Dr Ashok Seth, who is credited with pioneering many cardiological techniques in the Asia Pacific region, graduated in Medicine (MBBS) from the Jawaharlal Nehru Medical College, Aligarh Muslim University in 1978. Later he went to the US for higher studies and served as a cardiologist at the Queen Elizabeth Hospital of Birmingham University. He returned to India in 1988 and joined the Escorts Heart Institute, New Delhi as its Chief of Invasive and Interventional Cardiology and established the Invasive Cardiology programme at the institute. Currently, Dr Seth is Chairman of Fortis Escorts Heart Institute, New Delhi and Head, Cardiology Council of Fortis Group of Hospitals.
A recipient of the Order of Isabella the Catholic, Dr Seth was honoured by the Government of India with the fourth highest Indian civilian award of Padma Shri, in 2003, followed by Padma Bhushan, the third highest Indian civilian award, in 2015.
Since Dr Seth’s childhood was spent in different states, he finds himself fortunate to learn and know the diversity of language and culture for which India is known worldwide. A Punjabi by birth, Dr Seth spent his initial schooling years in Bihar and later studied in West Bengal upto pre-medical level. During his early schooling period in West Bengal, he witnessed the tremendous changes that were happening in the society, anxiety in the youth, fresh and extreme ideas they would have.
In an exclusive interview with India Medical Times, Dr Seth shares his childhood memories, dreams as well as the future ahead:
Tell us something about your childhood? If you were not a doctor, what profession you would have chosen?
When I was very young, I was very fascinated to become a pilot. I wanted to join the Air Force. I used to read a lot of war comic books — World War I and World War II. Once my father presented to me the Reader’s Digest’s volume related to World War. It had great stories about heroism, courage; it showed how courageous some of those fighters were and how they battled for their country. And some of these heroes were pilots. That gave me the inspiration and dreams to become an Air Force officer and fight for my country but, of course, that was not acceptable to my family at all. So, if I were not a doctor, I would have become a pilot. But I don’t think there was anything else in my mind. In a way being a doctor is something similar. I am still serving the country; I work hard, and am responsible for lives; so, in a way, I am doing exactly what army pilots are doing for the nation. For us, it’s a war against disease, to save the lives.
How the idea of becoming a doctor came to your mind?
My father wanted me to be a doctor. And there were not many options at that time. Life and education is much better now, there are so many options and career choices but back at that time, there were only two — either become a doctor or an engineer. Any if you wanted to become any third that was not acceptable. I remember my father telling me, when I told him that I wanted to do B Com, “Do you want to become a clerk in your life”?
So, apart from becoming an engineer or a doctor, the only third option was the Indian Administrative Service (IAS). But you won’t believe at that time a career in Railways was fancy; I remember my father once suggested — why don’t you prepare for admission in Jamalpur Railway Engineering College. Everybody used to be fascinated with the railway officers living in big houses — Railway quarters — and most of the junction towns were smaller cities but with huge railway quarters and then travelling in AC 1st Class railway bogies etc. Little things in life would make people think that these were good professions.
So, with these two options (engineering and medicine), my thought was clear that it had to be medicine rather than engineering. While I started my career in medicine in Bengal, many of the changes which were happening there in the society affected the education, exams were delayed etc. So, education was far getting behind. And then I decided to take the All India Institute of Medical Sciences (AIIMS) entrance exams so that I could move out of Bengal and become a part of the medicine world.
Is there any plan of Fortis entering the medical education?
Yes, of course, there are plans for medical education and I think once healthcare delivered, the automatic situation is that India needs good doctors, India needs more doctors and we have to be a part of that education system. We also have the ability to train them, teach them, to help the country as well as the healthcare industry because we need good doctors also. So, yes, that’s a normal plan and discussions are going on in Punjab, and very soon we will enter into medical education.
What should be done to realize the goal of Make in India, when it comes to medical equipments?
The single agenda we should have — all of us, the govt and the private sector — is how do we decrease the cost for the patients. Unfortunately, the stakeholders just stick around the table and don’t find the good solution. Any decision being made is a unilateral decision — cut the price of the job, cut the price of exams, put a ceiling to this, put a ceiling to that, do it free. But one has to understand that the government is shying away from its responsibilities.
Nobody can have free treatment in the world. It is too much to ask any country to provide free treatment, even developed nations such as US and UK can’t. But they created a system where even the poorest of the population can still have good care. I agree that government’s responsibility has to be good hygiene, sanitation and infectious disease control at the ground level. If you can’t provide food, sanitation, hygiene and infectious disease control to your population then you might not be a good government. The government will have to realise that it can’t provide better care to 1.2 billion populations for free. If you have to provide good quality care, it has to have a partner and has to create a system where care can be provided at a low cost. And low cost cannot be a unilateral decision. It has to be public-private partnership.
