The Myth of the Meritorious Doctor

Caste privilege in the medical profession
Kiran Kumbhar
Issue: December 3, 2021

Kiran Kumbhar, a physician and health policy graduate, researches the history of medicine and Indian history at Harvard University.

Protests in Mumbai, over the death by suicide of Payal Tadvi, an Adivasi medical student, in 2019 (October 13, 2020) | Twitter (DYFI-CEC)

Reservations are — wrongly — blamed for encouraging mediocrity in the medical profession. The historical record shows that the floundering foundations of the profession were laid by doctors who came 'purely through merit'.

The current chaos regarding admissions in postgraduate medical courses through NEET, although primarily a result of the incompetent and authoritarian working style of the union government, has nevertheless given rise to vicious commentaries against caste-based reservations. A particularly atrocious aspect of these commentaries, most recently heard in a monologue by a TV presenter, Palki Sharma, is the claim that reservations have “encouraged mediocrity” in our country.

This is a claim frequently made by persons and groups opposing caste-based reservations, and implicitly suggests that the presence of candidates from underprivileged caste communities in the medical profession, the engineering profession, and elite educational campuses has led to a reduction in the 'quality' of graduates and professionals in India. This is because, according to them, reservations mean that most of those persons are able to enter these spaces despite insufficient 'merit'.

Such claims are as old as the policy of reservations itself. Many of the underlying assumptions are as old as the caste system itself, through which, around the turn of the first millennium, an artificial hierarchy in the worth of human beings was reified by those who put themselves in the 'higher' varnas.

Strands of opinion converge in the assertion that in the absence of reservations, only the 'best' candidates, with the most 'merit', irrespective of their caste and other backgrounds, would become doctors.

There is also a smaller proportion of privileged-caste people who do not subscribe to the hierarchical ideas of the caste system, but argue that due to reservations, persons with inadequate 'merit' receive 'unfair' advantages at the expense of 'meritorious' individuals. Both these strands of opinion converge in the assertion that in the absence of reservations, only the 'best' candidates, with the most 'merit', irrespective of their caste and other backgrounds, would become doctors and engineers and administrators and scientists. If some of the more passionate anti-reservation claims are to be believed the country will 'prosper' again under this state of affairs.

There is no evidence, however, that in the absence of reservations, only (or even mostly) the best-suited and the most capable persons will enter campuses and professional spaces. The belief that once we dismantle reservations only the 'best' will advance, is based on a misplaced faith in the screening power of conventional examination and testing systems — for which the shorthand of 'merit' is used.

Those who vehemently argue that reservations have encouraged 'mediocrity' in the medical profession ignore the historical fact that mediocrity actually flourished and thrived in the profession when 'merit' was ruling the roost.

When 'merit' ruled

Some parts of this story are common knowledge. Training schools and colleges in modern medicine were established in British India beginning in the 1830s. Throughout the colonial period, the profession — like most other modern professions adopted by Indians — was composed almost exclusively of persons from privileged castes or other privileged backgrounds. In most parts of the Indian subcontinent, there were few to no reservation policies in existence, whether caste-based or otherwise. Often, active efforts were made by administrators to deny admissions and government jobs to candidates from underprivileged castes, as happened in the case of Padmanabhan Palpu, a doctor and social reformer in Travancore in the late 1800s.

Even after the adoption of the Constitution, the medical profession continued to be dominated by persons who entered it based on “merit”.

Even after Independence, although the Constitution mandated reservations for Dalits and Adivasis, privileged-caste groups successfully resisted their proper and complete implementation. These obstructionist attempts are best exemplified by the Champakam Dorairajan case. The verdict of this case offered dominant caste groups the privilege of claiming 'castelessness' (and later the apparently casteless 'General Category') ,even as they continued to enjoy the enormous privileges of their caste identities. In 1970, a report of the Parliament’s Committee on the Welfare of Scheduled Castes and Scheduled Tribes expressed displeasure with the unsatisfactory way medical colleges implemented reservations. Some had not yet introduced the quotas, some reserved a much lower percentage of seats than mandated, and most failed to fill the reserved seats with the appropriate number of Adivasi and Dalit students. This meant that even after the adoption of the Constitution, the medical profession continued to be dominated by persons who entered it based on 'merit'.

The dominance of 'merit' was all the more acute in leadership positions. A quick look at the list of the presidents of the Indian Medical Association, established in 1928, shows that almost everyone who helmed it (and indeed occupied other prominent positions) hailed from non-Adivasi and non-Dalit backgrounds. It was the same story with the organised associations for specialists, which began to come into being not long after the IMA was established, like the Association of Otolaryngologists of India and the Federation of Obstetric and Gynaecological Societies of India.

Then there were the various State Medical Councils, which theoretically worked to maintain discipline in the profession and punish erring doctors. Since their membership entailed the possession of substantial social and economic capital, it is highly unlikely that the few newly minted Adivasi and Dalit doctors would have been able to enter those spaces, which too thus continued to be dominated by privileged caste 'merit' doctors. Besides, the 1970s and 80s saw a proliferation of private medical colleges that rarely implemented any reservations policy, except what could be described as a nearly 100% quota for those who could pay enormous capitation fees or make ‘donations’.

