The doctor in the 21st century
I WAS brought up and educated in the colonial era. I practised conventional western medicine in an urban environment. I have been a witness to the heady post-World War II days when, with the emergence of some effective antibacterial medicines, diseases which were formerly lethal, such as pneumonia or tuberculosis, could be effectively treated. Western medicine, which used to be more or less at par with traditional systems of medicine before these discoveries, suddenly surged ahead. I was full of optimism that soon we would have answers to most problems which beset the health of our people.
I am now getting somewhat disillusioned. Not only are we nowhere near to achieving our earlier dreams of conquering diseases or providing an equitable service to our people, we are actually witnessing the congealing of what was at one time considered a healing profession into something mechanistic and often commercial. The healer who provided comfort and support to the sick is becoming a relic of the past. We may have become more efficient but, in the process, somewhere down the line, we have become less humane. And we, who at one time occupied a lofty position in society, are under attack. Where have things gone wrong, and why, is something I have often asked myself.
It is not uncommon, as we grow in years, to look back and romanticise our past, fondly recalling the glory of yesteryears. ‘How good things were those days’, we say. I do no want to indulge in the luxury of such ruminations. But I do believe that we have, for all the progress we have made, lost out in some precious things and restoring some of these does seem important to me. I confess I have little to offer except to make a very personal and experiential statement. I have found this a useful and salutary exercise to attempt.
When I first entered medical school, medicine was considered a good profession. I did not imagine I would make a lot of money, but I hoped that I would earn the respect and affection of my patients, and even though I expected to lead a hard life, I knew I would be reasonably well off.
My medical school had some good teachers as also quite bad ones. But the good teachers were very good indeed. They were interested in their students, knew them by name, and offered an example of simple living and high thinking. Perhaps, being subjugated by a colonial power, they subconsciously wanted to prove that they were in no way inferior to their British counterparts. This made some of them fiercely independent and we almost worshipped them. Most of them did not engage in writing research papers and yet were quite original. Fancy audio-visual aids were not available to them and they made up for this by developing powers of expression which are seldom encountered these days. They were accessible to us and took pride in us if we performed well.
During my student days, I had an opportunity to see and hear some of the great teachers and clinicians of our country. They made a deep impression on me. Above all, they oozed wisdom, scholarship, goodness, concern and humility. Where is this class of people today? And why are they fast disappearing?
At that time, medicine was more of an art than a science. We had nothing specific to offer for our common killer diseases and so we largely relied on what would today be classified as the non-technological function of medicine. This meant a lot of talking, holding of hands, standing by and caring. Non-technological though it was, it was very valuable because it provided the family comfort, confidence and reassurance, and these were then, as indeed they always will be, a very important ingredient in the equation for recovery. The good doctors understood their society, and possessed a lot of wisdom.
Traditional healers, it should be remembered, were much better in this art. They were rooted in our traditions and culture and understood the way our people thought. They used a language and idiom which was understood by their patients. Since they had lost the patronage of the state, they were gradually elbowed out of the urban areas. Rural India was always neglected by our imperial powers and this is where they survived and do so even today. If one wishes to have a feel for these two contrasting systems, western and traditional, I cannot recommend a better source than Tara Shankar Bandhopadhyaya’s great Bengali novel, Arogya Niketan. I think it should be made compulsory reading for all our medical students. There cannot be a better introduction to wisdom, as opposed to smartness, in medicine. A more recent, and rather scholarly account of this phase is available in Poonam Bala’s book, Imperialism and Medicine in Bengal and the book entitled Imperial Medicine and Indigenous Societies edited by David Arnold. As a practitioner of western medicine, my arrogance has been suitably humbled after reading these revealing works.
While traditional medicine could not grow because it lacked patronage, western medicine adopted the tool of scientific method. We owe to science a special vote of thanks. It has provided some extremely useful bits of information which, with some very painstaking work, has resulted in a much better appreciation of how the human body works. We are getting a greater insight into how it responds to influences which can derange this exquisitely balanced system. Of course, we have to have the humility, and honesty, to accept that there is a lot more about which we do not have a clue. Our ignorance exceeds our knowledge, and this is why we need more of science than ever before.
