‘TMC is surviving on a
Robin Hood model’

Mammen Chandy never tires of reiterating the reason why the Tata Medical Center (TMC) in Kolkata exists. “We have to keep our costs low and find the resources to treat more people who are poor,” says the institution’s director. “That is our mandate.”

There is no shortage of wrinkles to be ironed out for TMC to stay true to its commitment. It helps that an expansion project, completed in early 2019, is better enabling the Center in living up to its promise, but the struggle to remain a sustainable operation as well is ceaseless and immediate.

The soft-spoken Dr Chandy, who has headed TMC since its inception in 2011, talks to Horizons about how the hospital has grown, the multiple challenges it has overcome and, on a personal note, the everyday sorrows and joys of being a cancer specialist.

How has TMC evolved in the nearly nine years since it was established?

When we opened in May 2011, we had only 100 admitting beds and that went up to 140 by 2015. By then we were running at peak capacity — we had to refuse patients — and we had broken even. We needed to expand. We needed to increase bed capacity in order to start speciality training programmes, a necessity because you won’t get junior doctors to come and work here unless you are offering them an education or specialised training. That was our expansion imperative. Also, we had reached a certain standard in terms of equipment and technical know-how, but we needed more.

Phase II was completed in January 2019 at a cost of about 2.6 billion, and it has slowly been operationalised. We have enhanced our capacity to 437 beds. We now have a dedicated floor for children, so that everything that a child patient needs is in one physical area. We have the latest equipment and technology, a custom-built laundry, a proper kitchen and extra capacity for our central sterilising operation. Additionally, we are doing a lot of molecular biology.

What is the big advantage you have gained with phase II?

We needed phase II to survive and to thrive, and we somehow managed to find the money for the project from different sources. Our enhanced capacity allows us to be comfortable when it comes to inpatients, but with outpatients we are already filled and our labs are also running to capacity. As for the overall infrastructure, what we have now is stunningly beautiful. The architecture is by CannonDesign, an American firm, and it is superb. When I come to work, I say to myself, “What a privilege it is to work in this institution and in these surroundings.” You are actually able to do what you are supposed to do.

Despite all the expenditure and the consequent increase in running costs, we are on solid ground financially. We should, by the end of the financial year in March 2020, have a surplus of about 100-110 million. This is not sufficient. We are not earning enough to replace high-end equipment and we cannot increase our rates. TMC is surviving on a Robin Hood model: the rich are paying twice what their treatment costs, the poor pay from cost to nil. We are trying to cross-subsidise.

We are earning but cancer treatment is a bottomless pit. The costs are so high that it’s difficult to be viable. We don’t, for example, charge the ‘maximum retail price’ [or MRP] on drugs. That means 150 million a year in charity to patients. We can earn if we want to earn, but that is not the purpose of this hospital. TMC is not a corporate establishment. We have to keep our costs low and find the resources to treat more people who are poor. That is our mandate.

We are not saying that we cannot be viable. We are viable, but we will continue to need assistance for capital expenditure. Which is why we approached Tata Consultancy Services for our IT requirement. And we now have a state-of-the-art system as a result. Our radiology division is, I think, one of the best in India. That costs money and somebody has to pay for it. My hope is that we build up our corpus to the extent that we don’t have to turn any patient away, especially not children.

With TMC, the Tatas have created a unique institution. This is a tertiary cancer centre and we have to be the gold standard. We have a protocol wherein the 10% who can afford the best treatment in the United States can have that treatment here. Then there is the 20% in the middle who we charge, followed by the 70% that cannot afford to pay anything. Some of my colleagues say everybody should be on par, but that is not possible.

Are expensive treatments worth the money?

Sure, if you can be cured, but that is not the problem. I was doing my [hospital] rounds this morning and there is this father and his [cancer-stricken] son is reaching the end of the road. The father has no money, so I have to choose a pathway. I won’t say, “No more treatment.” I will choose a pathway where you are not selling your house or liquidating your bank accounts. We often have to make decisions based upon financial resources. We don’t want a 10-million treatment that will extend a patient’s life by three months.

