Capital: The Eruption of Delhi

Five

Two sisters who had locked themselves inside their Noida residence for the past seven months and were living in inhuman conditions were rescued by the local police on Tuesday. The sisters, both in their forties, were rushed to hospital, where the condition of one of them was described as critical owing to severe malnutrition and dehydration.

Both sisters have PhDs and were until recently successful professionals. They are said to have fallen into severe depression after their father, an army officer, passed away a few years ago. The sisters also have an estranged brother living separately in Delhi. He and his family reportedly had no contact with the sisters for the past four years. The death of the family’s pet dog a few months ago is said to have aggravated their depression. The sisters had lost their mother much earlier.

A doctor in the hospital said, “The sisters arrived in an extremely emaciated condition. The elder sister was unconscious and suffering from internal and oral bleeding. The other sister is very disoriented in terms of time and space.”

— News item, April 2011⁷

In the older centres of the global market, observers felt they knew exactly what all these developments in far-off India meant. The technology companies, the cafés, the mixed-gender groups of professionals drinking after work, the alternative lifestyles: Americans recognised it all immediately as — America. Knowing publications such as the New York Times ‘explained’ to their readers how the landscape of the rising Asian giant was, through the spread of cappuccino drinking, rapidly becoming just like their own. ‘How India Became America’⁸ went the title of one such article:

Recently, both Starbucks and Amazon announced that they would be entering the Indian market […] As one Indian newspaper put it, this could be “the final stamp of globalization”. For me, though, the arrival of these two companies, so emblematic of American consumerism, and so emblematic, too, of the West Coast techie culture that has infiltrated India’s own booming technology sector, is a sign of something more distinctive. It signals the latest episode in India’s remarkable process of Americanization.

Cold-War suspicion between India and the United States was laid exuberantly to rest in March 2000, when Bill Clinton made the first state visit to India of any US president since 1978. His tour came at the peak of the Nasdaq’s technology-fuelled boom, and Clinton was quick to acknowledge the contribution Indians had made to this extraordinary period of American capitalism. “Indian — Americans now run more than 750 companies in Silicon Valley alone,” he said, singling out for tribute tech godfathers Vinod Khosla, who had graduated from the Indian Institute of Technology in Delhi before going to Stanford and co-founding Sun Microsystems, and Vinod Dham, who had studied at the Delhi College of Engineering, migrated to the US and masterminded the development of Intel’s Pentium chip. But the president added, “We’re moving from a brain drain to a brain gain in India because many are coming home.” India, he said, citing the successes of companies such as Infosys, is “fast becoming one of the world’s software superpowers, proving that in a globalised world, developing nations not only can succeed, developing nations can lead.”⁹

Clinton’s benedictions resembled those, not of a drily detached superpower, but of an emotional older sibling. America and India shared, after all, so much of their DNA: America, too, had won independence from Britain, albeit 170 years before India; and the fact that the two countries now enjoyed such close business ties stemmed in part from the language they both inherited from this history. Both were democracies; both were extremely diverse and found their unity in a liberal constitution. And both seemed to display the same inborn predisposition towards free enterprise. In a statement that could have been a declaration of the indispensability of brotherly love, Clinton concluded, “A lot of our future depends upon whether we have the right kind of partnership with India.”

It was a theme that Indian ideologues would develop elaborately over the coming decade. As China rose, as wars against Islam brought America into engagement with India’s neighbours Pakistan and Afghanistan, Indian elites made a fervent case for the ‘natural’ partnership of their country with the superpower. “In terms of the scale and ambition of our respective political experiments, we can only be compared to one another,” said Indian historian Ramachandra Guha to Time magazine.¹⁰ The argument could of course be profoundly self-serving, as was demonstrated with its most conspicuous outcome, the Indo-US nuclear deal of 2008, which, since India refused to sign the Nuclear Non-Proliferation Treaty, went against existing American law, but which Indians skilfully lobbied for nonetheless on the basis that India’s interests, in these days of Asian instability, were an essential outpost of America’s own. “The nuclear deal [is one] that the Indians regard as basic recognition of their status as a major power,” approved Fareed Zakaria, columnist at Newsweek and conspicuous promoter of the Indo-US partnership, and even if it destabilised the global nuclear equilibrium, it could present no grounds for anxiety since “India’s objectives are exactly aligned with America’s.”¹¹

As America’s global predominance fell subject to an increasing range of challenges, the US too found it soothing to imagine India as a ‘second America’. If the centre of global power was to shift to Asia, if American hegemony was to decline, perhaps India could provide the guarantee that American values continue to reign. The future managers of the world might look somewhat different, but inside they were exactly the same. The future of the world, in other words, presented no unpleasant surprises. It would be exactly like the present.