The discovery of vitamins, some of the hormones, an understanding of water and electrolyte balance and some of the antibacterial medicines have made a tremendous difference in being able to treat many diseases which were formerly often lethal. Diabetes, tuberculosis, typhoid, pneumonia and some bacterial infections no longer pose the threat they did earlier. But one can cite some twenty major diseases, including cancer, rheumatoid arthritis, stroke and hypertension, about which we still do not have a clue and our knowledge or insight into these unsolved diseases is comparable to the situation for infections diseases in 1875, with similarly crucial bits of information missing. So let us not attribute to medicine a greater store of usable information with coherence and connectedness than actually exists.
The introduction of scientific methods, as distinct from empirical observations, brought about a sudden twist in the manner in which medicine was formerly practised. Objectivity gained respectability and it became necessary to quantify data. Measurement is the hallmark of science and so subjective reactions of the patients, their fears and pain and apprehensions were considered as distractions from cold scientific reason – emotions are so difficult to quantify. Now the medicine man began to adopt the mannerism of a cold scientist. Besides, manners lost their importance and laboratory investigations acquired increasing legitimacy. We stopped being good listeners. A certain degree of aloofness gained respectability. The emotional links between doctors and patients started weakening.
While one cannot quarrel with objectivity and quantification, a very rich source of data obtained by listening to the patients and then subjected to analysis, was lost. Recently, however, the worthwhileness of such studies has been amply demonstrated by the writings of Oliver Sacks. When I read his work on migraine, I felt for the first time that here was someone who really understood me – no other scholarly work on migraine has provided me the understanding and the capacity to cope with my very personal problem. Oliver Sacks himself once suffered a major knee injury which led him to spend a long time in a plaster cast. His book, A Leg to Stand On, reveals a greater insight into the neurophysiology of recovery and rehabilitation than any orthodox work on injuries or rehabilitation which I have encountered.
Now this kind of research all of us can undertake – even in general practice – and this could possibly elevate our methods of management to far more effective and humane levels. I would value detailed, accurate and honest case histories as examples of excellent research, instead of churning out meaningless tables of dubious laboratory data and publishing papers to augment our career prospects. Our medical journals are currently unwilling to publish such personalised, subjective material, but I wish that some of us could come forward to initiate such a move.
This is the time when new drug industries entered the healing enterprise and saw a vast, untapped market that they could exploit. Using the powerful advertisement media, they made us believe that we lived at bay, in total jeopardy, surrounded on all sides by human seeking germs, shielded against infection and death only by a chemical technology that enables us to keep destroying them. We are instructed to spray disinfectants everywhere. We apply potent antibiotics to minor scratches and seal them up with plastics. We live in a world where the microbes seem always to be trying to get at us, to destroy us, and we only stay alive and whole through diligence and fear.
This commercialisation is a perversion of Pasteur’s painstaking work which has been converted into an organised, modern kind of demonology. We assume that bacteria somehow relish what they do. Good hygiene is one thing but these are paranoid delusions on a societal scale. Remember Pasteur himself confessing on his death bed, ‘Bacteria are nothing; terrain is everything.’ This was paying homage to the ‘seed and soil’ concept which most traditional systems recognised.
It needs to be emphasised that in real life we have always been of relatively minor interest to the vast microbial world. Pathogenecity is not the rule. Indeed, it occurs so infrequently and involves such a small number of species, considering the huge population of bacteria on this earth, that it has a freakish aspect. Staphylococi live all over us on our skin. When you count them up, and us, it is remarkable how little trouble we have with them; only a few of us are plagued with boils. Streptococi are amongst our closest inmates. They have been living in our throats for a long time. But it is our own reaction to their presence, in the form of rheumatic fever, that gets us into trouble.