In 1980, the report of the Mandal Commission confirmed the near-complete monopoly that continued to be held by privileged-caste groups in educational campuses, professions, and services, despite their total share of the population being less than a fifth. Reservations, thus, played a miniscule role in the overall composition of the medical profession (and possibly all other elite professions), at least until the implementation of the Mandal recommendations began in the 1990s.

A dark underside

What was the quality of this 'meritorious medical profession'?

In privileged circles, heart-warming stories from this period abound. For example, of kind family doctors who would visit the home whenever grandma had an illness or the little one ran high fever; or of the committed doctor and his 'lady doctor' wife who ran the neighbourhood nursing home where everyone went with their illnesses and where 'papa' was born, delivered by the doctor’s father decades ago; or of the doctor with a public image who often gave radio talks, or lectures on family planning, or arranged free medical check-up camps in nearby villages with the Rotary Club or the Lions Club. Apart from these local doctors there were also those who were showing their talents on national and global stages by performing complex procedures and doing important research, and those who were being actively courted by the US and the UK. Doctors in popular movies were also, almost always, kind, skilled, and venerable.

“What shall one say about the inhumanity of the doctor who being an educated man […] treated an ailing [Dalit] woman lying in for two days worse than a dog or a cat?”

These stories about the meritorious medical profession are indeed based on reality.

But when we scratch the surface of history, many unpleasant stories also tumble forth. A doctor in a Gujarat village in 1927 who, when asked by a Dalit man to come see his seriously ill wife, said “I will not come to the untouchables’ quarters. I will not examine her either.” When pressured by a local official, he only “examined” the woman from a distance, prompting the husband to eventually wonder, after her death: “What shall one say about the inhumanity of the doctor who being an educated man […] treated an ailing woman lying in for two days worse than a dog or a cat?” Or the story of the doctor in Patiala who “crudely” treated and “forcibly expelled” a Dalit woman from a public dispensary. From contemporary newspaper articles, government files, official reports, and legislative proceedings, we come to know of doctors in government hospitals who patients found to be “callous,” “careless,” “rude,” and “indifferent”, and those in private practice who were considered to be “impersonal,” “lacking the human touch,” “businesslike,” and “serving only the affluent society”.

Although popular Hindi-Urdu films produced in Bollywood seldom depicted such stories, there were exceptions. In the 1971 film Anand, one of the two featured doctors was a private practitioner who often prescribed unnecessary investigations and medicines (although he rationalised his malpractice by saying that he channelled his excess profits to the benefit of his low-income patients). Chetan Anand’s Tere Mere Sapne, from the same year, went far beyond Anand in portraying the state of day-to-day medical practice in India. It documented the prevalence of incompetence and negligence, and the presence of practices like cuts and commissions, and underhand agreements between doctors and pharma agents, a full four decades before the TV show Satyameva Jayate discussed them in 2012. A contemporary review in the Times of India was titled “‘Tere Mere Sapne’: Doctors in the Dock”. The movie seemed to suggest, the reviewer wrote, that “the incidence of the moral violation of the Hippocratic Oath is rising, lucrative prospects […] are bringing about increased disregard of medical ethics, and the medical profession, too, has been infected by the rat race.” A reviewer for the Illustrated Weekly of India wrote that the film succeeded in “drawing pointed attention to what ails the medical profession,” but nevertheless touched “no more than the fringe” of what was a “very live problem” of the day.

Awachat discussed how it was difficult for decent doctors to engage in “ethical” practice, and how the medical councils had done precious little to halt the spread of unethical practices.

While most leaders of the profession tended to brush away instances of malpractice, negligence, and corruption as the work of a “few black sheep,” it was widely known within medical circles that these were actually widespread. A 1975 article by physician Anil Awachat, also titled “Doctors in the Dock,” provided a discomforting glimpse into the world of contemporary medical practice. This article, in some ways, was the non-fiction counterpart of Tere Mere Sapne. Awachat discussed how it was difficult for decent doctors to engage in “ethical” practice, and how the medical councils had done precious little to halt the spread of unethical practices. Three years later another doctor, Arun Limaye, penned an eloquent Marathi memoir, Chloroform, in which he discussed (among other things) the banality of corruption, incompetence, and negligence in medical practice at that time. Displaying an honesty which is still rare in Indian medical writing, he candidly talked about the prevalence of both genuine medical errors and avoidable mistakes, providing several hair-raising examples from his experience.

[A leading doctor] supported sex-selective terminations of pregnancy and downplayed concerns over its potential adverse effects as “simply feminist propaganda.”