But American newspapers’ bucolic descriptions of couples in shopping malls and bourbon-drinking corporate executives listening to jazz seemed, in their emphasis, profoundly foreign to those who were actually living through India’s transformation. ‘Globalisation’ was not homogenisation, nor even Americanisation. The presence of American brand names did nothing to alter the fact that India was a vastly poorer country than the US, whose relationship to Western capitalism was full of historical ambivalence — and what was emerging in India looked like nothing ever seen in America. Even those Indians who sipped coffees in shopping malls felt a very different content to that activity from the one felt on the other side of the world. The shopping mall was only one part of a carved-up landscape, inner and outer — for there was no continuity between the world inside the mall and the one on the other side of its walls, where street traders, shanty towns and traffic jams awaited the departing consumer. The mall itself, moreover, had arrived as part of a rapacious economic torrent that had turned everything upside-down, destroying things human and divine, scattering objects and energies, and setting down alien needs and rituals in the rubble. Global capitalism might have appeared serene and civilised in its ancient heartlands but this was not how it felt when it suddenly burst in somewhere new. This is why the system failed to produce, at its edges, those tranquil, docile citizens that Westerners so often assumed were an inherent part of the package.

Crudely materialist accounts of India’s rising middle classes assumed that, since they now had incomes many times larger than twenty years ago, they must be that many times happier. But many of the things that drained life of its happiness had also swelled proportionately in that time, and many people did not actually feel any kind of spiritual profit. It was true that there was an exhilarating freedom to earn and to buy. But there were, correspondingly, very few guarantees: if something went wrong you were on your own. The middle classes who benefitted from that new market freedom often realised only too late that, though their salaries might be high, they lived more vulnerable lives, in many respects, than the poorest members of many another society.

• • •

I park in the car park of one of Delhi’s new corporate hospitals and walk towards the building. As I arrive, I am shocked to see a dead woman lying face down on a stretcher right outside the main entrance. She blocks the door, and I have to skirt around her to go in. She is heavy-set and only middle-aged. I sit down in the waiting room, where I’m supposed to meet some people. They haven’t arrived yet and through the glass I regard the stretcher with continued disquiet. I decide to go out and see what is going on.

Standing with the dead woman is a young man who turns out to be her son.

“She was in this hospital for three weeks. After they discharged her we took her home, but her condition got worse and she died early this morning. We didn’t know what to do. So we brought her here.”

He has been crying. He adjusts the scarf that has been thrown over her, the better to cover her face.

“We asked for a stretcher and we got her out of the car, but when we tried to take her inside they stopped us. They said she was none of their business anymore. So we don’t know what to do.”

We both consider her, lying under the hot morning sun.

A car pulls up in front of the entrance. It is the man’s brother. He gets out, and between them they lift the woman off the stretcher and try to get her into the back of the car. She is a big woman and it is a tiny car. The two distressed men are unable to bend her legs, and they cannot force her through the opening onto the back seat. It is an unbearable scene.

At that moment, another family member drives up. He embraces the two men hurriedly and considers the scene. He is furious. He storms into the hospital and emerges with two members of the staff. A vociferous argument ensues, during which the hospital representative repeats, “She is not a patient in this hospital. We cannot take responsibility for her.”

“Their mother has just died!” the relative shouts. “They need your help! How do you expect them to move her?”

A crowd has gathered, and the situation becomes impossible for the hospital staff, who concede defeat. A few minutes later an ambulance pulls up, the dead woman is loaded inside, and a small procession sets off for the cremation ground. The crowd disperses and I sit back down in the waiting room.

It is a well-appointed room, with the sort of good fittings and bad paintings that grace such rooms all over the world. Over the entrance is the sign displayed in every Indian hospital which informs patients that it is illegal to engage in ‘pre-natal sex determination’ — this being an important, though far from watertight, measure against female foeticide. Since this is a corporate hospital, there are all kinds of helpful corporate flourishes: a suggestion box, for instance, and an information desk with a friendly ‘May I help you?’ sign over it. A TV screen shows computer animations of medical procedures that can be purchased here. Posters advertise laser surgery for vision defects, and various treatments for scars, stretch marks and wrinkles; the happy, healthy families in the pictures are, as they are in so many contemporary Indian advertisements, white.