There is, in fact, a marvellous symbiosis between them and us. We help each other. Swallow antibiotics and they get rid of the resident bacterial flora from our intestines and all hell is let loose. ‘It is only cyclically, for reasons not understood,’ as Lewis Thomas points out, ‘but probably related to immunologic reactions on our part, that we sense them and this reaction of sensing is clinical disease. Our arsenals for fighting off bacteria are so powerful that we are more in danger from them than from invaders. We live in the midst of explosive devices; we are mined.’
I am sure we are paying too little attention and respect to the built-in durability and sheer power of the human organism. Its surest tendency is towards stability and balance. It is a distortion, with something profoundly disloyal about it, to picture the human being as a tottering, fallible contraption, always needing watching and patching, always on the verge of falling to pieces. This is the doctrine that people hear most often, and most eloquently, in all our information media. We ought to develop a much better system for general education about human health, with much more curriculum time for the acknowledgment, even celebration, of the absolute marvel of good health that is the lot of most of us, most of the time. Most ailments get better by themselves; many, by the next morning.
As a profession, we have not only failed to fight against the falsehood perpetuated by the drug industry but we have in fact become partners in their profit making enterprise and with what trivial bribes of small gifts and dinners! The chapter entitled ‘The Pill-Pedlars’ by David Gould, a former editor of New Scientist, in his book The Medical Mafia, is an absolute eye-opener. The entire continuing education of most doctors is through the sales literature freely distributed by our drug industry. And our public now knows it. How, then, can we expect the respect and goodwill of our patients?
The emergence of electronics, digital display systems, microchips and computers have now suddenly changed the entire scenario. The extent to which both patients and doctors have become mesmerised by contemporary diagnostic technology is indeed remarkable. It appears that no doctor is now willing to make a diagnosis – and no patient is willing to accept one – without recourse to the formidable diagnostic armoury of the medical-industrial complex.
New methods of investigations are continually being produced by the massive bio-electronic industry. The low backaches that housewives come to me with, are more often than not directly related to the very nature of their daily chores. But when asked what their problem is, they simply point to their CAT scans (and now MRIs, for heaven’s sake) as their complaint. Somebody is clearly advising them to travel to Bombay from Jaipur for an MRI and the report, possibly as an award for the money required to be shelled out, points an arrow at an image which is anatomically not even remotely related to the region where the trouble lies. This is not only a gross abuse and a waste of money for a totally unnecessary investigation, which when used with discretion can provide some very worthwhile information, but it also often leads to uncalled-for surgery. We have started treating images rather than patients.
So disturbed were some physicians by this kind of madness that the New England Journal of Medicine published a whimsical article entitled ‘CAT Fever’. It is an article which should be read by all doctors and patients alike. And yet Jaipur, in the last two years, has already had five CT machines installed. Quite clearly, it seems to be a good money-spinner.
What does an honest, well-meaning doctor do in such an environment? Should he succumb to the market forces? If he does not, would he not be accused of negligence by the patient? I think we can no longer afford to brush aside or hide under the carpet the distortions which are taking place with increasing frequency in our post-industrial society.
Let us try to understand the inevitable march of so-called high technology which carries with it what Fuchs has called the ‘technological imperative’ – a tendency to take action whatever the cost, if it offers even a slight possibility of utility. This situation increases the cost of medical care without coming up with any evidence that the benefits exceed those of adopting a more modest approach. Enthoven has expounded on what he terms ‘flat-of-the-curve-medicine’, i.e. the medical variation of the economic law of ‘diminishing marginal returns as input into a system continues to increase.’ Medicine should consider the possibility of contributing more by doing less.
Medical Research and State Imperialism
As doctors and teachers, many of us dream of contributing to medical research. Clinical research of the kind my teachers practised, or the kind of documentation which Oliver Sacks exemplified, is not considered respectable enough. Modern research is an expensive business and requires external funding. Being a government employee, I could only turn to our official research funding organisations. But, my experience of facing the exalted committees who sit in judgement over research proposals was so disheartening that I had to back out. Only work which they consider worthwhile is funded and this, in turn, is determined by what out politicians and bureaucracy want.
