ON 15 APRIL 2013, JS Verma, the former chief justice of India, won an “Indian of the Year” award from NDTV for his work heading a committee to reform the country’s rape laws. A day later, he fell distinctly unwell. On 17 April, he was admitted to the Fortis Escorts Hospital in Okhla, in south Delhi, where he was discovered to have severe gastro-intestinal bleeding. For over a decade, Verma had lived with coronary artery disease, in which the arteries feeding the heart progressively narrow, affecting blood flow to it. One of his daughters, a doctor, had helped diagnose the condition herself. But Verma had managed the problem well enough. Members of his family said that working eighteen to twenty hours a day on the rape law reform committee, through December 2012 and January 2013, had not strained him unbearably.
However, Verma also had significantly deranged liver function, which affected the organ’s ability to make proteins essential for clotting blood. Verma’s family alleges that his doctors at another hospital had identified this problem during a check-up months earlier, but outright ignored it. Instead, they had prescribed Verma new medication, including an additional blood-thinning pill, that was actively harmful under the circumstances.
On 19 April, Shubhra Verma, the justice’s eldest daughter, received a call from Naresh Trehan, India’s best-known cardiac surgeon and the founder of the Medanta Medicity hospital in Gurgaon. Trehan asked her to move her father to Medanta, assuring her of better care there. This was not a surprise; the doctors at Fortis Escorts, a cardiac-specialty hospital, had suggested the move themselves. “Trehan said, ‘Get your father here,’” Shubhra recalled. “‘He is precious to the country and to me. I have known him for fifteen years. We will take good care of him.’”
Then, on 22 April, Verma died at Medanta, under circumstances dissatisfying to his family. His condition had worsened, they claimed, because Medanta’s doctors ignored, or delayed by long hours, crucial treatment protocols. Even more seriously, they alleged that the time sheets detailing the medical attention the patient received were “tampered with” to indicate that doctors saw Verma in a timely fashion, even though none of his caregivers had seen a doctor attend to him at any of the recorded times.
The story hit the papers, pitting the Vermas against Medanta and Trehan. In October that year, in reaction to the Vermas making details of the case public, Trehan gave a television interview to CNN-IBN, in which he divulged details of Verma’s diagnoses, treatment, and previous medical history. Shubhra said that, in a conversation with her, Trehan threatened to reveal that the distinguished jurist had liver cirrhosis and hepatitis B. Both diseases carry a certain social stigma: cirrhosis is commonly attributed to excessive alcohol consumption, and hepatitis B can be acquired through unprotected sex. Trehan had been persuasive when asking Shubhra to place her father in his care; now, she was appalled by what she called the doctor’s “extreme insensitivity and aggression.”
Verma’s wife, Pushpa, demanded an inquiry into his case at the very highest levels of government. A letter to the prime minister’s office requesting an expedited procedure was signed by such eminent judges and lawyers as MN Venkatachaliah, Soli Sorabjee and Gopal Subramaniam. The Vermas brought cases of medical negligence against Medanta and Fortis Escorts, as well as against the hospital they said had ignored the incipient liver condition. Trehan himself was accused of “vengeance,” and a gross violation of the Medical Council of India’s ethical guidelines. The case was dismissed by a Delhi Medical Council disciplinary committee in June 2014, and is now being appealed at the MCI.
THE VERMA CASE HAD AN exceptionally public fallout, but the kinds of doubts it raised are by no means uncommon in Indian households. The country’s health sector is among its least transparent and worst regulated. The bare-bones public health system is plagued by institutional decay and an abiding distrust of its doctors and nurses. And over the years, the private sector has acquired an unsavoury reputation for greed and mismanagement, with experiences of rampant breaches of confidentiality, a lack of informed consent during treatment, and questionable decision-making by doctors common in hospitals throughout India.
In the last decade, the Indian government has increasingly relied on for-profit solutions to the country’s growing health challenges. This has dovetailed with the sidelining, and the undermining, of the country’s public health system. For its part, the private sector has grown aggressively over the last three decades, and currently accounts for the vast majority of India’s hospitals and medical services. It has glittering facilities and achievements to its credit, and there is now no doubt that it is capable of delivering exceptional care to those who can afford it.
Medanta Medicity, with a capacity of 1,500 beds, exemplifies this state of affairs. No stranger to high standards, or to high-profile patients, it is one of the largest multi-specialty hospitals in the country. It boasts state-of-the-art facilities such as a Hybrid Operating Room—a futuristic surgical theatre equipped with minimally invasive imaging devices. Treatment is expensive: a heart bypass at Medanta can cost between Rs 2 lakh and Rs 2.5 lakh, compared to under Rs 60,000 at the public AIIMS.
Medanta’s biggest asset, however, is Trehan, whose reputation precedes him. He had a flourishing surgical career in New York for over a decade, before he returned to India in the late 1980s and established himself as one of the country’s pre-eminent cardiac surgeons. He founded one of India’s top single-specialty hospitals—the Escorts Heart Institute, now Fortis Escorts Heart Institute. Trehan’s exit from that project was mired in controversy, but Medanta rose soon after. He continues to see between forty and fifty patients a day. His clients include India’s home minister, Rajnath Singh, and the finance minister, Arun Jaitley.