Corporate hospitals like this one have been a conspicuous addition to the Indian landscape. Until the 1980s, all hospitals were run by the state. India had a distinguished medical fraternity and several of these government hospitals, such as Delhi’s All-India Institute of Medical Sciences, set up by Nehru in the 1950s as the nation’s flagship research institute, had international reputations for medical excellence. These older institutions still provide care to the majority, but precisely for this reason they are unable to offer the sophisticated medical apparatus that has become so familiar to the middle classes through American hospital TV dramas. For this ‘world-class’ care, the affluent turn to the new corporate hospitals, which are nearly all majority-owned by billionaire business families — members of the entrenched power elite with the political connections required to negotiate the acquisition of the necessary tracts of urban real estate. Three such healthcare moguls live in Delhi and belong to one Punjabi family — whose members arrived in the capital as refugees from Partition, as is the case with most of the city’s leading business families — which collectively runs finance companies, insurance companies, clinical research companies, film production companies and airlines — as well as hundreds of hospitals, not only in India but all across the world. In India, these corporate hospitals have not only generated an entirely new healthcare experience for the Indian middle classes — stylish, well-equipped and, of course, expensive — but have also gone a long way to pioneer, through medical tourism and telemedicine, entirely new kinds of global healthcare marketplaces.

The room is full of people. Here and there I can spot frail sufferers of dengue fever in the company of solicitous family members: it is just after the monsoon, and therefore peak mosquito season. Opposite me is an old man in a wheelchair: his wife speaks on her mobile while his son strokes his hand and speaks reassuringly into his ear. Next to me three Australian women, wearing Indian clothes and jangling with anklets, debate what time they need to arrive at the airport.

An imposing woman enters through the front door and waves at me. She is dressed in a sari and wears large glasses. I have met her only once, at a party. Her name is Aarti. She comes over to me with two young companions whom she introduces loudly.

“This is Amit, whom I told you about,” she says, “and his cousin Shibani.”

We greet each other. Shibani smiles politely; Amit seems ill at ease. I propose that we repair to the hospital café, and we head off in that direction. Aarti chats fluidly to me as we walk past all the people waiting outside consulting rooms. I see an Arab family in pristine robes and think to myself that it is often in hospitals that one realises how many foreigners live in this city. We come to the café, which is a franchise of a well-known chain and which therefore exudes the same nauseating smell as every other café under this name. It comes from the muffins, which they microwave until they are burning hot and serve with a knife and fork.

The TV is on silent, and set to MTV. Everyone orders cappuccinos.

“You all met in this hospital, is that right?” I ask as we sit down.

“We met in the intensive care unit,” says Aarti. “We were there every day, and we shared our stories.”

I would put her in her late fifties. She comes from the city’s propertied Punjabi elite and speaks loudly and with confidence. Amit’s speech is mouse-like in comparison.

“I never thought I would come here again,” he says.

I ask him what happened to his mother but he defers to his cousin.

“He went through such trauma after his mother’s death,” she says, “that he couldn’t work for months. Now he works very hard because he doesn’t like to be in the house anymore.”

She recounts the details. A couple of years ago, Amit’s forty-four-year-old mother began to have difficulty swallowing, and he took her to one of Delhi’s big corporate hospitals. When, after two months of tests, the doctors could not work out what was wrong, they advised him to take her to see the experts at the All-India Institute of Medical Sciences. But there was no room there and the specialists had no time. Half of them were quitting to work for the corporate hospital in which we are now sitting. One of them told Amit to consult him here, which he did. The specialist conducted three days of tests and presented a diagnosis: Amit’s mother was suffering from polymyositis, an inflammatory muscle disease.

Shibani and Amit are in their mid-twenties. Shibani is quiet and serious; she wears a slim-cut salwar kameez. Amit wears a shirt and jeans. While Shibani is talking, he wordlessly shows me a photograph of his mother on his mobile phone. A rotund, smiling woman in a sari.

“That was before all this began,” says Shibani.

She continues her narrative.

“The doctor immediately told us he wanted to give her an injection that would cost 4 lakhs [$8,000]. Amit did not have that money, so he called his uncle to ask if he could borrow it. The doctor told us this would restore his mother’s muscles and there was no alternative, so we had to do it.”