This is administered research at its worst and having been a member of the governing body of the Indian Council of Medical Research (ICMR) and seen from inside the machinations which go on, I came out frustrated and angry. The scientist-turned-bureaucrat is often a pompous fool and, having failed to achieve anything worthwhile himself, gets a vicarious pleasure in showing his superiority. Instead of scouting for talent, which ought to be their major objective (and we have no dearth of talent in our country), they sit back and wait for people to come and kow-tow before them. I had, therefore, no option but to choose areas where I could rely on community support, and depend on ‘user-reaction’ as my main tool of investigation rather than an expensive gait analysis laboratory which I had no means of setting up.
When the Government of India set up a centralised production unit for producing components of artificial limbs and appliances, they were upset that I was not promoting their products. They even wrote to my state government that it should put a stop to what I was doing. When an imaginative officer in the Department of Science and Technology helped me get funding to work on appliances for poliomyelitis, someone came along as soon as he retired and ordered me not to share my work with other countries because the government held the intellectual property rights over work funded by them. And these very people cry wolf when Carla Hills comes along and says the same thing!
When I realised that the western artificial limb, suitable for the chair-sitting, shoe-wearing culture of advanced countries, was posing numerous problems for our own amputees, and tried to work out an acceptable design for our floor-sitting, barefoot-walking culture, the orthodox in the profession viewed this work with derision, even though my amputees were more than satisfied. Because I used traditional craftsmen to give shape to my ideas, I was accused of introducing quackery into our profession and every possible obstacle was put in my way. It was only when my work earned the approval of the West that it began to be appreciated locally. Which brings us to another enigma that our researchers face. It is considered respectable to work on problems which engage the attention of the advanced countries, howsoever irrelevant these might be for our own. This explains why most of the research done here is borrowed, meaningless and second rate. The well-known Egyptian architect Hassan Fathy wrote a marvellous gem entitled Architecture For The Poor. I wish our medical researchers would turn to this work for inspiration. But if wishes were horses...
When I see the plight of medical teachers today, and witness the absurdities of the research climate in our country, and when I see how we have become victims of the market forces and a technology gone out of control, I wonder whether I did right to choose the profession I did. The context within which a doctor works today has changed beyond recognition and a redefinition of his role seems to be called for.
Medical Care For The Poor
With the enormous escalation in the costs of medical treatment, largely due to the use of expensive and often unnecessary technologies, the availability of this treatment to the poor is clearly out of the question. This inequity is heightened because of the increasing tendency among doctors to use the most glamorous methods available. Such a medical system is fiscally unsustainable even in the richer nations of the West. It is hardly surprising, then, that the anger of our deprived patients is inevitably directed towards us.
While providing a system of education which is rooted in the West, our policy makers continue to exhort young doctors to go out and work in villages. This is clearly untenable, and it is high time that this issue is taken up by the medical profession itself. Some of our best minds have been working on alternative systems of providing a good standard of medical care to our villages. The Aroles, brilliant products of the Medical College at Vellore, could have had a lucrative future ahead of them. Instead, they decided to work for the poor, needy villagers. Choosing to settle down in a drought-prone village in Ahmed-nagar district, Maharashtra, they have made Jamkhed into a legend. Utilising the services of illiterate village women as health workers, running an ongoing education programme which has transformed these women into extraordinarily effective instruments of social change, the Aroles have been able to improve the vital health statistics in their district from far below the national average to a level that can match the best in the world. Jamkhed has acquired the stature of a pilgrimage centre for me.
Dr. N.H. Antia, who headed the plastic surgery department of J.J. Hospital in Bombay, is among a handful of Indian surgeons who were awarded the prestigious Hunterian Professorship of the Royal College of Surgeons in England for his outstanding work in reconstructing the disfigured faces of leprosy victims. Through this work, he became increasingly interested in leprosy as a disease, and began to look at its social problems. Gradually, he moved into community medicine and now runs a research organisation on community health, attracting some very bright young minds from a variety of disciplines – medicine, economics, sociology, statistics and so on.
