Dr Hema Divakar is a leading obstetrician and gynaecologist in Bengaluru, a leading Indian specialist in high-risk pregnancy and foetal medicine and a visiting faculty to Devraj Urs and Kuppam medical colleges. She is also president of the Federation of Obstetric and Gynaecological Societies of India (FOGSI) and is involved in policy making for the Government of India on women’s health issues.
In an exclusive interview with AalaTimes, Dr Divakar shares her mission of providing affordable and accessible healthcare for women in India.
Please tell us something about yourself. How has been your journey so far as a doctor?
I was born and brought up in Mumbai. My grandparents were from Karnataka but my father was working in Mumbai. I have done my MBBS (GS Medical College / 1982) and MD (Obs & Gynae / Wadia Maternity Hospital / 1989) from Mumbai.
It was my passion to pick up one course every year. So I did my Postgraduate Diploma in Medical Law and Ethics; Diploma from All India Institute of Management; Masters Degree in Alternative Medicine; and PG Diploma in Preventive and Promotive Healthcare etc.
In 1990, we established Divakars Speciality Hospital for women healthcare in Bangalore. So from 1990 onwards the journey in Bangalore is still going on. We established some quite niche segments of healthcare such as high-risk pregnancy, diabetes in pregnancy, recurring pregnancy loss, fibroid clinic and the genetic disease clinic at Divakars Speciality Hospital. For adolescents, we have Yuva Clinic. In productive age, diabetes in pregnancy (DIP) is a huge phenomenon in the country, so it needs a special focus. That’s why we have a DIP Clinic for it. For 40+ generations, we are labelling it New Life Clinic because it’s a new beginning.
What made you specialize in Obs & Gynae and later take up courses in medical law and ethics, management and alternative medicine?
Gynae was my first career option. All other degrees I picked up after I started my practice because I wanted to do my hospital management in a more professional manner. In those days we had to double up both as clinicians and managers. I believe that whatever I do, I have to reach an excellence. One day in a five-star hotel, I saw an ISO certification and thought what it is all about. Then I decided to get this certification for my clinic as well. So in 1994, our clinic was the first private hospital in Karnataka that got an ISO certification. Passion for quality healthcare is my tagline. Everybody asked why are you doing it; has the government mandated it; or what are you going to get out of this? I didn’t listen to anybody. It’s just that some quality standard put up made life so easier, really!
At the same time, there were so many litigations happening and I was called in as an expert opinion maker for those cases. But I said no. Then we approached the National Law School in Bangalore to bring in the course of ‘Medical Law and Ethics’ and we were the first batch and degree holder of this course. I am very passionate about doing the things, which I want to do.
I am also passionate about Holistic Healing and Music Therapy etc. So that’s how I did my MD in Alternate Medicine, which encompassed naturopathy etc. I did all this because I wanted to have insight into what are the other things beside mainstream allopathic medicine.
The mindset of people in India is that they come to you only when they are sick. There is no concept of preventive healthcare. Preventive illness and promoting wellness is again a strong mantra, which we want to cultivate.
That’s how I started taking one degree after another and I believe there is no end to learning. I always want to remain a student, as you can never say you know all.
How has the field of Obs & Gynae developed in India?
India is a very challenging place to work. Necessity is the mother of invention, this holds very true for our country. If we see our rural practitioners, they have their own novel ways of tackling certain situations based into Indian context. The standard of care if you want to see in the high level tertiary care institutes is best in the world. Our surgeons are superbly skilled because they handle so much volume of work. Practice makes you perfect.
The cost of healthcare in tertiary care institutes may seem high in the Indian context but in the overall world context it is very-very cheap. Also, if we look at care and compassion, I think we are much better than that of the western world.
I can say we are well positioned as far as the rich sector is concerned but as for the poor it’s like all here and none there. That’s the gap we want to bridge because there should be health equity.
In our country there is so much importance given to so many things but not to healthcare. And even in the healthcare sector, so much importance is given to cardiac surgery and hi-fi things but not to women healthcare. It’s not like a woman is sick always but it’s a dictate of nature that she has to reproduce, it is a job that she has to do to propagate the human species. She is putting herself into so much risk, it may even cost her life and she is not getting enough care, so it’s not fair as we think. It’s a matter of human right that she needs to be taken care of because in the west there are only 16 women out of 1 lakh who die during delivery. But in our country the ratio is 230 women out of 1 lakh.