The injection he was proposing was intravenous immunoglobulin, which has been shown to assist recovery from polymyositis. This therapy is still poorly understood, however, and it is unusual to offer it before administering corticosteroids. After administering the injection, the doctor sent Amit’s mother home, giving Amit and Shibani instructions for feeding her with protein powders through a tube in her nose. At home, however, her lungs were filling up with the constant flow of saliva which she could neither swallow nor spit out. Afraid that she might drown, they rushed her back to the same hospital in the middle of the night. There she was given an oxygen mask and diagnosed with pneumonia. The next day, more tests revealed that she also had a kidney infection. She was immediately transferred to the intensive care unit.

The doctor remained calm about all of this. He said,

“I knew this would happen. But if I had told you all the side effects of the immunoglobulin, you wouldn’t have gone ahead with it.”

He put Amit’s mother on renal dialysis. A temporary tube in her arm was replaced by a permanent one in her chest. Then the doctor set about trying to rescue her respiratory system from the saliva flow. He administered another dose of immunoglobulin to strengthen her lungs. Then he performed a tracheostomy and inserted a tube to divert saliva away from the windpipe.

“They said it would only be needed for fifteen days,” says Shibani. “But after fifteen days they said she needed a permanent tube and the one they had put in was only a temporary tube. The permanent tube cost another 75,000 rupees [$1,500].

“We were spending so much money. The day rate for staying in the intensive care unit was 16,000 rupees [$320]. Oxygen and dialysis came to as much as 45,000 rupees per day [$900]. Every night, Amit had to visit relatives all over the city to borrow money. People were giving us cash from their wedding funds.

“You don’t know what to do. When you have the patient lying on the bed, the person who has brought you up, you are so emotional you cannot think. And this is how they get you.

“It was going on for weeks. Every day they would say, ‘Your mother is recovering.’ Our hopes would rise. Then they would say, ‘She is not recovering.’”

We are a quiet group. Shibani’s voice is soft, and we are all gathered around it. Amit looks into his half-drunk coffee as he listens; Aarti’s gaze takes in the hot morning outside, and the manicured garden.

“Meanwhile her blood platelet levels had sunk to critical levels. And her saliva was still not controlled, so that she could no longer even talk, let alone eat. The doctor proposed another drug which would cost 1.7 lakhs [$3,400]. They administered this drug, which was supposed to restore her system and control her saliva flow. It had no effect. The doctors said to us, ‘Of course it is not working. All the medicine is being flushed out of her body by the dialysis.’

“It was hell in there. People were dying at such a rate in the intensive care unit that there was panic all the time, and no one to take care of Amit’s mother. The doctors never came to see her. They had no link at all to their patients. We were not allowed to go into the ward to see her. They never told us anything except, ‘She needs more medicine.’ There was nothing we could do except pay the bills. Every evening we received the bill for the day and we handed over the cash we had borrowed from our family. When you went to the accounts department, you saw massive trunks of 1,000 and 500 rupee notes being carried out to the bank.”

Aarti laughs wryly. Shibani continues,

“We asked to take her out of intensive care, which was so expensive, so they put her in a normal ward where we could spend time with her. But she had reached a terrible state. She had bedsores and she was continually crying. All she would say was, ‘Take me out of here!’

“We asked the doctors what we should do. They said, ‘She is not eating. We need to put a hole in her stomach so we can feed her through it.’ While we were discussing this with them, a nurse came in to tell us that Amit’s mother had passed away.”

Tears begin to pour down Amit’s face as Shibani recalls this moment.

She says, “And you know what the doctor said to us? He said, ‘Perhaps if we put her back into intensive care and put her on a ventilator, she’ll revive. We can try that.’ So I said, ‘On one condition. I want to stay with her the whole time and watch what you do.’ And the doctor said, ‘Families are not allowed into the intensive care unit.’ So we said, ‘Then we won’t do it.’ And he said, ‘Of course, if you don’t want your mother to live, then… I mean there is a 1 per cent chance that she will live — who are you to decide that she should not survive? But if you don’t have money… ’

“But we were done. It was over. We told the doctor, and he left us.

“We went in to see Amit’s mother. Immediately someone came to collect the outstanding money. They talked to us across her dead body. ‘You have 2 lakhs [$4,000] outstanding. Please pay.’ They had no respect. They talked over her body. In India we respect the dead, you know? They were so rude.”

Amit intervenes. “When we cremated my mother, the priest told me her bones had turned to powder.”

Shibani is fiery with the rage all these memories have aroused.

“People are dying for no reason,” she says. “At least we have a little money. We met people who were kicked out of the hospital when their insurance money was used up, and the doctors hardly bothered to sew them up. Of course, people who have no money at all don’t have a chance.”

