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of the doctors and other health staff, while they found the use of the govefnmenthospitals helplessly unavoidable for the sarne reason mentioned in the case ofBirbhum, i.e. public hospitals are comparatively less expensive than private ones.

As the maioity of our respondents were poor villagers, in most cases hey foundthemselves unable to afford the high cost irrvolved in hospitalisation (and also, insome cases, elt helpless becauseof the long distance to the nearest hospital), despitehaving the urgent need to admit a patient to hospital. Also in some cases,as fespon-dents in both the districts reported, authorities of the public hospitals refused toadmit 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 avillage in Dumka district was taken to the SadarHospital with a lot of difficulty. Thepatient 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 refusedadmission. What the patient received as "c fe" was a prescription for medicines tobe 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. Thepatient died within a day.M r n r c R t - A B U S F S : A T A L t S o R D E R S

If the non-availability of medical treatment from the public health delivery sys-tem imposes aheavy economic burden on the suffering people and their families (asthey have to depend upon the market to buy medical assistance),unethical and cor-rupt 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, oper-ate without sufficient medical education. In almost all the study villages (and also insome 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 thingthey were seen to do was to administer saline water evefl before doing a physicalcheck-up, let alone trying other modes of treatment. According to a Block PHC in-charge in Dumka, "These illiterates without knowing the consequencesof adminis-tering saline kill many patients. There is very litde scope for using saline water incasesof malana;rather, it generally proves counterproductive if administered duringfever. The only motive behind such ill-ptactices is to squeezeas much money as pos-sible from the poor ignorant patients."

In fact, one of our research team members witnessed a malaia patient dying insuch a condition. His field note reads:

I)una Soren. Caught a fer.'er3 da,vsback. First he did not take it seriouslv - hethought it r.r.as colrilnon fever and u'ill come dorvn shi:rd1i That rvas not t{} he.On the second night he srarted shir.ering hear.il-i'.His n-rother put e lot of r;rgsand clothes on him. Yet the sirivering colltinued. In thc morning his m

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househ

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that Hembram had low blood pressure!This time he had to spend only Rs 75, whichincluded his bus fare.

Nflhile private practitioners are accused of medical abuse which they indulge inonly to eafn money, in the most unethical ways, government doctofs wefe also fre-quently held responsible for negligence in treatrnent. A patient with a ftactured leg wastreated at the Dumka Sadar Hospital. He had to spend Rs. 800 for the treatment. Butafter the plaster was removed, his leg was found to have become deformed. The frac-tured bone had not joined propedy. The government doctof told him that it wasirreparable. Later, the patient visited ^ prirvatedoctor in Patna. He had to go througha surgrcal operation to repair the damaged leg, which claimed a sum of Rs. 15,000.

Casesof medical abuse n Birbhum too ranged from quacks to qualified medicalpractitioners, though to a lesser extent compared to Dumka'

Many of the quacks of Birbhum were seento remove the foils of the medicinesbefore gt ri"g them to the patients. Some people in the study area and some qualifieddoctors maintained th'at such practices Oy th. quacks) was to safeguard themselvesfrom future legal complications (death caused by wrong medicarion etc.). Some ofthe quacks wete also reported to have been using "magic tfeatment" or religious rit-uals (puja,manot,etc). One such quack told us that no foreign practices could be suc-cessful in India unless it was backed by Indian religious futh. "Viswase rnila1uasta'tarke bahudar- it is faith that yields fruit, not reasoning". One quack started his allo-pathic practice when he was only a student of Class 8. He has a reported atea of 10-12 villages where he travels regulady. According to him his popularity had increasedbecause of the "unique" practice of mixing allopathic medicine with religious ritu-als. 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 seekservices from the public or private qualified practi-tioners also reportedly fall prey to medical abuses.After consulting with a goverffnentdoctor in his private chamber a pregnant woman was admitted to a sub-divisional hos-pital of Birbhum for chjldbirth. At the time of delivery neither a doctor nor a nurseassistedher. She was releasedafter three days (and during her stay in the hospital sheremained almost unattended). In the evening of the day of release rom the hospitalshe started shivering and was taken back to the private clinic of the said doctor, whereshe was told that there were traces of placenta in the uterus. She was prescribed med-icines.worth Rs. 800. \X4eenthe problem persisted, despite taking the prescribed med-icines (that her husband had to ^rrange for by borrowing money), she visited the doc-tor again and agasn, ut there was no positive result. Only the list of medicines wasmade longer and consequently the burden of loan. Finally, when she was advised bythe doctor to get admitted to a nursing home, her frustrated husband took her toanother doctor who, thankfirlly, could cwe her at a compamtively cheapet cost.

Collection of prescriptions (in most caseswritten on plain of scfap paper), med-icine packagesand diagnostic reports by the research team and subsequent examina-tion by some expert doctors indicate severalcasesof medical abuse by the public andprivate qualified doctors. They include use of wrong and excessivemedicines (a

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rtient suffering from simple cough was given medicines for TB), lack of care inagnosing the diseases coffectly and prescribing blindly (advising multiple antibi-ics for the same illness, use of banned combinafion of multiple drugs, e.g.coughrup, non-enteric-coated digestive errzymepreparations), doing surgical operationsrelessly, arid so on and so forth. Refetence to a Particular diagnostic laboratory oredicine 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 eafntmrnission from medicine comparries. One of the doctors in Jharkhand was seenI prescribe one particulat tonic in every prescription. The medical fepfesentative ofrat particulaf company told one of the tesearchersthat the doctor was paid a cer--in percentage as commission on the wholesale price of the medicinel One of theoctofs was evell seen to pfesefve the prescriptions in duplicate as a fecofd' since heould get his share from a particular pharmaceutical company!

Medical abuse through excessiveand unnecessary prescribing of medicines isot new in our country. The Hathi Committee (1975) found that thousands of dif-rrent brands of different combinations of medicines vrere available n the Indianrarket. which wefe not necessafv. nstead of such a long list of medicines, the com-rittee suggestedthat the production of medicines be limited to 1'17 generic prod-cts, which were sufficient to tfeat every kind of disease n the countrylo. The'Vfodd{ealth Organisation recommended 258 drugs, while the pharmaceutical industry inndia (largely contfolled by the multinational companies) is permitted to ptoduce andtafket mofe than 60,000 drugs and formulations. There are about 50,000 brand,roducts of irtational combinations and yet the standard textbooks recommend only,r--)ixed-dose dtug combinations.l 1

The drug production in the country was wotth Rs.10 crotes n 1'948; n 1'999 t;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 usingrd promoting unethical practices by doctors - siphons out this amount from the:/)rnmon people mainly becauseof the absenceof a regulatory mechanism'

Lack of effective regulatory and controlling measufes for drug use (and abuse):rn be seen clearjryn the rural areas.Buying medicines ovef the coufrtef without pre-criprion is a general practice in India. S7ehave observed medical abuses of more,.rious nature. In both the study districts we were told by some respofldents that:ev had bought medicines from grocers in the local baals (periodic - generally. eekly - markets). \7e have seeo a quack selling expired medicines labelled "physi-::rn's sample". The list of such practices can go on endlessly'

. , i A L i M ? L I T A T I C N SO I H I A L T I I A i L : { " 4I ' 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