There are probably very few surgeons who have demystified the high technology of modern plastic surgery as successfully as Dr. Antia. His ward orderlies have been taught suturing skin flaps, a task which they perform with a dexterity that would amaze surgeons. He can perform a complicated operation in a village hut and his experience of the extremely expensive germ-shielding, air-conditioned burns unit which he pioneered at the J.J. Hospital, Bombay and the simple, commonsense approach he used with greater success in a modest district hospital in Thane, is so revealing and educative that it should be written up and distributed to all hospitals. It would make our surgeons pause and reflect when asking for controlled environment operating rooms to be able to perform safe surgery. Now, with private five-star hospitals cropping up like mushrooms, this controlled environment is being used as a selling point. Do we want our scant resources squandered like this?
The work done by Dr. Arole in Jamkhed, Dr. Antia’s work in Bombay, or Dr. Sanjivi’s work in Madras needs to be more widely known and discussed. Rural health care can no longer be left to our politicians and the bureaucracy. But it is here that our Medical Association and the Medical Council of India have failed miserably.
Some Critiques of Modern Medicine
It is interesting that a formidable critique of modern medicine is emerging from the affluent societies of the West. We might do well to remember this before we import wholesale a technology of medicine whose effectiveness is being questioned by many thinkers, even in the land of its origin. Probably the most strident criticism against the modern medical establishment has been voiced by Ivan Illich. When I first read his book Medical Nemesis, I was deeply disturbed. In a rare display of scholarship, and with his church background, Illich comes across like a medieval inquisitor, a prosecutor of the most brilliant kind. He had impeached the medical establishment as a major threat to health. He finds the medical establishment sickening beyond tolerable bounds for three reasons :
i) It produces clinical damage which outweighs its potential benefits. This encompasses the entire gamut of ‘iatrogenic’ or doctor induced diseases. Remember Carl Sandburg’s famous statement: ‘I took so much medicine that I was ill for a long time after I got well.’
ii) It obscures the political conditions of an over-industrialised society which renders it unhealthy.
iii) It takes away (or expropriates) the power of the individual to heal himself.
A retrospective medical audit reveals that many of so-called achievements of modern medicine should really be attributed to social reformers. Food, housing, working conditions, neighbourhood cohesions as well as cultural mechanisms make it possible to keep the populations stable. In this, Illich has the full support of a profound medical philosopher like Rene Dubois. A very important point made by him is the role of modern medicine to transforming pain, impairment and death from a personal challenge into a technical problem. We are accused of preventing the public from learning how to cope with their own problems, encouraging them to submit passively to an organised profession which has a vested interest in maintaining its hold on a captive population. We use our knowledge as a weapon, to wield power; we are indeed a disabling profession.
From within our own establishment, voices of protest can be heard. Medicine Out of Control – The Anatomy of a Malignant Technology is the title of a book by Dr. Richard Taylor. If anyone wants to know the inside story of the overselling of modern medicine, over-investigation, super-specialists, coronary care units, unnecessary surgery, screening and medical check-ups, the diseasification of pregnancy and childbirth, and the medicalisation of life, here is a veritable source-book containing some thought-provoking information. One will find that use of science in medicine is one thing but its transformation into practice is another. The analogy of nuclear science vs nuclear weapons would not be out of place.
The other variety of critique deals with some conceptual problems which have been ably summed up by Ashis Nandy and Shiv Visvanathan in a seminal paper entitled ‘Modern Medicine and its Non-Modern Critics’. According to this critique, the relationship between the modern doctor and his patient is to methodically decompose the patient as a person and convert his into a set of laboratory findings. This shadow patient (urine, blood, ECG, X-ray, etcetera), reconstructed from the results of laboratory tests, acquires a medical reality and autonomy of its own, and it is with this shadow that the modern hospital is concerned. The rest, that is the patient’s personal and clinical realities, are seen as variables which induce compromises with the science of medicine. They are not seen as variables that have an intrinsic scientific status. Indeed, as Tariq Banuri has argued, a basic postulate of modernisation is the superiority of the impersonal over the personal.