He is a familiar face in the media. In December 2012, when the victim of the gang rape in Delhi that kicked off nationwide protests—and triggered the formation of the Verma committee—died, Trehan became one of the de facto spokesmen on the matter in the newspapers, offering commentary on the intricacies of the case and its treatment. The victim was attended to by teams from the All-India Institute of Medical Sciences and Safdarjung Hospital; Trehan was the only doctor from a private hospital to be involved. In 2010, at the height of the anti-corruption protests led by the striking Anna Hazare, Trehan and a team from Medanta were often seen on television, monitoring Hazare through his four-day fast.
But Trehan’s influence also extends well beyond the limelight. A competitor of his pointed out to me that Trehan has only one hospital to his name—unlike Apollo or Fortis, Medanta is not a chain. Yet the power he wields in the private sector is disproportionate to the size of his business. In the three decades since the Indian government permitted the operation of bank-funded private hospitals in the country, there have been only two doctors who have seen such enormous success as entrepreneurs. Prathap Reddy, who convinced Indira Gandhi to allow banks to fund hospitals in the country, and founded the Apollo group of hospitals, was the first. After him comes Trehan, born and bred in Delhi, now ensconced among its political and social elite.
“Trehan is no doubt among the top influencers on health policy,” a senior official in the health ministry told me. “Doctors like Devi Shetty, Srinath Reddy, Prathap Reddy and Naresh Trehan leave a huge imprint on the country’s policy.” Shetty, a philanthropic cardiac surgeon, manages Bengaluru’s Narayana Hrudayalaya to provide affordable healthcare; Srinath Reddy heads the Public Health Foundation of India, a health ministry think tank. (Disclosure: I worked as a consultant with PHFI intermittently between November 2011 and August 2014.)
Cardiac surgeons and cardiologists have been disproportionately influential in health policy formation in India, thanks to the vast majority of Indian politicians belonging to an age group for which heart disease is a pressing concern. Cardiac care specialists have always had greater access to the corridors of power than other kinds of doctors. In a country where evidence-based policy-making is still an uncertain prospect, perhaps access to a vulnerable politician is the most efficient method of policy intervention.
“If you are writing about the health sector, why profile Trehan?” Shivinder Mohan Singh said to me. “In terms of sheer size, Fortis is the largest health-care provider in India.” Fortis Healthcare, of which Singh is managing director, comes under a vast umbrella of his family’s businesses, comprising the Fortis Group, Ranbaxy Laboratories, and the health-insurance company Religare. Nonetheless, he admitted, “Our influence is not proportionate to our scale of operation.”
Trehan is reportedly consulted on every major health-related decision taken by the union government, and heads several major initiatives that influence health policy at the highest levels. He has been the chairman—since 2000, and effectively in perpetuity, as a leading public health expert told me—of the health committee of the Confederation of Indian Industry, or CII, a powerful industry body that lobbies the government on behalf of private interests across various sectors. Over the last few years, through the tenure of successive administrations, Trehan has become a member of the health ministry’s Key Advisory Group; the vice chairman of the Services Export Promotion Council; and the chairman of the Healthcare Skill Sector Council, formed in 2012 by the UPA government—all posts he continues to hold.
As the Bharatiya Janata Party-led government seeks to make real headway in solving India’s health crises, it is confronted with two broad challenges. The first is to combat the health sector’s severe shortage of human resources. The second is to calibrate the role of insurance in public health care, which has grown in importance, and will play a vital role in shaping future health policy. In both cases, private interests stand to gain tremendously from business-friendly government decisions.
The rewards will be rich. On 1 January this year, the government released a draft national health policy, which remains in the public domain for suggestions and open consultations until the end of February. It projects that the private health-care industry, currently valued at $40 billion, will grow to be worth $280 billion by 2020. As a “perennially and most rapidly growing area of the economy,” its current growth rate, of 14 percent, is expected to leap to 21 percent over the next decade.
The industry’s dramatic growth, however, will struggle to keep pace with India’s looming health crises. Strategies employed to combat them will be decisive factors in the country’s development in the coming decades. For years, entrepreneurs have been lobbying the government to implement expensive solutions, by way of public-private partnerships, at both the state and central levels. These solutions include the state purchasing care from private hospitals; increasing cover on government insurance schemes; providing subsidies for infrastructure, including land, power and water; and offering tax rebates to entrepreneurs willing to set up hospitals in underserved areas.
Interviews with several medical entrepreneurs, officials in the health ministry and Trehan’s aides all confirmed the widely held view that Trehan is heavily invested in ensuring that private players have a central role in whatever reforms are planned for the health sector. Some of these people also pointed out that private interests would clash with the larger aim of the public good—and, indeed, may already be doing so. Many critics point out the government’s current penchant for pro-industry policy is proving ruinous to public health facilities, already long-neglected, and falling behind in the race to capture talent. Coupled with the high cost of private medical care, the overall situation is likely to prove detrimental to national health targets.
In the course of several conversations with Trehan over the last three months, it was clear that he saw the aligning of government and private interests as inevitable. “We have to pull up our boot straps,” he told me. The private sector has spare capacity to offer the government. But the government has to appreciate that the private player “has a cost of delivery, and a 10 to 15 percent margin,” he said. As long as that was understood, “I think we could make a big difference.”