“These hospitals are totally corrupt,” says Aarti. “Patients are only profit. Nothing else. Anything they can’t understand they call cancer because then they can pump you with the most expensive medicines. This religious, spiritual country — the humanity is going out of it. Very little good is being done but a lot of harm is being done.”

“What happened to your husband?” I ask her.

“He died here too. Just before Amit’s mother. He was a very good man. We had forty-three years of beautiful companionship. These days very few people can say that. I was married to a man who never stopped thinking about me and looking out for me.”

I realise Aarti must be older than she looks.

“He came from a well-known family. There were famous journalists and academics in the family, and film stars. He had a successful career and we moved in good circles. Anybody who’s anybody in Delhi, I know them.”

Aarti has to take a minute to establish her class position. Her story has additional weight because she is someone.

“My side of the family is well-known too,” she says. “Both my grandfathers were titled. My father’s father was from Jalandhar. He became chief engineer of the railways: he was knighted and received an OBE. They were a famous Delhi family who used to be very close to Indira Gandhi. My mother’s family came from Lahore — they lost everything in 1947 and came over to stay in Delhi. My grandfather did very well in business and acquired a grand mansion in the diplomatic enclave.”

She is so Delhi. It drives me crazy.

“My husband was never sick. He was 6’1” and strapping. He never wore glasses. He never went to a dentist in his life and his teeth were all his own. When he was seventy years old he used to thrash thirty-five-year-olds on the badminton court. He never took a rest in the afternoon. During the forty-three years we were married, apart from a few colds and a back injury, I don’t remember him ever being ill.

“In October 2009 everything went wrong. On 4 November he went into hospital and by 5 February of the following year, he was gone.

“The problem was never diagnosed, though I sent his tests to dozens of doctors. It started with a viral fever and then he became very weak. A low-grade fever continued for some time. A multitude of tests were done. We were sent to see endocrinologists who gave him expensive drugs. At first those drugs put him in a cold sweat and then they gave him a stroke.

“You see, he never took medication in his life. If he had to take an aspirin he used to cut it in half. He couldn’t take so much medicine. They started pumping antibiotics into his system four times a day just because it cost 5,000 rupees [$100] a time. I said, ‘What are you doing? You are only thinking about drugs and money, but I love him and I can see what it’s doing to him.’

“They started chemotherapy without a diagnosis! They had no idea what was wrong with him. The doctors were so well-known, I felt I had to do what they said. But each time I listened to the doctor, my husband got worse. And it was only when I didn’t listen that he got any better.

“I took him out of that hospital and went to another. I went with all his test results but they wanted to test everything again — there was incredible over-testing. They said they wanted to do a biopsy of his lymph nodes, which had become swollen with all the medication. It would be a simple procedure with a local anaesthetic.

“The night before it was supposed to happen I was sleeping in his hospital room when I suddenly woke up. It was dark, it must have been one in the morning, and I saw there was a beautiful nurse standing in the room. If you saw her you would say, ‘What a beautiful woman!’ So I opened my eyes and saw this extremely beautiful woman standing by my husband’s bed. She had brought a form for him to sign, authorising the hospital to do a much more expensive procedure under general anaesthetic. Can you imagine? My husband was almost delirious with the drugs, and he would have woken up in the middle of the night to see this angel in his room asking him to sign a piece of paper? I told her to leave, that this wasn’t what the doctor had told us, and I took my husband out of that hospital the next morning.”

The combination of high costs and low information that characterises this system is an insidious one, and leads to a paranoid panic which only makes things worse. Patients consult twenty doctors because they trust none of them. They abort therapies and change hospitals, with the result that there is no sustained treatment.

“When we arrived in the next hospital, my husband began to recover. They gave less medication. His platelet levels had dipped to 45,000 per microlitre before we came there — they are supposed to be above 150,000 — but they began to rise again. After a few days, he was ready to leave hospital. But they decided they had to get more revenue out of him, and they faked his blood test result.

“He was ready to leave: he was putting on his scarf. He hated being in hospital and was very happy to be leaving. Usually, the blood tests came up automatically on the monitor in his room. On that morning they did not. He was getting his coat on but we couldn’t leave before the test results arrived. There was no reason to worry — his platelet count had risen from 45,000 to 90,000 while he had been in that hospital.