Schemes by government such as Janani Suraksha Yojana (JSY) have driven many people to healthcare institutions but I can’t say how successful it is. Because it’s like we are throwing them into a place where there is no guaranty for cleanliness and hygiene; there is no guaranty for the availability of specialist doctors; there is no guaranty of availability of healthcare providers 24×7; there is no guaranty about the competency of healthcare professionals and no guaranty about their standard of practices. But volume has been pushed there. You can get 100 times better results if the institute is strengthened by the competency. That’s where we are bringing in this ‘Helping Mothers Survive’ concept on a fast track.
It’s not like that our doctors and nurses are not doing good job but the number of patients is so high that it’s humanly impossible. You have to provide more human resources and also have to shift the task. The lower cadre can look into routine things and only serious matters should come to senior doctors. So this kind of managerial thing, distributing your expertise and resources well – that needs a lot of attention.
You can’t blame doctors as they are working under huge pressure. And if something happens to a patient then doctors are beaten up. People want 100 per cent guarantee for everything. So, that’s another threat.
FOGSI has declared zero tolerance for violence against doctors. You can’t beat up a doctor; it may be a wrong judgment or negligence also but that does not have to cost his or her life. You can prove him guilty or not guilty, you can make him accountable in some manner, take him to court, that’s the process but nobody wants to follow the legal procedure.
What have been the innovations in this field since you joined the profession?
The new innovations that are more exciting are innovation with low cost. Suppose there is a protein test that we have to do, so one strip the doctor is cutting into three, which costs about Rs 50 each and costing about Rs 200 for one strip. Now, JHPIEGO (John Hopkins Programme for International Education in Gynaecology and Obstetrics) has come up with an innovative pen that can do 400 tests in less than 10 cents (approximately Rs 5). It is a low cost innovation that any layman can do. It’s not like anything hi-fi for which any expertise is required.
Likewise we have innovative devices for protein test, blood pressure measuring devices, electronic records which report whether a delivery is progressing properly or if there is need for doctor’s help. So for these kinds of devices you don’t need to have any expertise. These kinds of simple medical gadgets are reliable, easy-to-use and can be taken home-to-home. This is for masses.
Technology based devices at higher-end care such as harmonic calculator etc, which are very costlier, are also now available in India. So the both ends — home-to-home and higher-end care — are getting exciting day by day with these kinds of innovative devices. Also, mobile devices for breast cancer detection etc are available nowadays. So, we are merging IT into medicine to get best out of it.
What are the issues FOGSI is going to focus on during your tenure as its President?
The major focus is on saving mothers. But we started four years ago with save the girl child programme. We believe that let her born, the next step is educate her because that has made a huge difference in neighbouring countries; so, save the mother, save the girl child, give her education, save the next generation, enhance the quality of her life, allow her to age gracefully. It’s like a journey through the ages but the key focus remains on saving mothers.
How the federation is going to help address the issue of sex-selective abortion and the need to save the girl child?
We want to finish the demand and supply of pre-natal sex determination and abortion of the girl foetus — the supply from the doctor’s side and the demand from the family and patient for these kinds of activities.
We are suspending the membership of clinics or doctors who are involved into such kind of crime as FOGSI can do only this much but it’s quite a shame to know that one is suspend from such an organization which has enough impact on peer group to avoid these kinds of activities.
We are also informing the concerned authorities that there are the doctors performing these kinds of activities so that the supervisor and inspectors could catch them.
District health officers and FOGSI are working together to discuss what should we know and what should patients know during the filling up of forms and about the laws etc.
Save the girl child is a major initiative but the change in the mindset of society will take time to come and also education will matter into this as well. We are also running health education programme back to back with many other programmes — school programme, college programme, public forum programme etc. Also with Yuva Clinic, DIP Clinic and New Life Clinic, people are getting awareness that there are also some niche areas that they have to look for. Overall the challenges have to turn into opportunity.
What are the major problems that your members are facing? How is the association helping its members?