A senior official in the health ministry, speaking on condition of anonymity, said that the speed of Trehan’s ascent set him apart. The official added, “We can keep arguing for better quality, affordable prices—and yes, private players are, indeed, profiting from poor patients—but we cannot argue that Trehan does not deliver.”
As an example of how he operated, the official pointed to the CII’s role in organising the agenda of the Healthcare Sector Skills Council, which was formed in early 2012 to lay down educational and clinical standards for health-care professionals, including lab technicians and compounders, who currently learn their skills on the job rather than through formal training. It was Trehan who took into account the demands of multiple groups, including the Planning Commission, the health ministry and various industry bodies, to manouevre the CII into control of the new agency.
“I am not close to any government,” Trehan said, when I asked him about this. “I am neutral and I am friendly with everybody.”
But, “do you see it?” the ministry official said. “Isn’t it shocking that an industry lobby is the secretariat for setting up curriculum and standard operating protocol for all health-care professionals? Have you heard of such a thing in any other sector?”
Still, Trehan’s drive and talent are undeniable, the official pointed out. “At least he has started something.” This was a common refrain. Over the course of reporting this story, I heard the word “wheeler-dealer,” too, applied repeatedly to Trehan. The surgeon Pervez Ali Ahmed, once Trehan’s best friend, who played a key role in his rise to prominence, told me, “Naresh is a phenomenal salesperson. You cannot fault a person for networking in addition to practicing medicine. Lots of doctors don’t do it. There are far better cardiac surgeons in the country, but not half as well known as Naresh. That’s their problem, because they didn’t work at selling themselves. Why should you take anything away from that?”
Ahmed’s was a backhanded compliment. But one of Trehan’s longest-serving colleagues, the cardiologist Ravi Kasliwal, said something similar. “He has connections, and he has the personality and oratorical skills. Yeh toh help karti hi hai na yaar”—Of course these things help. “You can call it networking, but you can’t fault someone for having a personality that can engage people. It all comes from his heart.”
SEVEN YEARS AGO, Naresh Trehan, then sixty-one years old, was the executive director of Fortis Escorts Heart Institute, the largest free-standing private cardiac-care facility in the country. On his way to work on a May morning in 2007, his car was stopped at the gate of the hospital. His business partner, Shivinder Mohan Singh, the young MD of Fortis Healthcare, had hired bouncers to ensure that Trehan did not enter the premises.
The evening before, Trehan and Singh had met in the rooftop chambers of Delhi’s Taj Mahal Hotel for a serious conversation about their future. Trehan had already invested in his next personal project, Medanta Medicity, and was working on getting it off the ground. Singh, eager to expand the reach of his group, wished to buy a stake in the project. Over months of discussion, Trehan had repeatedly rebuffed the idea. Now, at last, matters came to a head. The Taj Mahal meeting ended with Singh suggesting they part ways.
“Oh, are you leaving?” Trehan asked him.
“No,” Singh said he responded. “You are.”
In a press statement following the expulsion, the Fortis management said curtly that they had barred the gates in order to get Trehan to “relinquish the post of executive director and concentrate on his upcoming new Medicity business venture.” Trehan had led Fortis Escorts, and been a minority partner in the venture, for nearly twenty years.
Trehan moved quickly: he reached out to Prathap Reddy, the patriarch of the Apollo group and his direct competitor, to ask if he could see his patients at the Apollo Hospital in Sarita Vihar, in south Delhi, instead. Reddy said yes, and Trehan, along with fifty other Escorts doctors who tendered their resignations in his support, moved with him to Apollo. So did most of their patients. They used the Apollo premises as a stopgap until the inauguration of Medanta, in January 2010. Trehan eventually sold his stake in Escorts to the Fortis group for Rs 70 crore.
His parents had not been doctors of this kind. Trehan’s earliest memories are of living in a one-room apartment in Delhi with fourteen other family members, who had migrated to the city after Partition. His father was an ear, nose and throat specialist, and his mother a gynaecologist. Both had practiced in Lyallpur, now Faisalabad, before 1947.
When the family realised they would not be returning to Pakistan, they moved into a three-room flat in Connaught Place. They lived in one room, and Trehan’s father saw patients in another. His mother used the third to deliver babies.
“That is how modestly we started,” Trehan said when we met in October last year, in his plush office in a corner of the Medanta campus. It is a self-proclaimed “seven-star” facility, spread out over forty-three acres. The hospital has forty-five operating theatres, and the infrastructure to cater to over twenty different super-specialty departments.
Trehan’s desk was covered with the things all doctors’ desks hold—piles of paper, medical journals, stethoscopes, a small replica of the heart. It was the week after Diwali, and boxes of sweets and dry fruits lay heaped behind him, a thin film of dust already gathering on them. On the wall to his right was a running display of certificates and trophies. His Padma Bhushan, received in 2001, held pride of place. The only photograph in the room was of Frank Spencer, a legendary cardiothoracic surgeon at New York University, who taught Trehan his skill. Spencer had signed it: “To Naresh, with admiration and great expectation, May 1990.”