“I went to ask why the results had not come. No one could tell me. The doctor said, ‘Let me call the lab myself.’ He looked at me and without listening to anything on the other end he told me that my husband’s platelet count had fallen to 43,000 and that he needed an emergency transfusion.

“I went into a panic. If his levels had fallen so much in ten hours, how much further could they fall? There was no question of going home — he could go into a coma. ‘I’m sorry my love,’ I said, ‘but you have to have a transfusion.’ I was panicking and not thinking that anything might be wrong. I had to find a donor quickly. My nephew rushed from Gurgaon to donate platelets. He was so sweet. He came as soon as he could. When he learned he had to give five litres of blood he went white, but he still gave it. He is like my third son now. I will never forget what he did.

“By the evening, everything was ready for the transfusion. Before going ahead, they did another blood test as per procedure. I demanded to see the results of that test. My husband’s platelet count was 90,000. Which meant it had never fallen in the first place! They had not given us the results in the morning just so they could sell a blood transfusion for 50,000 rupees [$1,000].

“During this whole time there had been a Sikh doctor in Texas who was monitoring our situation. He was a cancer specialist who had treated one of my friends. He was the only doctor who paid real attention to the reports I sent. Every evening he would call up at his own expense to find out what was happening. There was so much kindness in his voice. He knew what was going to happen and gave me advice about it. He said, ‘He could start developing fluid in his lungs — you have to be careful.’ So I told the doctors but they didn’t care about anything we said, the bastards — and then he got fluid in his lungs. The doctor from Texas told me to make sure he wasn’t given any steroids and then when he came to this hospital they started giving him massive doses and his system packed up.

“It was this hospital that killed him. They were so trigger-happy with medicines that they killed him. Before that, he had started picking up. When he went into the intensive care unit here — which is when I met Amit and Shibani — it finished him. I left him for a few minutes and when I came back he had tubes stuck in everywhere, and he was grunting and breathing terribly. He had burn marks on either side of his neck, which I never found an explanation for. I took him out of intensive care: I said he’ll die in my arms, not with all these strange faces peering at him. They’d put a central line in him because they didn’t have the patience to deal with the oedema from where the drip went in. I went back over the documents and saw that two minutes after they’d done that his heart had stopped beating.

“After he died I started my own investigation. In the early days I could only take a bit at a time because I would break down with the pain. But now I am starting to be much more serious. I am researching everything. Knowledge is never wasted. Money is wasted. Partying and merrymaking can be wasted. But knowledge, never.

“Twenty years ago, my husband’s sister persuaded their father to sign the family house over to her so she could sell it to developers without my husband’s permission. I went on a war footing. I had my own thriving business at the time but I put the whole thing on hold to throw myself into the legal battle. My husband couldn’t do it: he was ready to collapse, seeing his sister and father turn against him. For two years I did nothing else. I read legal textbooks and taught myself the law. I learned how everything worked. I learned to manoeuvre through the lawyer-judges nexus. And I fought the case myself. I was up against a big racket of builders and real-estate people but I won the case in two years. I made everyone’s life hell for all that time and in the end they had their hands together, pleading with me to leave them alone. No one could believe a case like this could be finished in two years — usually they take twenty. I had pulled out documents that no one could believe, ancient property files lost in Old Delhi.

“I learned the law then and I will learn medicine now. I helped at least twenty people after my court case and I will help many more when I find out what happened to my husband. I am hungry for knowledge. I worship knowledge. For me anyone is a superior person who can answer the questions that are troubling me.

“We didn’t have health insurance. We paid everything ourselves. The hospitals wanted to put him on a ventilator for a month so they could charge us 30 lakhs [$60,000]. They tried to put him on dialysis because they had a new dialysis machine. But there was nothing wrong with his kidneys.

“Terrible things went on. I met a woman who had come in for a heart attack. Her arms were blue from the wrist to the shoulder from tests. How many tests do you need to do to a woman with a heart attack? But you can’t ask any of those questions. Doctors have complete legal immunity: they ask you to sign forms at every stage indemnifying them. They are always offering you some wonder drug or other that will solve everything and will cost lakhs and lakhs. And after you have spent 40 or 50 lakhs and you are exhausted, they hand you a dead body and tell you to get out.”

Our coffee cups are cold.

Shibani and Amit are nodding to themselves. There is something remarkable about the complicity between these two cousins. Shibani is so meek in her appearance, and yet so powerful and impressive.

“You did everything you possibly could for your mother and for your aunt,” I say to them. “That must have meant something to her.”

Shibani glances at Amit.

