TRIBUTE
The great `little' man
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Dr. K.S. Sanjivi was a pioneer in promoting the concepts of community health care and holistic approach to medicine much before they became popular. In his centenary year, the doctor's students and associates talk to RASHEEDA BHAGAT about their mentor.
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THE HINDU PHOTO LIBRARY
IT wouldn't be an exaggeration to say that no other doctor in this part of the world has inspired the kind of devotion, admiration, respect, affection, and even awe, that Dr. K.S. Sanjivi did among those who met the little big man. The only "small" aspect of the man was his size.
The early 1980s was an era when both doctors and hospitals were excited about the advent of sophisticated diagnostic tools and expensive investigative gadgets. When every other assignment on the health beat involved covering the launch of new gizmos, it was a refreshing change to listen to Sanjivi talk passionately about the best diagnostic tool of a physician being his clinical skill.
"These days, even before physicians touch their patients, they start writing out a long list of investigations," he would say with a frown. Commenting on how modern investigations, some of them done quite unnecessarily "because the hospital has to recover the investment in fancy machines", he would talk about the need for preventive and promotive health care, and a "holistic" approach much before the word became fashionable in medical parlance.
In 1958, this excellent teacher and brilliant physician founded the Voluntary Health Services in Chennai, building up a great institution from nothing more than a dream. Its basic concept was prevention and cure of diseases and an income-based insurance scheme for the entire family. Medical education, research and reaching health care to the villages, were some of its other goals.
Jawaharal Nehru laid the foundation in 1961— till then the VHS office functioned from Sanjivi's house — and the hospital started in 1963 with 50 beds. Today it has 405, with all specialities barring cardio thoracic surgery. Remembering his mentor, Dr. N.S. Murali, Secretary of VHS and general surgeon, who was Sanjivi's student and involved with the VHS right from the beginning, says, "He was a soft spoken man who never tolerated second best. He was a stickler to punctuality and total dedication to work. If you went to his OP at 7.05 am, he would say you are too early for tomorrow!"
Also, he never behaved like a superior and treated his juniors like partners. "He would walk into our rooms, instead of summoning us, and talk about our cases, problems and plans for the institution. He never took consultation fees in his house and admitted the patient in the hospital. By his principles and dedication he was able to inculcate the spirit of service in others. None of us thought of a fee for the services we provided."Dr. K.V. Thiruvengadam, former Professor of Medicine at the Madras Medical College, was also Sanjivi's student: "He was a physician, medical teacher and human being of extraordinary virtue. He belonged to that age of physicians who believed in an initial dialogue with the patient, assessing the problem after analysing the symptom and examining the patient fully before deciding on any laboratory tests. At that time very few sophisticated tests were available, so he relied on the person-to-person contact with the patient. He was a simple man who made no attempt to exaggerate his skills or abilities in any way. His teaching was marked by absolute clarity in any subject he taught."
Most people who knew Sanjivi refer to him as a "simple and straightforward man with clarity of thinking and approach". The ethical manner in which he practised medicine is recalled and cherished. "He would see patients only by referral. A consultant should be one who sees patients referred by the GP; he can't be the GP and see the patients directly, because the family doctor knows the patients best," says Dr. Thiruvengadam who became Sanjivi's student in 1947. "From then on till his death, I was associated with him in some way or the other. His last days were tragic; he was blind and confined to bed. It was a period of unnecessary suffering."
He disputes the perception that Sanjivi was short-tempered. "I have never seen him angry. If at all he became angry, he would keep quiet rather than burst out in a fit of temper. But he was not effusive, and never bragged about anything. When his son Guhan (former Finance Secretary in the Tamil Nadu Government) stood first in the IAS exam, he didn't tell any of us. He always underplayed the achievements of those dear to him."
He was a stickler for rules. When Guhan was Finance Secretary, Sanjivi wanted some subsidy for the VHS. "He could have easily asked his son, but he chose to go to the Minister, who asked him `why are you coming to me... your son is the Finance Secretary'!" That was the man... he never threw his weight around."