In a personal communication, Ashis Nandy has reiterated (taking the cue from Tariq Banuri’s impersonality postulate) that there is a serious problem of dehumanisation not only of medical technology but of the medical practitioner himself. As the medical system becomes more capital-intensive and mega-technological, the tendency of the average doctor seems to be to reconceptualize himself or herself as a part of the medical technology, a cog in the wheel, so to speak. There is a need to attack this trend explicitly through a reconceptualisation of medical practice and medical intervention by recovering the concept of the general practitioner. But the doctor who trusts the voice of the patient more than the pathological test results, ends up being perceived as less scientific, even though he may be a more gifted healer and more respected as a practitioner. Professional honours and fame are likely to pass him by.
Specialization in medicine is another way to break up an individual into bits, where each part of his body is treated as a sub-system to look after for which a specialist is required. The family doctor or the GP has lost out in this process and he now seems to have no place in a medical scientist’s utopia. He is reluctantly being accepted as a residual category, instead of being considered the primary agent for health care, as he deserves to be. I plead for an elevation of the family doctor’s position in the hierarchy of our health care system, placing him higher than a specialist. This, I might point out, has always been the case in our traditional healing systems.
All medical systems are part of the biosphere. It is time we recognise that the biosphere does not remain the same when we take recourse to certain forms of medical intervention (e.g., the emergence of mutant strains of bacteria and viruses). There is thus a problem of defining the limits of human intervention in the living universe. Sometimes lesser or limited interventions in the short run allow one to intervene consistently over the long run. We must not make the life of the future generation more difficult.
The Art of Medicine – Physician as Communicator
When I retired from service and started a consultation practice, I realised for the first time that most people who come to me needed to talk. This was a new experience for me. A study conducted by Professor Madan, a distinguished sociologist at the All India Institute of Medical Sciences, New Delhi, revealed that in the OPD, on an average, a patient had to wait for four hours to be able to get two minutes of the consultant’s time. One might argue that the experienced consultant could arrive at a correct diagnosis in two minutes. But this is missing the entire point.
Words, when used by the doctor, can be gate-openers or gate-slammers. They can open the way to recovery, or they can make a patient tremulous, dependent, fearful, resistant. The right words can potentiate the patient, mobilize the will to live, and provide a congenial environment for heroic response. The wrong words can complicate the healing environment, which is no less central in the care of patient than the factual knowledge that goes into the physician’s treatment.
Being able to diagnose correctly is a good test of medical competence. Being able to tell the patient what he or she should know is a good test of medical artistry. The patients want assurance. They want to be looked after and not just looked over. They want to be listened to. They want to feel that they are in the doctor’s thoughts. In short, patients are a vast collection of emotional needs. And it is the physician who has the most of offer in terms of these emotional needs. It is the person of the doctor and the presence of the doctor – more frequently, and just as much as what the doctor does – that create a healing environment.
I cannot express it more effectively than Norman Cousins did, when he was recovering from a massive heart attack. ‘I pray,’ he said. ‘that the medical students will never allow their knowledge to get in the way of their relationship with their patients. I pray that all the technological marvels at their command will not prevent them practising medicine out of a little black bag if they have to. I pray that when they go into a patient’s room, they will recognise that the main distance is not from the door to the bed but from the patient’s eye to their own, and that the shortest distance between those two points is a horizontal straight line – the kind of straight line that means most when the physician bends low to the patient’s loneliness, fear, and the overwhelming sense of mortality that come flooding up out of the unknown and when the physician’s hand on the patient’s shoulder or arm is a shelter against darkness.’