“Actually we are not cousins,” she says. “We are in a relationship. But since we are not married, no one thinks I can play a legitimate role in this story of Amit’s mother, so we say we are cousins. The first doctors said to me, ‘She’s not your mother and you are not married to this man, so who are you to care for her?’ But I had to take care of Amit’s mother, because he was working.”

Aarti is surprised at this twist in their story, but she says nothing. The coffee grinder roars for a few seconds in the background. Everyone waits patiently through the silence in our conversation, not wanting to move.

Aarti says, “My husband was a tango dancer, a waltz dancer, a sportsman. He was a very hearty man. He was in love with life. When things started going wrong, he said to me, ‘If my legs go, I don’t want to live anymore.’ I said to him, ‘I’ll take care of you. We’ve been blessed with forty-three healthy years together. What does it matter if one of us is sick now? We can go on for many years more. I will give up everything to take care of you.’

“That’s what I did for those three months. He was never left alone. I never let them park him in a corridor which is what they always do. I said, ‘He is not queuing in a corridor on his bed where everyone can stare at him. He will stay in his room and come down when the doctor is ready.’

“But at the end, when I went into the intensive care unit here and saw him full of pipes I broke down and I said, ‘Go, go, my love, don’t stay in this world anymore. This is no life for you.’ And I took him out of there and back to his room. And I put on some beautiful devotional music from our Sikh tradition and I massaged his head all night. He was at peace, he was not grunting or making noises. He just slipped away. I stayed with him all night — but he did not die then. He knew that if he died, I would be left all on my own. He waited until the next afternoon, when everyone was there around us and he knew he could leave me with people who loved me. Even in death he was so considerate.

“I gave him a beautiful death. In all of this, that’s my only satisfaction.”

Aarti speaks with great matter-of-factness about all this. There is no outward emotion — except, perhaps, a certain zeal, for she is a woman in whom adversity releases great retributive energy.

“For forty-three years,” she says, “he gave me roses every Valentine’s Day. Once when we were in Bombay and he couldn’t afford twelve, he bought six. Other years he bought twelve or even twenty-four.

“This year I was talking to my sister in London and I said, ‘I’ll have to get used to not having roses on Valentine’s Day.’ But on the fourteenth, I arrived home in the evening and there was a massive bunch of roses from her. Her note said, ‘Aarti, he never left you. He will always love you. These are from him.’”

• • •

For most people in the world, medical adversity represents the greatest source of financial crisis, and India has never been any different. Until liberalisation, however, the cost of healthcare was lower by several orders of magnitude, not only because doctors charged lower fees, but also because the whole business was significantly less technologically intense. Magnetic Resonance Imaging (MRI) scanning machines, for instance, were rare, and most doctors made their diagnoses without access to expensive tests of these sorts. Drugs and therapeutic equipment, similarly, were both more rudimentary and cheaper before liberalisation allowed the entry into India of the world’s major pharmaceutical companies. So if serious health problems inevitably presented periods of financial stress, the cost levels were such that middle-class people could usually meet them by pooling the resources of family and friends.

The system worked also because doctors had high levels of prestige and credibility. While many government hospital doctors supplemented their income by offering private consultations at home in the evenings, in the hospital itself they worked for a fixed salary and had no financial stake in the diagnoses and treatments they offered. Their medical judgement was, in their patient’s eyes, uncompromised. There was every reason to feel secure, when consulting a doctor, that his or her interest was similar to one’s own.

After liberalisation this equilibrium was significantly disrupted. Government hospitals had by this time become conspicuously under-resourced, and the middle classes flocked to the new corporate hospitals. But the costs here were such that, in the case of the most extreme and drawn-out of illnesses, even affluent families could stand to lose everything they possessed. And though the middle classes began in the same period to invest in the new health insurance packages offered by private financial institutions, these were often adequate only for relatively minor treatments. Even the most comprehensive of them excluded treatment for several chronic diseases — various kinds of cancer, all illnesses resulting from HIV, anything at all that struck past the age of sixty-five — and total re-imbursement in one year to any one patient was usually capped at a relatively low level, usually between $5,000 and $20,000. The most devastating financial territory was entirely unsecured.

This already-dangerous situation was exacerbated by the new suspicions introduced by the conspicuous profit motive of corporate hospitals. There was no doubt that these institutions were corporations: they looked like corporations, they expanded — and bought and sold each other — with corporate speed, and they were administered by some of the country’s major financial interests. Patients in these hospitals were fully aware of the aggression with which big Indian businesses operated; they also knew that corporations were something of a fiefdom, whose practices went largely unscrutinised by any independent body — and they were therefore racked with uncertainty as to the nature of what was happening to them. Was this expense necessary to treat their condition or was the corporation simply trying to suck up their money?