Most of the time in sex selection cases, wrong doctors are caught, wrong machines are sealed unfortunately. The right ones are also caught sometime but they know how to escape! Public take direct action on doctors, they beat up doctors, ruin their clinic — that is again wrong. So, the challenge FOGSI members are facing is that many of them are held up for wrong things. Then they will say, why FOGSI is not doing anything. FOGSI can only do as much as it’s allowed in its framework because it’s an organization. It can suspend someone or educate people what are the do’s and don’ts. We have also created a cell in FOGSI for violence against doctors.
Also, communication is really lacking because patients are not told clearly what we are doing and why we are doing it. On one hand the older generation is not so much used to talking so much in a compassionate way because they are looking more at the machines than patients, second thing is lack of time. In one hour if an Indian doctor sees 20 patients, in one hour a doctor in US or UK will not see more than three because about 20 minutes he has to give per patient. Here we give two minutes per patient because there are hundreds waiting in the queue. Not in all centres but in many. And by the time he finishes his hit list he has other things to do, surgery, reports etc. The days and nights are hugely challenging and nobody can work as hard as Indian doctors do. But now the lifestyle of younger doctors is also changing, they want a life outside medicine too. And that’s very challenging because of volume of doctors available; nobody wants to take a job, which is 24×7.
Do you think that the PCPNDT Act has become a source of harassment for doctors?
I feel that law is needed but everything can’t be sorted out with the law. The final answer to all this is that each doctor should feel that they are doing wrong. It has to come from within. As far as the PCPNDT (Pre-Conception and Pre-Natal Diagnostic Techniques) Act is concerned I feel that it is needed, as at least there is something in the law.
FOGSI has issued a zero tolerance level to the supply of technology for sex determination. But some doctors might be doing it and that we need to cut down. So we are taking a pledge in every meeting because it’s like reemphasis to our own mind and mindset that don’t do this. This is a small step but the number of doctors doing sex-selection is decreasing day by day. And eventually it will come down to zero because even if a patient or her family asks for it there will be zero supply.
Secondly, the DOSST (Doctors Opposing Sex Selected Termination of pregnancy) cell is created in every society of FOGSI to keep an eye on whoever is doing this kind of activity and if someone is doing this, it is reported to the concerned authority. And the third thing is to suspend the membership of such doctors irrespective of where they come from and whatever their position is.
Have you noticed any trend in the number of caesarean operations being done in India?
This is a common perception that more number of caesareans is happening and the common perception is not wrong. We believe that the average number of caesareans should be anywhere between 15 and 16 per cent but in many of the urban centres we see as high as 60 per cent caesarean deliveries.
There are two important reasons for that — one, a new issue of request by the patient has been seen; nowadays it’s legal to request for caesarean operation and doctors can’t refuse that. The second issue is of high-risk cases such as taste-tube babies, elderly motherhood, diabetes in pregnancy etc. Ultrasound is a technology which helps us know that this baby is in trouble so pull it out now and then there are many indicators which have been expanded over the years.
One should also look at what kind of centre it is — if it’s a referral centre then it might have more number of caesarean percentage. If it’s a normal centre where normal deliveries and caesareans are done then it should not be very high. And if there we see a rising trend of caesareans then we need to check as why this is happening.
But overall, caesarean is a safe operation that’s why many are boldly going ahead for this and the second thing is the outcome. Fifty years back when caesareans were not done so often there were more mothers and babies which were dying because of lack of intervention. The outcome is really better now; it’s better to do one caesarean extra than to lose a mother and baby. In that context if you see, you have to trust and give a little bit of margin.
But, of course, there are black sheep here also; we can’t say that everybody will be doing very ethical practice but we are trying to bring in more and more ethical fibre, that’s the value which we are losing; so FOGSI is extremely cautious of that. We are getting many of our senior members as keynote address on ethics in medical practice because it will inspire the junior cadre to see that’s the way they should be.
How unethical is the practice of on-demand caesarean section operations? What should a doctor do when her patient demands such an operation?
Doctors should not think that’s the easy way out; they should not readily agree on that, instead they should ask the patient why she wants to go for a C-section. If it’s out of fear of labour pain which she will have to go through then doctors should reassure the patient that they have labour anaesthesia and the epidural which she can take to make the delivery completely pain free. There should be proper counselling before any further step is taken.
What could be the reasons of the troubled doctor-patient relationship in the present times? What should be done to make this relationship more cordial?