Among the oldest discoveries in the practice of medicine is the fact that human beings come equipped with resources of healing that are best mobilised not by detached scientific efficiency but by communication and supportive human outreach.
Needed – A Humane Technology
I believe that informed self-care should be the main goal of any health programme or activity. Ordinary people, provided with clear, simple information, can prevent and treat most common health problems in their own homes – earlier, more cheaply and often better than doctors. People with little formal education can be trusted as much as those with a lot. And they are just as smart. Basic health care should not be delivered, but encouraged. Instead of treating family members as a nuisance, we should invite them to participate in something which deeply concerns them. This calls for the medical profession trying to understand our social structure, the ways of thinking of our people, social and economic injustices our people are subjected to, their language and idiom. An insight into these converts a clever physician into a wise one. I very deliberately make this distinction between smartness and wisdom. Please look around and try to locate this class of wise people. They are becoming an endangered species which may soon become extinct.
These measures, I am convinced, would be in keeping with the new paradigms that are appearing in the field of health sciences. What we need is a technology which is more appropriate (in the sense which Professor Amulya Reddy has so clearly laid down), more humane, more scientific, less expensive and therefore more equitable, more harmonious with our belief system but without any room for superstitions and quackery, and which augments autonomous coping with illness or death rather than dependence on the passive, indifferent and expensive care available in our institutional systems. The physician, as knowledge-seeker and therapist, must possess the technique of the scientist and the vision of the humanist. Unbalanced development in either direction, continued too long, imperils the enterprise of healing.
These critiques of our profession should lead both to a re-examination of the role of the doctor of the future and the possibility of recovering the mobility of the profession. Our responses to the new moves being initiated to increase the accountability of the profession in the Consumer Protection Act are, I believe, being debated at a very simplistic level. I think the medical profession should appreciate that a change in their role is now called for and there is need to creatively respond to the changing situation, particularly from its critics, both internal and external.
But above all, we should never forget, that ‘patient care’ means really ‘caring for the patient’.
* Reproduced from ‘Our Scientists’, Seminar 409, September 1993.
N.H. Antia, Frch News Letters. Foundation for Research in Community Health, Bombay.
David Arnold, Imperial Medicine and Indigenous Societies. Oxford University Press, Delhi, 1989.
Mabelle Arole and Rajnikant Arole, ‘A Comprehensive Rural Health Project in Jamkhed’, in Health By the People. World Health Organisation , Geneva, 1975.
Poonam Bala, Imperialism and Medicine in Bengal. Sage Publications, New Delhi, 1991.
Tara Shankar Bandhopadhyaya, Arogya Niketan. Translated by Hans Kumar Tiwari. Rajpal and Sons, Delhi, 1962.
Tariq Banuri, ‘Modernization and its Discontents: A Cultural Perspective on Theories of Development’, in Dominating Knowledge edited by F.A. Marglin and S.A. Marglin. Clarendon Press, Oxford, 1990.
Norman Cousins, The Healing Heart. Avon Books, New York, 1984.
Human Options. Berkeley Books, New York, 1983.
Donald Gould, The Medical Mafia. Hamish Hamilton, London, 1985.
Ivan Illich, Medical Nemesis. Calder and Boyars, London, 1975.
Ashis Nandy and Shiv Visvanathan, ‘Modern Medicine and its Non-Modern Critics: A Study in Discourse’, in Dominating Knowledge edited by F.A. Marglin and S.A. Marglin. Clarendon Press, Oxford, 1990.
Ashis Nandy, Personal Communication, 1993.
A.K.N. Reddy, Appropriate Technology for Rural Development. Keynote Address in Appropriate Technology for Primary Health Care. Indian Council of Medical Research, New Delhi, 1981.
Oliver Sacks, A Leg to Stand On. Picador, London, 1984.
Richard Taylor, Medicine Out of Control – The Anatomy of a Malignant Technology. Sun Books, Melbourne, 1979.
Lewis Thomas, The Lives of a Cell: Notes of a Biology Watcher. The Viking Press, New York, 1974.