As everyone knows who has moved from one country to another, the last thing one becomes accustomed to is a new healthcare system; and the shift to this new healthcare regime in India would have produced suspicion even if its integrity were beyond reproach — and in many cases, of course, it was. But there was considerable disquiet within the medical establishment too, and many doctors confirmed that the storm in patients’ heads was not only in their heads. A surgeon from a leading government hospital felt that his entire profession was under threat from the new corporate hospitals.

“They are money machines,” he said. “They are about revenue maximisation, pure and simple, and they have led to a dangerous collapse in medical judgement and ethics.

“Let me give you an example. A leading surgeon left his job at the government hospital where I work to join one of the big corporate hospitals. He was offered a salary of 2.4 crores a year [$480,000], which was ten times his previous salary, but it was dependent on him delivering 12 crores [$2.4 million] of revenue to the hospital. Now, if he did the maximum possible number of operations in a year, he still would not deliver 50 per cent of that figure. So the rest had to be delivered by diagnostic tests. Which is why there has been such a huge escalation in tests. Patients are sent to do repeated MRI scans so that doctors can meet targets. Some patients have very high radiation exposure as a result of all this.

“Certain surgical procedures are carried out almost without indication. Anyone who has upper abdominal pain has their gall bladder removed. Forty per cent of these procedures are unnecessary. But the patient doesn’t know that. It’s usually not possible for a patient to find any evidence of malpractice.

“Look at the rates of Caesarian section. Some of the most famous obstetricians deliver 70 to 80 per cent of their babies by Caesarian. There is hardly a hospital in this city that offers a natural birth service. Why? Caesarians make more money than normal births, of course, but more importantly they allow doctors to determine the schedule and to fit more women in. It’s much more efficient.

“The pharmaceutical and medical equipment industries have a huge role in deciding treatment options because many of these doctors are working directly for those companies, which the patient doesn’t know. Drug companies pay many oncologists 10 per cent of the value of the chemotherapy they prescribe; a typical figure would be a crore [$200,000] of prescriptions a month. Cancer of the pancreas is a favourite, because if you get to the stage where you need chemotherapy you are anyway going to die within six months, so doctors can prescribe whatever they like.

“These hospitals are very dark institutions, even at the business level. Land is acquired for them by the government at an enormously subsidised level, and often the government donates money towards the cost of setting up the hospital, on the condition that it allocates a third of beds to the poor. But the hospitals never honour such commitments: there is no question of them writing off those kinds of profits. Later on, they sell a share of their company to the public for hundreds of millions of dollars and the newspapers laud them as self-made billionaires. But their fortunes were built largely from public money.”

He talks calmly, but with brimming outrage.

“You should write your entire book about this,” he says to me. “I can’t do it because all these people are my colleagues. But someone needs to write about all this. Pose as a patient and see what happens. Start telling people you need to buy a kidney and see where you are led. In my hospital I worked with an anaesthetist who was involved in a big kidney transplantation racket in Delhi. Kidney transplantation is very easy: you can do it in a normal flat. And India is the diabetes capital of the world, so many people are proceeding inexorably towards end-stage renal disease, which is completely wretched. Add to that a lot of poor people willing to sell a kidney and the outcome is obvious.

“The whole industry has become very sinister. Where does it find its cadavers, for instance? With all these new pharmaceutical companies and research laboratories, demand is growing on every side. Tissue banks need cadavers. Every company that manufactures implants needs to test them on cadavers. Now, the Mysore Anatomy Act of 1958 says that only unclaimed cadavers can be used for medical experimentation. But large-scale entrepreneurial medicine needs far more than this. So now you have bodies being stolen everywhere. They disappear from funeral homes and end up in surgeons’ colleges and corporations.”

I tell him how I recently met a man who supplied cadavers to a dental college. I asked him where he got them from and he told me he fished them out of the Hindon river, a tributary of the Yamuna. He just sat by the river every day waiting for corpses to float down.

The doctor smiles.

“That river flows through Ghaziabad. A lot of those people whose bodies end up advancing dental careers would have been killed in property wars. Bumped off by rivals. It’s an appropriate image for Indian medicine today. Taking the chaos of our society and turning it into profit.”