I personally feel that we must raise a voice from the demand side i.e. the patient side. She must know her rights that she can ask her doctor, she has the right to choose, she has the right to have the doctor’s time to discuss if she is not in agreement with what the doctor is saying or if she has a doubt and the doctor has to comply by that.
But as we know time is a constraint. Even if the main doctor is busy, he or she can groom the juniors who can spend that much of time with patients. Even the other members and the staff nurses, the entire team should be on board to answer any query that comes from the patient side. There are also other medium such as emails, chats etc — even I answer more than 200 email queries per day.
What measures should be taken to tackle the menace of breast and cervical cancer?
For breast cancer early detection is important; so self-detection and annual check-up will help largely in this case whereas in cervical cancer, primary prevention can be done by the HPV (human papilloma virus) vaccine.
Cervical cancer is caused because of viral infection where as other cancers in the body can have many reasons for that. By just stopping some virus you cannot cure your liver cancer or lung cancer. But if somebody has cervical cancer hundred per cent of them have to be have this infection because without this viral infection one cannot have cervical cancer. That is the major breakthrough that we have got in cervical cancer.
There are 100 types of HPV virus out of which 98 are detected and vaccines have been made for that so if you take the HPV vaccine that means you are 98 per cent covered. For the other two viruses, vaccine has not been developed yet but these two are very rare. These are early prevention but the screening programme that we have such as the Pap smear (Papanicolaou test) or the HPV test or the annual check-ups are for early detection because cervical cancer is a very slowly evolving disease. If one is getting infected today with the HPV virus, it will take 15 years to develop it into cervical cancer.
How safe is the HPV vaccine?
It is like unprecedented scientific evidences available for the same. The ICMR (Indian Council of Medical Research) and the government of India have published a document which speaks about the HPV vaccine’s safety because all other developed countries have got it into the government programme since the safety is unquestionable.
How do you think the country can bridge the huge gap between demand and supply of qualified medical practitioners?
Public-private partnership (PPP) is one way because many are going to private institutes and private people are handling most of them. Many islands of excellence can be created with partnership between private and public institutions. The bottlenecks can then be avoided and insurance schemes can be put into place. Affordability and accessibility, if we jell all of these, the healthcare will definitely improve.
The problem in our sector is life is a life it can’t be categorized. Whether you are poor or rich, your life has to be saved. If you don’t have money, you have to die; if you have money you can get best of the care — this situation is a pure no-no in the healthcare sector. We have to bridge that gap; everybody cannot be served for free, so the public-private partnership has to be stronger because that’s the way from where the healthcare for everybody can come.
It is reported that unnecessary hysterectomies are being performed in Indian private hospitals to economically exploit poor women as well as government-run insurance schemes. What’s the reality?
We at FOGSI perform many ground reality studies and the reports are true. Sometime we think that just because we are not doing it, it’s just the hyped-up thing but it’s really true. Here again because the patient is not questioning why this has been done, doctors are misusing this silence.
What we found out from our studies is many of our women in villages are told by their elders that now that you have finished raising your family, you better get rid of your uterus now because sometime in future if it gives you trouble and by that time you will be aged and there would be other diseases so better you remove it early. That is the kind of teaching they are giving to their women, which is wrong. So, for this, women need to speak up, raise the noise level; they should know what their rights are.
What’s the most difficult personnel decision you have made so far in your career?
The most difficult decision would be the decision to take up the post of FOGSI president. It was a very difficult decision because it is a post which needs special attention and everybody’s expectation is sky-high. There are lots of challenges but I think there is lots of hope in the country and in our society that we have to make India the world’s No. 1 destination for women’s healthcare. We need to facilitate so many things between the practitioners and the government, the practitioners and the police, NGOs, so that is the link and networking we have to do. So, that’s a challenge.
What’s your message to the budding obstetricians and gynaecologists?
Don’t think that what you do doesn’t matter because every bit counts. Each one has to do their bit for the country. Since we have progressed a lot, in the next ten years India will be the face of development in all other sectors. If we want to showcase better healthcare, we need to integrate our ethics and skills, care and compassion which we presume was natural in generation previous to us, but the younger ones have to be specially coached into it; we have to pay attention on that as well.
by Rajni Pandey