The desk faced two sofas, both full of patients. They came in one by one, to receive Trehan’s undivided attention for a few minutes each. This was the innermost of the three chambers in which patients waited to see him. Outside, there was a waiting room; beyond that, an outpatient department with rows of chairs, crowded like a railway station. Our conversation took place in between Trehan’s consultations. He recommended an angiography to a man with only thirty percent heart function, and joked reassuringly with an elderly woman whose blood pressure had gone off the charts. A third patient, at the end of her consultation, told him she was a nurse. “What are you doing working somewhere else?” he asked her. The tone was salt-of-the-earth; the doctor was a celebrity, but still a friend, rather than a deity, for a sight of whom queues of attendees waited outside his doors.
Back in his childhood, Trehan’s parents worked pro bono, largely for fellow immigrants in straitened circumstances. They put in twelve hours a day, Trehan remembered, and never got to spend much time with their children. They had not wanted Naresh to become a doctor.
Trehan went to the Modern School on Barakhamba Road, in central Delhi. He was never much of a bookworm, he admitted, and his friends were rich kids who didn’t need to study. “Dad used to say, ‘They’ll just inherit; you’ll have to work your butt off.’” The elder Trehan worried his son was far too easily distracted by sports and girls. Then, at age sixteen, Naresh met and fell in love with Madhu Purie, daughter of Vidya Vilas Purie, the wealthy film financier and owner of Thompson Press. Both sets of parents were displeased.
In 1963, Trehan got into King George’s Medical College in Lucknow, one of the best teaching institutions of the time. “My parents thought the distance would break our relationship,” Trehan said. “But it brought us closer. I would travel every other weekend to Delhi to meet Madhu. We were kids and in love.”
In college, he found himself “un-accepting,” he said, of the casual acceptance of patients dying of treatable conditions. “These patients could be saved abroad. Doctors were doing new procedures,” he recalled. “Who allows people to die when there is something to available to save their lives?” Trehan began to plan a move to the United States. He and Madhu married in September of 1969, and relocated the next month.
Trehan became a first-year resident at the Thomas Jefferson University Hospital in Philadelphia, and began to ask around for the best tutor for cardiac surgery. Everyone agreed on the same answer: Frank Spencer in New York. But the folklore surrounding Spencer was intimidating. Rumour had it that the waiting list of students for his classes ran five years long, and that he did not speak to foreigners. Trehan wrote him a letter explaining that he had come from India, where people were dying. He, Trehan, was eager to learn everything he could and go back to his country to save them. It was a tragedy, he added, that Spencer did not speak to foreigners. Spencer wrote back promptly to say this was not true, and asked Trehan to interview for the last remaining seat in his programme that year.
Trehan said there was a “line around the block” for the seat when he came down from Philadelphia to Spencer’s office in New York. “I believe it is not your brilliance, but a sequence of events and how you actually seize them that matters,” he told me. “On this day, the guy who was interviewing me asked me a question. That set in motion a series of events that helped my career immensely.” The question was about what Trehan found most interesting in surgery. Diverticulitis, Trehan responded—a common digestive disease. He had found a book on the subject, swallowed it whole, and “regurgitated the whole thing,” he said. “It is what helped me get ahead of those three hundred buggers standing outside, queuing around the block.”
The interviewer took him to meet Spencer immediately, and got him a spot at a lecture the doctor was delivering. Trehan was mesmerised, and realised that everything he had heard about the man was right. He called Spencer’s secretary every morning at 9 am to ask if he’d made it. The list of applicants was whittled down slowly, first to 150 candidates, then to seventy-five. At last, the secretary told Trehan that Spencer had signed his contract the night before. Afraid that it might get lost in the post, Trehan took the day off work, drove to New York to add his signature to the contract, and took Madhu to Mexico to celebrate.
For the next seven years, Trehan was on “Spencer service”—during which residents got to go off the clock only every other night. He reported to duty at six in the morning, left at eleven the next night, went home to sleep and came back again at six in the morning. I had said to Trehan, earlier in the conversation, that his critics considered him brilliant and arrogant in equal measure. “I have lived three lifetimes worth of work,” he said in response.
He had, he claimed, a curious advantage over others in the programme. He was born left-handed, which is traditionally considered unlucky in some Indian families. As a child, he had had his knuckles broken by his Hindi tutor, trying to get him to write with his right hand, he said. It made him ambidextrous. “I could finish my surgeries in half the time because I could suture with both hands.” This, he said, is something he can still do.
The Spencer programme took in thirty-two first-year residents. Half of these were eliminated every year. Only four became chief residents; of these, only two made it to Spencer’s cardiac surgery programme. Only one of these then made it to a faculty position. In seven years, Trehan made it to the top of the pyramid.
Perhaps he already knew, then, that he was a star. “Well, I am not arrogant,” he told me. “I was possessed. I am driven by my passion. It is my junoon.” His greatest regret was that he short-changed his family for time. His parents had been right about the consequences of becoming a doctor.
THE PRIVATE SECTOR WAS PRACTICALLY non-existent in Indian health care a generation ago. Through 1979 and early 1980, the Chennai-based doctor Prathap Reddy did the rounds of the prime minister’s office to get Charan Singh to sign off on his pet project, a hospital in his home city that he would call Apollo. In Pranay Gupte’s biography of him, Healer: Dr Prathap Reddy and the Transformation of India,Reddy claims that Singh “took one look at my application, tore it up and reportedly tossed it into the wastebasket.” Singh did not approve of the idea of Indian businessmen borrowing money from abroad, nor was the political climate of the time hospitable to private enterprise. It took another two years, a change of government, and a careful negotiation of what Gupte calls the “rings of fire” of Indian bureaucracy, before Apollo was founded. It received 50 percent of its funding from Indian banks, and the rest from foreign investors.
