NEW DELHI -- Everything about 33-year-old Vishal Chand pointed to a myocardial infarction when he presented to Tata Main Hospital in Jamshedpur, India, with chest pain.
His heart activity was so erratic that his ECG 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 are 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% chance of getting stuff you don't need," estimates Jishnu Das, PhD, a lead economist at the World Bank in Washington, D.C., who has been studying India's healthcare sector for years.
'Qualified Quacks'
Consider heart attack, 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% of the time, when they made one at all, and prescribed helpful drugs to just 3% 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, with India's highest infant mortality. 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 Amit Sengupta, MBBS, a public health expert with People's Health Movement in Delhi.
Casual Doctors
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 4 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 2 minutes per patient. Many didn't check the temperature of patients who claimed to have a fever.
In one of Das' 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 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.
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, 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.
Take cough and cold medicines. According to a 2010 report in the journal Fundamental & Clinical Pharmacology, more than 1,300 such products were on sale in India in 2007. Nearly all were drug cocktails, with up to 21 active ingredients in a single product. Many included medicines with opposing effects, and 27 contained banned combinations.
Lack of oversight puts patients at risk. The FDA withdrew U.S. 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 carbinoxamine-containing products 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 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 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.