An important moral test for the profession came in the late 1970s when technological advances made it easy to identify the sex of a foetus and perform sex-selective abortions. By 1982, according to a report in the Guardian, “unscrupulous private practitioners [had] commercialized the test to make quick money by pandering to the popular prejudice against female offspring.” A doctor at AIIMS claimed to know “at least 50” doctors who were “doing brisk business” through such pregnancy terminations. Despite some media outrage over the role of doctors, the medical profession by and large did not seem too perturbed, and its leaders did not feel the need to take any proactive steps. The Times of India reported that D.N. Pai, a doctor famous for his sterilisation camps under the family planning programme, supported sex-selective terminations of pregnancy and downplayed concerns over its potential adverse effects as “simply feminist propaganda.”

A backlash

There were indeed doctors who were appalled at the overall state of affairs in the profession, as is evident from the writings of Awachat and Limaye. Some came together to form local activist and social work organisations. Others devoted themselves to research, advocacy, and health reform. Yet others, propelled by a strong commitment to social work and perhaps even the desire to keep their distance from the “rat race”, migrated to rural and tribal areas and established practice over there, often facing many social and economic challenges. And some established private practice in cities or worked in government hospitals, creating little, though often well-known, islands of ethical medical practice around them. But such doctors and doctors’ groups remained (and continue to remain) a minority in the larger medical profession.

“An enormous rise in the number of complaints against doctors went on to show the extent of latent public distrust in the “meritorious medical profession.”

The generally positive public image of doctors had undergone substantial emaciation by the 1980s. This was most apparent in the public response to the Consumer Protection Act. Soon after the Act was passed in 1986, many people, who had either lost a family member or suffered serious injury due to what they believed to be negligence and avoidable mistakes by doctors, began to take them to the Consumer Courts. An enormous rise in the number of complaints against doctors went on to show the extent of latent public distrust in the 'meritorious medical profession'. Years later, a functionary with the advocacy group Medico Friend Circle recalled how “between 1988 and 1994, the Medico Friend Circle (Bombay Group) was literally flooded with cases of medical malpractice, as if there was an explosion of public anger against a system substantially alienated from people's needs, […] the growing arrogance of providers, and their refusal to be socially accountable and sensitive.”

A dangerous myth

This forgotten history of the work and legacy of the “meritorious medical profession” helps us inspect the claims around reservations and merit in new, better light. The above survey makes it clear that claims purporting a direct relationship between reservations and “mediocrity”, and an inverse relationship between “merit” and “mediocrity”, are simply myths.

The absurdity of the claim that scores in exams and interviews are sufficient to help us identify the “best” doctors, scientists, or bureaucrats has often been called out in the past.

It is not reservations which bring mediocrity into a campus or a profession, but a host of other factors: for example, individual traits and socialisation processes which normalise abusive behaviour towards patients or religious hatred in health facilities, and systemic issues like the profit motive in private hospitals which pushes doctors to incorrect and unnecessary diagnoses and treatments. Such factors are unrelated to one’s station in the conventional meritocracy or in the caste hierarchy—except when a supposedly “higher” station socially sanctions one to engage in discrimination, harassment, and unprofessional behaviour.

Philosophically, this is not a spectacular revelation. The absurdity of the claim that scores in exams and interviews are sufficient to help us identify the “best” doctors, scientists, or bureaucrats has often been called out in the past. The Mandal Commission report, for example, said that “what we call merit in an elitist society is an amalgam of native endowments and environmental privileges.” The political theorist Kancha Ilaiah Shepherd dubbed conventional merit as a brahminical version of merit, “based upon imported textbooks and mugged up reproduction [and] recitation, as a Hindu priest does in a temple.”

Myths around reservations and “merit” have caused the institutional murders of many of India’s young, including medical students and resident doctors.

But myths are frequently more powerful than facts; so powerful they even kill people. Myths around reservations and 'merit' have caused the institutional murders of many of India’s young, including medical students and resident doctors who were stigmatised, taunted, and harassed by seniors and professors. Despite plenty of real-world evidence to the contrary, many influential persons from privileged-caste groups continue to exclusively equate Dalits, Adivasis, and Shudras (the 'reserved category') with ineptitude and incompetence. Among the many insults which the colleagues of Payal Tadvi — a resident doctor from an Adivasi background who died by suicide in 2019 — subjected her to was the barb: “People like you are only worthy of being clerks” (my translation). What is most worrying is that many privileged-caste adults socialise kids and teenagers into assuming this false equation as the “natural” order of things. Such deplorable socialisation was evident last year when a privileged caste college student felt they were doing the right thing in ranting against an Adivasi professor and saying that people like her were 'meritless idiots'.

Considering the persistence and power of these myths, and the influence and power of those who believe in them, it is unlikely that the demeaning and entirely false claim about reservations 'encouraging mediocrity' is going to go away any time soon. However, one hopes that at least now people will stop using that common anti-reservation gibe: “Would you trust a doctor who has come through reservation?” One also hopes that now when someone curses the medical care system in India, they would at least be aware that its floundering foundations were laid by professionals who came 'purely through merit'.

 

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