The 1980s were also a defining decade for Indian health policy. In 1978, India signed the Alma Ata Declaration at the World Health Assembly, promising “Health for All” by 2000. To follow up, India unveiled its first ever formal health policy in 1983. Since the birth of modern India, the government’s outlook on public health had been limited more or less to damage control—containing epidemics of diseases such as leprosy and tuberculosis. Public health researchers, as well as historians, have said that since India’s politicians were focused on industrial growth during the country’s early years, crucial social sectors such as health and education were deprived of attention. This set the course for a history of neglect and decay.
It was only in the sixth five-year plan, which ran from 1980 to 1985, that policymakers ruefully acknowledged that there was “a serious dissatisfaction with the existing model of medical and health services with its emphasis on hospitals, specialization and super specialization and highly trained doctors which is availed of mostly by the well to do classes.” The model “is depriving the rural areas and the poor people of the benefits of good health and medical services.” Like almost every essential service, the building and operation of hospitals in India was effectively monopolised by governments, which had done little to meet overwhelming demand.
Today’s swanky new hospitals owe their existence to the sixth and seventh five-year plans. The sixth plan document admitted that the private sector would have to be engaged to meet India’s growing requirements. The country needed “a greater emphasis in the direction of competitive ability, reduced cost and greater mobility and flexibility in the development of investible resources in the private sector,” the planners noted. The government would have to adopt “flexible policies to revive investor interest in the capital markets.”
In the early 1980s, Trehan was a doctor of repute in the United States, practicing at the New York University Medical Centre in Manhattan. He was already dreaming, however, of a project that would take him home—a first-rate hospital that specialised in cardiac health, unparalleled anywhere in India. He and Madhu both had strong roots in Delhi, and she had already established herself as a force in Indian journalism. In 1975, she returned to the city and established India Today magazine, although it was taken over shortly afterwards by her brother, Aroon Purie, when she became pregnant and moved back to New York.
One evening, sometime between 1983 and 1985—no one is quite clear on the date—Trehan went to a party at which he met an amazingly like-minded man. Pervez Ali Ahmed was an Indian cardiologist, also based in New York, who routinely referred patients requiring surgical intervention to Trehan. They soon discovered they had much else in common, and became the best of friends. Crucially, Ahmed also wanted the same thing as Trehan: to set up a hospital dedicated to cardiac care in Delhi. He happened to be the son of a former president of India, Fakhruddin Ali Ahmed—a political connection that proved to be vital as the two of them set about bringing the dream to life.
“Ours was a great love story to tell,” Ahmed said when we spoke in November last year. “Two boys leave America and come back to India and want to do something for the country. Reverse brain drain.”
Over the next few years, they met at each other’s Manhattan apartments, discussing plans for the hospital that would become the Escorts Heart Institute. Once the plan was put into action, they flew to Delhi every other week to see it come to fruition. “It was a huge amount of money coming out of our pockets,” Ahmed remembered of those flights. “There were no feasibility studies by KPMG in those days.” They found a site on Okhla Road, and hired an architect. For two or three days at a time, one or both of them turned up, discussing design and structure, and even picking out the bricks and marble that went into the making of their hospital.
They also found a backer in one of India’s leading businessmen—HP Nanda, the promoter of the Escorts group, which made tractors and farm equipment. A person involved in the Escorts hospital project at its early stages told me that Nanda was close to Vidya Vilas Purie, Trehan’s father-in-law, and that Trehan got Nanda’s interest through the connection. Ahmed told me that he and Trehan were Nanda’s “blue-eyed boys, and he was a powerful man back then.”
The Okhla Road site, on the other hand, was acquired with help from Ahmed’s associates. “With my connections, we were able to get the land for Escorts,” he told me, although he refused to elaborate further. In 2005, when Escorts Limited sold its 90-percent stake in the hospital to Fortis Healthcare, serious flaws in the acquisition process retrospectively came to light. The land had been leased to Escorts by the Delhi Development Authority at a massive concession, bringing the price down to nearly one-fourth of the prevailing market rates. The hospital was listed under the Societies Act, as a charitable institution. “We had agreed to keep 25 percent of beds for patients from economically weaker backgrounds, another 25 percent of beds were for patients who’d pay subsidised costs and only 50 percent of patients were to fully pay for services,” Ahmed said. None of these agreements were kept, and the Fortis Escorts deal was quickly mired in a legal wrangle. The DDA’s case against Fortis Escorts is sub judice, and the office of Nikhil Nanda, Escorts’ current managing director, offered no comment on the history of the land deal, since Escorts is no longer a party to the case.
Ahmed and Trehan’s relationship, for its part, soured even before the hospital opened its doors. Ahmed told me that Trehan used him for his political connections, and sided with the Nanda family to push him out of the venture. “Escorts was my idea,” he said. “It would not have been possible without me. I never got the credit for it.” The initial agreement between himself and Trehan, whereby they would jointly own Escorts, was a purely verbal one, Ahmed claimed. “But when the organisational structure was shown to me, I was reporting to him. He owned the hospital along with the Nandas. This was not acceptable to me and I left.”