Dr. Thiruvengadam clarifies that the concept of community care became Sanjivi's passion after retirement. As a medical teacher, "initially he did not fancy becoming a director of medical services. But in the last lap of his service, he thought he should get the post because he was the senior most. But unfortunately he missed it and was greatly disappointed. But, in a way that was good, because it made him all the more determined to develop the VHS. This was no mean task and he really worked hard to raise the money, showing a rare commitment. He had to attune himself to a different wavelength in the medical field, but he switched over to community health very well."
One of Chennai's well known diabetologists, Dr. C.V. Krishnaswamy, who heads the Diabetes department at the VHS, where a special project on juvenile diabetics provides children lifelong free medical care, marvels at Sanjivi's ability to encourage youngsters and spot "potential leaders". Having worked under Sanjivi as an assistant physician at the Railway Hospital, where Sanjivi became a visiting physician for chest diseases after his retirement, on his return to India after further education overseas, "Sanjivi urged me to spare a few hours a week for the VHS. I joined the VHS in 1967, taking over the already existing diabetes clinic. He could give such responsibility to a young doctor. The man was a giant; and internationally well known for his work in tuberculosis."
But while doctors like Murali and he continue to work at the VHS, today, sadly enough, the institution of Sanjivi's dreams is not able to attract outstanding talent.
Dr. Murali attributes two reasons for this — capitation fees and commercialisation of medicine. A doctor after spending eight years on his education sees engineering and management students "being offered Rs. 20,000 or 30,000 at campus interviews. So how will he settle for Rs. 8,000 to 10,000?" VHS cannot offer better salaries because, with 70 per cent of the patients being treated free of cost, it is not self-sustaining. It was built with Sanjivi not leaving a stone unturned to raise funds. Today it gets an annual grant of Rs. 20 lakhs from the Tamil Nadu Government, but this is hardly enough.
"With the economic downturn in the last couple of years, company donations have come down, and individual donors are few. Today we manage because we pay only the nurses and the junior doctors and all our consultants are honorary. But that might not be for too long," says the VHS Secretary.
Appealing for donations, Dr. Murali adds that the core group managing VHS is using Sanjivi's birth centenary to collect a corpus fund and create new services and facilities "so that we need not depend on philanthropy. We have to reorganise the system to become self sufficient."
He adds that Sanjivi himself was against giving away anything free and had initiated the concept of family insurance. For a negligible monthly amount, the family members were eligible for free medical treatment. But even this scheme was not a success "because the concept of paying when you are well is not there in our country. So the renewal of the premium is practically zero, even though it is as little as Rs. 50 for the free group and Rs. 350 for the top-end group." The VHS also has an image problem; it is seen as a "poor man's hospital where people do not want to be seen."
Today the concept of community health care has gained ground, particularly in rural areas. "Preventive and promotive health care that he emphasised, compared to curative care, have caught up and every hospital now talks of village programmes and immunisation. The mini-health centre, which is a forerunner of the PHC, was his brainchild and we still run 14 mini-health centres where there is ante-natal care and other services," says Dr. Murali.
But while these are the nuts and bolts of the health care delivery system that Sanjivi conjured four decades ago, what about the values he stood for? Are there doctors who swear by values that made medicine a profession quite different from others?
Dr. Murali's response: "You can count the number on the fingers of just one hand. Today we don't have role models because of commercialisation of medicine and capitation fees. Medicine is seen not as a service but as an industry. What can you say of an era when girls enter medical colleges so they will have to pay less dowry and then don't practise after marriage?"
But Dr. Thiruvengadam is more optimistic... and generous. "I feel the generality of doctors is good and want to stand by the profession. I see some of the finest GPs today. Of course there are a few black sheep."
On the commercialisation of medicine, he says medical care is expensive today because of the high investment in big hospitals. "But though expensive, some of the sophisticated investigations are saving lives today."
On Sanjivi's birth centenary, the profession needs to reflect on what he often said: "In India, where poverty kills the initiative of the people, particularly the illiterate, we cannot wait for patients to come and knock at the doors of big institutions, because often that is too late."
E-mail the writer at rasheeda@thehindu.co.in
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