indulge in only to eafn money, in the most unethical ways, government doctofs wefe also frequently held responsible for negligence in treatrnent. A patient with a ftactured leg was treated at the Dumka Sadar Hospital. He had to spend Rs. 800 for the treatment. But after the plaster was removed, his leg was found to have become deformed. The fractured bone had not joined propedy. The government doctof told him that it was irreparable. Later, the patient visited ^ prirvatedoctor in Patna. He had to go through a surgrcal operation to repair the damaged leg, which claimed a sum of Rs. 15,000. Casesof medical abuse in Birbhum too ranged from quacks to qualified medical practitioners, though to a lesser extent compared to Dumka' Many of the quacks of Birbhum were seen to remove the foils of the medicines before gt ri"g them to the patients. Some people in the study area and some qualified doctors maintained th'at such practices Oy th. quacks) was to safeguard themselves from future legal complications (death caused by wrong medicarion etc.). Some of the quacks wete also reported to have been using "magic tfeatment" or religious rituals (puja,manot, etc). One such quack told us that no foreign practices could be successful in India unless it was backed by Indian religious futh. "Viswase rnila1 uasta' tarke bahudar- it is faith that yields fruit, not reasoning". One quack started his allopathic practice when he was only a student of Class 8. He has a reported atea of 1012 villages where he travels regulady. According to him his popularity had increased because of the "unique" practice of mixing allopathic medicine with religious rituals. Another quack said that he uses a long range of antibiotics,"konl ekta to lagbei! (One of these will surely work!)" This he did, as he had to save the patient's life. Many of the people who seek services from the public or private qualified practitioners also reportedly fall prey to medical abuses.After consulting with a goverffnent doctor in his private chamber a pregnant woman was admitted to a sub-divisional hospital of Birbhum for chjldbirth. At the time of delivery neither a doctor nor a nurse assistedher. She was released after three days (and during her stay in the hospital she remained almost unattended). In the evening of the day of release from the hospital she started shivering and was taken back to the private clinic of the said doctor, where she was told that there were traces of placenta in the uterus. She was prescribed medicines.worth Rs. 800. \X4eenthe problem persisted, despite taking the prescribed medicines (that her husband had to ^rrange for by borrowing money), she visited the docbut there was no positive result. Only the list of medicines was tor again and agasn, made longer and consequently the burden of loan. Finally, when she was advised by the doctor to get admitted to a nursing home, her frustrated husband took her to another doctor who, thankfirlly, could cwe her at a compamtively cheapet cost. Collection of prescriptions (in most caseswritten on plain of scfap paper), medicine packages and diagnostic reports by the research team and subsequent examination by some expert doctors indicate several casesof medical abuse by the public and private qualified doctors. They include use of wrong and excessive medicines (a

rtient suffering from simple cough was given medicines for TB), lack of care in agnosing the diseases coffectly and prescribing blindly (advising multiple antibiics for the same illness, use of banned combinafion of multiple drugs, e.g. cough rup, non-enteric-coated digestive errzymepreparations), doing surgical operations relessly, arid so on and so forth. Refetence to a Particular diagnostic laboratory or edicine shop or doctorwas also found in many cases' As we were told by some doctofs, believed to be very ethical in their practices, any of the doctors prescribe ^ raflge of unnecessary medicines simply to eafn tmrnission from medicine comparries. One of the doctors in Jharkhand was seen I prescribe one particulat tonic in every prescription. The medical fepfesentative of rat particulaf company told one of the tesearchers that the doctor was paid a cer-in percentage as commission on the wholesale price of the medicinel One of the octofs was evell seen to pfesefve the prescriptions in duplicate as a fecofd' since he ould get his share from a particular pharmaceutical company! Medical abuse through excessive and unnecessary prescribing of medicines is ot new in our country. The Hathi Committee (1975) found that thousands of difrrent brands of different combinations of medicines vrere available in the Indian rarket. which wefe not necessafv.Instead of such a long list of medicines, the comrittee suggested that the production of medicines be limited to 1'17 generic prodcts, which were sufficient to tfeat every kind of diseasein the countrylo. The'Vfodd {ealth Organisation recommended 258 drugs, while the pharmaceutical industry in ndia (largely contfolled by the multinational companies) is permitted to ptoduce and tafket mofe than 60,000 drugs and formulations. There are about 50,000 brand ,roducts of irtational combinations and yet the standard textbooks recommend only 1 ,r--) fixed-dose dtug combinations.l The drug production in the country was wotth Rs.10 crotes n 1'948;in 1'999tt ;as wofth Rs 29,000 cfofes.12When the PHCs and other public health sefvice units :ffer from acute shottages of drugs this gigantic pfivate drug market often using rd promoting unethical practices by doctors siphons out this amount from the :/)rnmon people mainly because of the absence of a regulatory mechanism' Lack of effective regulatory and controlling measufes for drug use (and abuse) :rn be seen clearjryin the rural areas. Buying medicines ovef the coufrtef without precriprion is a general practice in India. S7e have observed medical abuses of more ,.rious nature. In both the study districts we were told by some respofldents that - generally :ev had bought medicines from grocers in the local baals (periodic . eekly - markets). \7e have seeo a quack selling expired medicines labelled "physi::rn's sample". The list of such practices can go on endlessly'
.,iAL I4 i M ? L I T A T I C N SO I H I A L T I I A i L : { " I ' J T 5

The presence of various ailments in peoples'lives has some obvious implica: ,ns that create direct negative effects in their social and economic life" W'e have ' and diverse problems arising from the health ailments of the fespondents which