Govt can cap the price of imported medicines and equipments but it can’t cap it enough to make it practically affordable to common public. Why don’t we encourage indigenous manufacturers and create a medical equipments manufacturing zone. Let’s take taxations advantages for the creation of new devices in the country. Let’s put down legislation and rules for quality control of those devices so that we don’t put rubbish into people’s body. Let’s create devices which are not only good but are quality tested also. But all this will happen only if the stakeholders sit together. We need to create micro insurance schemes more and more. We know the benefits of these schemes but yet things are not moving fast enough in any direction. At the end of the day, the government and the private sector will have to understand the benefit of public-private partnership.
At this time, the government and the private sector are sitting at the opposite side of the table, each suspicious about the other. Everybody will have to understand that while the government has the reach, it can’t actually service people, and the private players have the ability to service people but have not got the reach. If the two combine together then the reach and service can be delivered. Cost can come down, what we need is partnership. The agenda of both, the government and the private sector is same — how do we deliver healthcare to the citizens. The government should look at the private healthcare as — thank god we have got this group who are actually servicing at least the people who can pay so that we can concentrate on the people who can’t pay.
What would happen if the private sector were not there like in UK? UK did not have private healthcare, it got drained because the government had to pay for even those people (richest citizens) who could afford for themselves. Let’s try to deliver quality care to common man at low cost. Why should a common man get poor quality care, stent just because service is free? Let’s not differentiate quality care. If the partnership is correct, even the poor person will actually have quality care at an affordable cost. The cost may be borne by government or private institutions but the cost can be cut down. The second thing is — how the partnership can be evolved.
We can create six or nine more All India Institute of Medical Sciences, no matter what the numbers are, all of these institutes will be flooded with patients and the reason being everybody with any disease lands at these institutions even though they could have been treated at the district general hospital. There is no treatment done at the district hospital. Across the world, the district general hospitals are actually able to take care of 70% of these diseases and then they refer the rest 30% which they can’t take care of. But the scenario in India is different, the district general hospitals here can’t treat a heart attack, they can only do simple operations. If we don’t have good district general hospitals then what are we talking about creating All India Medical Institutes. Every country has the most robust medical system at district level because they are able to do 70-80% treatment right there. The government is not being able to take care of it; it has only managed to take care of the primary healthcare system. And, of course, that should be the focus, 70% of our population rely on primary healthcare centres. But to get to one district hospital every patient has to travel at least 150 miles to a healthcare facility where even 20% of what we do here is not available. So this is where a public-private partnership comes in.
Public sector needs to go to tier 2 – tier 3 cities and the government needs to provide the facilities; here are our already established hospitals without any equipment which we have been trying to run, the institution is there, the building is there, here is our partnership, take this up. Treat 70% of the cases here, treat x number of patients free, take 10% of the profit. I don’t know why we are not doing it here, it happens across the world. But we tend to create more hurdles than the solution in our own healthcare systems. The two groups are working far apart, talking to each other infrequently with suspicion, trying to create a partnership which travels very slowly. The government feels that the private players are there to make money; private players think that there is inefficiency and red-tapism in the government sector. I hope that it changes; I am not saying that it has not changed in the last few years but the rate of change is slow. Every time we open a facility in a tier-2 or tier-3 city, the medical cost is decreasing for the common man because we are bringing the healthcare at his doorstep. If a person has to travel from rural area to urban healthcare facility — the cost spent on travel, food and stay of all the family members travelling along will increase the treatment cost. Now think of a district general hospital partnered with the private sector in a tier-2 city, for the patient residing nearby that will decrease the cost to 70% because he is saving on those extra cost of travel, food and stay. Now the whole government agenda revolves around ‘do it free’ — no world has done it free. Somebody has to bear that cost.
England tried to do it free and continued to do it free but later they rapidly transferred it to some sort of business where they asked rich people to take private insurance schemes because the waiting list for a knee replacement surgery went upto seven years, for bypass surgery it went to one year because it was a free system. People used to die on the waiting list if there was no backup. So, a free system can’t function, it has to be subsidised. And it has to be subsidised intelligently in a manner that patient and government both can benefit. We are very late for that, the government should have done it 20 years ago knowing how a whole of Australia gets added onto India every year. The reason we are far behind is because healthcare is nobody’s important agenda, it’s just a talk and the country carries on. One thing, which I am very happy about, is that at the grassroots level of sanitation, hygiene and infectious disease control focus has been there. Things have got well over the years at the grassroots level of at least focusing on these core issues.
The biggest brunt of healthcare delivery is falling not on the poor people or villagers, it is falling on the middle class of this country who take a lot of brunt of this country on their own soldier, work hard — these are those teachers, those factory workers xyz. Middle class healthcare is looked after by very few and yet they have to pay a heavy cost for their healthcare where 70% of their earnings are destroyed. And the aspiration of getting good education for their children, marriage, retirement or to build their own home goes in a jiffy for a single bypass surgery or angioplasty.