Ahmed quit Escorts in 1991, and returned to New York to practice there for some years, before moving back to Delhi. He now practises from his private clinic in Kalkaji, in south Delhi. Last year, he dipped his own toe into politics, as a Trinamool Congress candidate from Assam in the Lok Sabha election. He and Trehan are no longer friends.
Ravi Kasliwal, who left Escorts with Trehan to set up the cardiology department at Medanta, told me the same story, although in his version it was he and Trehan who started Escorts together. As an afterthought, he added, “There was this other gentleman.” He snapped his fingers to try and remember the name. “He was Fakhruddin’s son.” Ahmed was initially a part of the project, Kasliwal said, once he recalled his name. “But he had some internal issues and left.” By contrast, by the time Trehan was locked out of the hospital, he owned all the remaining stake in Escorts, roughly a ten-percent share.
BETWEEN ESCORTS’ INCEPTION AND 2003, when the foundation stone of Medanta was laid, Trehan appeared to be a man with a single-minded mission to make Escorts the best cardiac care facility in all of South Asia. In 2005, when the Fortis group bought the hospital out from the Nandas, it was “a milestone acquisition in many ways,” Shivinder Mohan Singh told me. “It was single specialty—pretty much the reference point for most of Asia for cardiac treatment. They had already figured out what they needed to do to get good talent and run it as a large system.” The Fortis group also had a prior connection with the hospital: Singh’s father, Parvinder Singh of Ranbaxy, had sat on the Escorts board for some years. “Our idea was to do a multi-specialty flagship together—to have an education institute, a research institute, a preventive-care facility, etcetera. We got into the deal with Escorts thinking he was a natural fit.”
Trehan’s new partners had bought the Nandas out for R650 crore, convinced that Escorts was exactly what Fortis’s portfolio needed. They were aggressive expansionists—they already owned hospitals in Noida, Mohali and Amritsar, and were looking to grow quickly through northern India. (They now have sixty-six hospitals across the country, more than any other hospital chain). If this instinct had not come into conflict with Trehan’s own ambition, the split need never have happened.
Following the debacle of their partnership, Fortis decided never to hire a “superstar” doctor again. “When we talk about superstars, we talk about doctors who either because of their skill, or opportunities, or networks, non-clinical abilities, positioning or PR, get a certain aura that is different from their clinical skill set,” Singh said. But this, he added, changes them. “Superstar physicians feel ‘I can do no wrong and my hands are god’s hands.’ Then the business is in trouble. The business doesn’t lend itself to that kind of personality.” Singh had not wanted an acrimonious parting from Trehan, he said, but it was justified; it had been the right decision for the company.
The hospital gates were locked to Trehan on a Friday morning, the day before the courts went on summer holiday. On Saturday, when Trehan returned to the hospital again, the bouncers from the previous morning had been replaced by close to a hundred policemen and a full battalion of Rapid Action Force servicemen, with an arsenal that included a water tanker with a hosepipe, used in riot-control operations, and tear gas and lathis. The management had clearly prepared for every eventuality.
When I asked Ahmed if he enjoyed watching Trehan being thrown out of the hospital built on their common ambition, he said no. “That was management treating a clinician badly. Now, everyone has a deep distrust for management and non-clinicians. There is a ‘we’ and an ‘us’ syndrome in Indian hospitals—magnified, of course, by the Trehan–Singh fight. That is not good for industry.” But knowing Trehan, Ahmed added, it was certain that whether the divide helped or hurt him, “he made a lot of money either way.”
I brought the Escorts story up with Trehan at our second meeting, in December, and he was wary in his responses. “Name one doctor who has given up two million dollars a year to work for three lakhs a year,” he said. “Medanta was created purely because Cleveland, Mayo Clinic, Harvard”—top-notch US medical facilities—“were not available in India.” His work in New York had been lucrative; his colleagues thought he was crazy to return home. He had come back, though, because he was “fatally proud” of India, he said.
We were speaking on the sidelines of a CII health summit at the Lalit, a luxury hotel in central Delhi. The occasion made it evident that whatever Trehan’s vision was for his practice, and his business, it had grown to envelop the whole country. For two days, Trehan stepped up on behalf of private health care, lobbying hard with attending ministers and policymakers to further ease the sector open for them. At our previous meeting, back in his office on the Medanta campus, he had told me that some of the papers I saw on his desk were drafts of key health policy announcements, to be made in the budget session in progress. He declined to share them with me.
Trehan told me categorically that he would speak neither about Ahmed, nor Shivinder Mohan Singh, nor the Nandas. It would involve “cleaning dirty laundry in public,” he said. “I am a thorough gentleman, and I will always behave like one.” He did not offer any comment on the DDA case against Fortis Escorts. About Ahmed, eventually, he said, “He cannot blame his failures on me.”
He did, however, offer a different version of Escorts’ origin story. “I was in New York,” he said, “when Indira Gandhi’s foreign secretary”—Romesh Bhandari—“approached me saying someone close to her was in need of a bypass surgery. At that time, bypass surgeries were not done in India.” Following the patient’s recovery, Trehan said, Gandhi told her personal secretary, RK Dhawan, to help him with a land deal. People like Trehan, she said, should return home, so that Indians would stop needing to go overseas for surgery.