Science and technology are going at a pace which is unbelievable and there are all these new treatments coming along. As for affording such care, it’s an emotional situation. When you have an only child who has relapsed leukaemia and needs a treatment that costs 2.5 million, you are ready to sell your house, your property and everything else to have that treatment.

I honestly don’t think there will ever be a time — and there will not be such a time even in the United States — where every child who has cancer and needs an expensive treatment will get it, or have the state pay for it.

We are struggling with the issue. I cannot put a poor patient on the floor. TMC is entirely air conditioned and there is a cost attached to that. You may say air conditioning is a luxury but it is not a luxury when you consider the fact that it reduces post-operation risks.

Where to from here for TMC?

Further expansion cannot happen here. We have to strengthen the systems we have established such that they can continue, and we have to be economically viable. But I am not so much worried about the viability of the institution as I am about being able to help more and more patients who need the sort of care that TMC can give.

When the whole of phase II is operational, we can have a surplus of about 300 million. We have secured financial assistance for patients from the central and state governments and the Dorabji Tata Trust donates 4.5 million a month, which we utilise to subsidise treatment. We are using every available resource to reduce costs for our patients. We have a lot of activities to support them and we have social workers for assessment and support. What we don’t have, as of now, is a good donor campaign; we have to strengthen that.

Do patients from this part of India, rather than come to TMC, still go down South or to Mumbai for cancer treatment?

The quality of cancer care in eastern India was so poor that people had lost faith in the system; they would much rather go to Vellore or Mumbai. That is changing. A patient who has gone to Mumbai and then comes here doesn’t go back to Mumbai.

What about cancer treatment in general in India? How has the country been faring?

India has done very well in the production of generic medicines at a much lower cost — it is an example for the world — and we do this without compromising on quality. Drugs that are sold in the United States for $400 a dose are available in India at a twentieth of the cost. Our pharmaceutical industry has done us proud.

In treatment, diagnostics and patient care, you can have whatever you would have anywhere in the world. We are, however, nowhere near global standards in research, in new discoveries, new drugs and new molecules.

It is often said that more and better research improves outcomes

To me research means constantly asking the question: how am I treating my patient? What is the gold standard in the world? If my patient can afford it, can I give him or her that treatment? And are my outcomes as good as anywhere else in the world? We are constantly looking at our outcomes and comparing them with international standards. That’s clinical research and I am happy to say that TMC is doing that.

In just 10 years we have reached a high level of quality and integrity of practice. We are fortunate to have doctors who don’t do private practice. We struggle with nurses but we are trying our best there. We have outstanding technologists and our labs are as good as anything you can get.

Do you get a chance to practice and to do research?

I don’t do research because that is too demanding. I do a lot of clinical work and my expertise is in blood cancer and bone marrow transplants. I still enjoy that; it keeps me going. I love having students asking me questions.

How have you made peace with the stress and sadness of being a cancer specialist?

As an individual you have to grapple with the reality of suffering. I used to do a series for students on the meaning of suffering and I took them through different religions — Judaism, Hinduism, Buddhism, the new and old Testaments — while trying to offer explanations. With time you learn to insulate yourself a little bit from it all, but patients and their problems do affect you.

Just last week we lost a patient and I still haven’t got over it because I feel I’m missing something. I don’t spend sleepless nights over a patient for whom nothing more could have been done. But when something goes wrong and you can’t understand why it went wrong, then it affects you personally. Most of us who have been doing this for many years learn not to let it get to us completely. I think your faith also helps.

We make life-and-death decisions every day. Recently, one of my patients came back here with a critical relapse, four years after I had treated him. Since I had developed a rapport with the family, I could talk to them and explain the situation. There was a nice sense of closure.

I got a Christmas card once from someone whose child had died after receiving good care here. You would be surprised at the number of patients who we treated years ago, who are now grown up and married and have children of their own, and they still keep in touch. When you treat a patient as an individual, you get involved in hundreds of things.