How reliable are indigenous stents? What has been your experience in using them?
I am a great proponent of ‘Made in India’ and therefore very actively involved in it. In Vapi (Gujarat), Haridwar (Uttarakhand) companies have come up which actually manufacture good quality stents, and I am proud of some of these Indian companies because they are now representing worldwide and talked about. I have done the first study on two of the companies making stents and actually proved them and now the paper is into publishing proving that they are good. The important thing is that the research and science here is not very robust because when we talk about stents from outside, the FDA (US-FDA) and many other countries mandate rigorous science, research and trials, they want a large amount of data on a large number of patients over a long period of time to be satisfied about the safety and the effectiveness. Unfortunately, those legislations are not in place in India. In India, what is needed is 100 patients and we put it in them and as long as they are fine it’s considered OK. But that’s not a (safe and effective medical) device; a device needs hundreds and hundreds of patients to be followed up over the years to tell you it’s safe. The stents made in India are not truly Indian; though they are made in India, they are copied from the West. Yet we should encourage them because if the cost is low, that’s what matters, we copied well (smiles)! The quality control relies on the company itself, the proof of it in large trials doesn’t exist, so there is always a concern that we have done it only in X number of patients. Is it going to be good if implanted in 2000-3000 patients? Are we going to see the effectiveness in the same manner? It will take time to recognize a good level of stents as compared to the West.
Do you think stents are overpriced in India and should their price be controlled by the government like the essential drugs?
Stents’ cost can be lowered down definitely. Government needs to sit down with the stakeholders, coming to a conclusion. It can’t be a unilateral decision. Then only we can get best advancement of science and research. Of course, one can get a stent at Rs 15,000 as well as at Rs 50,000. The lower price one can be outdated rubbish just like an outdated car or computer. But here we are dealing with the human life; we can’t compromise with the quality. The issue is you can’t take the unilateral decision in a situation where a patient’s life is concerned.
What are some of the initiatives taken by Fortis to make India as an attractive place for medical tourists? What are the future plans in this regard?
Medical tourism is a very important aspect not just in monetary terms but also because of the fact that India is a leader in healthcare delivery and people are going to travel for medical needs. We have the best expertise, equipments and world’s best hospital in our country. We are compassionate people in general; we are caring in nature. Patients, who travel to the West, pay five times more than the cost and here we can do that at lower cost. So, it is natural to expose ourselves to patients worldwide. Patients from all over the world should come here for treatment. Another aspect, are we having lesser number of our own patients that we are looking at the patients from outside world? Yes, if money making is the concern. We can charge them extra; anyway we are doing it at 1/5th of the cost. For every 4-5 foreign patients we treat, if we are able to subsidize the cost for a couple of Indian patients then why not? That way I will be happy to push the medical tourism, let flood our hospitals with foreign patients provided we are able to subsidize our Indian patients. Otherwise I say all we are doing is to make sure that it’s a good business; the bad thing about this thing is that when we push medical tourism, a lot of hospitals look at it as good business. And business should not be the thought process. The issue should be how can we actually take the advantage of patients coming to us who have the capacity to pay so that we can actually provide them the service and earn such money that we can subsidise enough of our Indian patients.
Recently, you received the Padma Bhushan award and now Fortis Escorts has been judged as the “best single specialty hospital in cardiac care”? How awards are important in your life? How do they help an already well-recognised individual and institution?
It doesn’t affect me; after all, I am just a focussed, compassionate person doing a job sincerely hour after hour, day after day to the extent that I don’t have much of social life, or much of family time. So, when these awards come, in a way, I am thankful to God that he put me in a profession which gives me so much of joy that I don’t feel it as profession. For me, work becomes easy as I enjoy it. It is a joy that I get working day by day. Personally, I am very thankful for being recognized for these all. It is always encouraging to have peers association but it also puts a responsibility on me to continue to deliver best of the best. And it is the responsibility that I will love to take and each time I get these awards I have to get better, I cannot be any worse. Because I become the representative of that award and that award is representative of what I can deliver. It gives me joy, satisfaction and makes me more responsible.
CritiNext, the critical care venture, has been quite successful. Is there any other field where telemedicine has huge potential?
The other fascinating thing has been dissolvable stents. Recently, my editorial came out in one of the biggest journal of angioplasty across the world. I got to review the dissolvable stents and made up of what I have done, techniques used, our representative of what the world is doing now. It is one of the big areas which we are showing path to the world. I was asked to demonstrate live thesis to the United States, Europe of things which we have pioneered, recognize as the top most people in the world in the bio-dissolvable stents. You sit in India and some of the techniques you use become standard in the world. We may have imported stents from outside and now we are showing how to implant it.
by Rajni Pandey