He stopped there, and told me he would reserve the rest of the story for his soon-to-be-commissioned book. He had initially agreed to a series of conversations with me that touched on his career, his personal life, and his approach to health policy, respectively. But he treated the past with caution. After this meeting, the tenor of our remaining conversations changed. Like the CII summit, he would focus only on what lay ahead.
INDIA’S HEALTH SECTOR IS PRESENTLY in the middle of a radical transition, because the health of Indians is changing. We live longer than we used to. In 1990, Indian men had an average life expectancy of 57.3 years; this is now 64.2 years. Life expectancy for women jumped from 58.2 years to 68.5 years in the same time. The country’s disease patterns have changed dramatically in the past two decades, thanks in part to economic progress and increased incomes. Infectious diseases such as leprosy, plague and tuberculosis are no longer considered the country’s worst nightmares. Instead, India now fears a near-epidemic incidence of non-communicable diseases such as diabetes, respiratory disorders and cardiovascular ailments.
Private health care adapted to India’s new demands with exceptional skill. Large hospitals across the country found ways to cut down on bureaucracy; they instituted preventive health check-ups; most major hospital chains aggressively sold affordable package deals, loyalty cards and memberships to their patients. In contrast, the government sector has continued to struggle. Its condition is alarming because most people, especially in rural India, rely solely on public medical care. This means that, far away from the plush environs of the “medicities,” the most vulnerable people cannot get assistance for even their most fundamental health needs.
In November 2014, a state-run mass sterilisation camp in Chhattisgarh was responsible for the deaths or critical health failures of nearly a hundred women, after it conducted laparoscopic tubectomies using infected instruments. The patients were given drugs laced with rat poison, the surgeries were conducted at an abandoned hospital without proper permission, and doctors chasing monetary incentives contingent on meeting certain targets violated a government guideline that restricted the number of surgeries they could perform to thirty per day.
The private sector emerged “by default” because of the government’s chronic under-spending on health, Srinath Reddy, the president of PHFI, told me. After the liberalisation of the economy, businessmen “also managed to secure financing from multiple sources for private-sector expansion. During this time, the government should have strengthened medical colleges and district hospitals, but that did not happen.”
When Trehan got up to speak at the CII conference in December, his message to the audience was clear: he wanted the private sector to provide health care to people, and be reimbursed by the government. The national health policy draft, that is currently up for public discussion, reiterates this vision. Indeed, its proposed division of responsibilities is exactly what private health care lobbies such as the CII’s health committee have been pushing for. Primary care in semi-urban and rural India, largely focusing on mass campaigns such as polio eradication, will remain the government’s responsibility. The government is also tasked with promoting traditional medicine, yoga, and other preventive health practices. These are low-profit—in many cases, non-profit—services.
Meanwhile, the private sector will take care of secondary and tertiary requirements, with the government paying for insured patients. Over the next financial year, the BJP-led government is set to activate its National Health Assurance Mission, an insurance scheme that will cover a set of essential medical services for all Indians. This is in keeping with global trends—the prolonged debate in the United States over the enactment of “Obamacare” to regulate the cost and quality of health insurance is a case in point. When unveiling the NHAM scheme, authorities claimed that they would integrate previously existing public insurance schemes into a single-payer system. Programmes such as the Rashtriya Swasthya Bima Yojana, or RSBY, a cashless scheme that provides coverage to families living below the poverty line, and other existing state-level schemes, will all be rolled into this arrangement.
In the coming years, small and mid-sized hospitals will benefit greatly from the government purchasing care from them through insurance schemes. Meanwhile, large hospitals such as Fortis and Medanta will continue to serve the rich, who can afford their own health care. The result is likely to be a tiered system, in which the gulf in between the quality of care at large hospitals and smaller ones will increase significantly.
Trehan is a firm backer of what is called the “provider–payer split” in this scenario. “If the government increases RSBY cover to R60,000 and gives R2 lakh floating cover per family, over 70 percent of the people who cannot access health will be brought into the loop immediately,” Trehan explained when we met again, in late January. “I have said it so many times, the government needs to work with the private sector. That is the only solution.”
At the CII summit, Trehan claimed that the private sector already provided for 80 percent of India’s health care needs, while the government covered only the remainder. At least thrice in his speech, he asserted that the government contracted private-sector health-care providers at “unreasonable” rates. “The current government rates do not cover the cost of tertiary care per international standards,” he said. “Smaller hospitals, without overheads of proper sanitation, staff and clean environment, take up the government empanelment.”
Trehan’s argument overlooked the fact that the government has always offered heavy subsidies to private hospitals when leasing out land, providing infrastructural services such as water and electricity, and other major incentives, such as tax rebates. The Indraprastha Apollo Hospital was famously given fifteen acres of land in Delhi’s Sarita Vihar for a grand total of Rs 1, in exchange for the hospital providing a generous amount of free care to poorer patients—but the conditions of the lease, it turned out, were subsequently repeatedly violated.
The government, Trehan proclaimed, ought to “transparently assess cost of procedures, add another 15 percent for profits, and private hospitals will happily contract with the government. We have to make profits.” A room full of private hospital owners cheered him on.
Public health activists pointed out the flaw in this arrangement. “There is ample evidence to show that whenever a health sector is heavily dependent on insurance, private hospitals deny services for many categories of illnesses, and there is oversupply of some services,” Amit Sengupta, an activist with the India chapter of the People’s Health Movement, an international non-profit network, told me. “They resort to various fraudulent measures, including charging informal payments. The overall cost-escalation of services is a routine feature.” Empirical evidence from around the world does show that wherever governments have outsourced public health duties through insurance schemes, costs have risen.
Many of Trehan’s views on India’s looming health care crises are at odds with the opinions and experiences of others in the field. Experts agree, for example, that one of the gravest symptoms of the situation is the severe strain on human resources. The former health secretary Keshav Desiraju said that the shortage of doctors and nurses was a “huge, fundamental issue” for the government. According to India’s 2013 national health profile, the country has 381 medical colleges with a total of 43,576 seats for undergraduate medical degrees. But right now, Desiraju said, only about thirty thousand students graduated in each class. Of these, he explained, “some go abroad to study further, some get into post-graduate courses in India, some we lose to the private sector, and the remaining come into the public health system.” Even among the young doctors who start work in government hospitals as a last resort, the majority prefer to work in urban areas.
To Trehan, this is simply a problem of “hospital standards,” in which private hospitals come out ahead because they manage their resources better. “None of the private hospitals have increased costs in the past five years,” he told me. This was in spite of the fact that “human capital costs more and more every day, and hospitals like Medanta only hire the best. We survive because we maintain and constantly improve efficiency. Compare that to the per-unit cost of running a government hospital. Include subsidies. And you will see that a surgery in a government hospital is actually more expensive than in a private hospital.”
Trehan’s calculation of resource efficiencies illustrates why the decay in public health service suits private entrepreneurs. Sengupta, the public health activist, pointed out that the stability of medical costs in private hospitals did not necessarily indicate their concern for the public interest. As the volume of patients seeking medical attention from private hospitals increases, there is no need to raise rates in order to maintain profits. “This is already happening,” he claimed. Additionally, there remains no way for the government to prevent “moral hazard”—to stop private enterprises from pursuing unnecessary investigations and procedures to boost revenues.
In 2012, Trehan was appointed to head the Healthcare Sector Skill Council, which is funded by the National Skill Development Council, a government body that finances vocational training initiatives. To many observers, this was yet another indication of the CII’s growing influence over the health sector—and a sign that the concentration of talent in private medical enterprises was set to intensify further. Over the last two years, there appears to have been no government participation in the functioning of the HSSC. Desiraju said the health ministry frequently took a backseat in situations like these, because it lacked the expertise to participate in any dialogue. “In an ideal situation, a think tank or an academic body should have done it,” he said, of the HSSC’s direction and agenda. “But we don’t live in an ideal situation. The government should be setting the curriculum and minimal standards required for training as health professionals. Unfortunately, staying away from this discussion is now not even a carefully thought-out policy decision by the health ministry. It is just incompetence.”
The government currently invests 1.3 percent of the GDP into health care—paltry by global standards, where many of the world’s most industrialised nations allocate well over ten percent of their GDPs to health care, and even some significantly poorer countries, including Bangladesh, often spend more of their GDP on health than India does. The national health policy draft promises to raise the investment to 2.5 percent of GDP in the next five years—a move that would partly ease the strain on health ministry budgets. But the Modi government’s recent budget announcements have followed a well-established pattern of slashing funds for health care. When I asked CK Mishra, an additional secretary at the ministry, where this money would come from, he replied, “There is no money. There is going to be no money. We are doing our best, given the circumstances.” Days after the CII summit, news broke that the government had ordered a cut of nearly 20 percent in its next annual healthcare budget, due to fiscal strains.
Mishra was also a part of the CII conference at the Lalit, along with elected officials such as Mahesh Sharma, the minister of tourism, and Shripad Naik, the newly appointed minister of AYUSH, the department of Ayurveda, yoga and naturopathy, Unani, siddha and homeopathy. To Sharma, Trehan suggested that the Incredible India campaign, which promotes India to international tourists, could advertise medical tourism as one of the country’s many attractions. If medical visas were made more readily available, and if the government reached out a little more to private entrepreneurs, he said, they would all be ready in short order to conquer the next waiting markets—the SAARC and African countries.
Trehan had “set the context” for the conference at the outset by getting on stage and pointing out that no country has yet been successful in really providing “care for all.” With Naik in the audience, Trehan launched into a well-oiled performance. “We know that the private sector is painted today as money-hungry, cutting corners, too expensive,” he said. But there were “certain truths” that the media simply did not understand.
“There are some issues on our side but they are minor,” he went on. “The major issues are on the government’s side.” The private sector wanted “to participate in the growth of India. The country’s people are suffering, and we need to surmount this issue.” Trehan’s tone turned beseeching as he faced the government’s representatives in the room: “Work with us.”
A few minutes later, Trehan disappeared into a VIP room with officials from the health ministry, including CK Mishra and Arun Panda, also an additional secretary of health. Outside it, the room filled, and people began to line up. I crossed Arvind Lal, the chairman and managing director of Dr Lal’s PathLabs, a major Delhi-based pathology firm, waiting his turn for an audience. The queue, like in his waiting room at the Medanta OPD, only grew longer.
Correction: The print version of this article incorrectly stated that Madhu Purie studied photojournalism in the United States. The Caravan regrets the error.