Last December, Dilshad Chaudhry traveled with about 100 of his fellow villagers by bus to a local Indian medical-school hospital. They'd been told that foreign doctors were coming to tour the facility, and check-ups would be free.
There was nothing wrong with Chaudhry; he was accompanying his brother, who had a back problem. But "every person was told to lie in a bed even if they're not sick," he said. The 20-year-old electrician said he never saw any foreign physicians that day, but the hospital's Indian doctors kept checking that the phony patients were in bed. "They wanted to make sure no one escaped," he said.
That was the same month government inspectors visited the hospital, which is at Muzaffarnagar Medical College, 80 miles northeast of New Delhi. The inspectors checked, among other things, whether there were enough patients to provide students with adequate clinical experience. They determined there were.
But a year earlier, inspectors had found that most of the college hospital's outpatients "were fake and dummy and seems to be hired from nearby slum area," according to the official report. "In paediatric ward all children were admitted ... without any medical problem and were hired from nearby area!!!!!"
"I am not very keen to reply," said Dr. Anil Agarwal, the school's principal, when asked about the episode with Chaudhry.
India's system for training doctors is broken. It is plagued by rampant fraud and unprofessional teaching practices, exacerbating the public health challenge facing this fast-growing but still poor nation of about 1.25 billion people.
The ramifications spread beyond the country's borders: India is the world's largest exporter of doctors, with about 47,000 currently practicing in the United States and about 25,000 in the United Kingdom.
Schools and scandals
In a four-month investigation, Reuters has documented the full extent of the fraud in India's medical-education system. It found, among other things, that more than one out of every six of the country's 398 medical schools has been accused of cheating, according to Indian government records and court filings.
The Reuters probe also found that recruiting companies routinely provide medical colleges with doctors to pose as full-time faculty members to pass government inspections. To demonstrate that teaching hospitals have enough patients to provide students with clinical experience, colleges round up healthy people to pretend they are sick.
Government records show that since 2010, at least 69 Indian medical colleges and teaching hospitals have been accused of such transgressions or other significant failings, including rigging entrance exams or accepting bribes to admit students. Two dozen of the schools have been recommended for outright closure by the regulator.
Paying bribes – often in the guise of "donations" – to gain admission to Indian medical schools is widespread, according to India's health ministry, doctors and college officials.
"The next generation of doctors is being taught to cheat and deceive before they even enter the classroom," said Dr. Anand Rai. He exposed a massive cheating ring involving medical school entrance exams in the central Indian state of Madhya Pradesh in 2013. Rai was given police protection after he received death threats following the bust.
The poor state of India's medical education reflects a health system in crisis. The country has the highest rates of mortality from diarrhea, pneumonia and tuberculosis, creating pressure to train more physicians. Patients are regularly denied treatment at public hospitals that are so overcrowded, often the only way to see a doctor is to pay a bribe.
The causes of the crisis are manifold: Too few doctors. A government-backed surge in private medical schools which, to boost revenue, frequently charge under-the-table fees for admission. Outdated government regulations that, for example, require college libraries to keep paper copies of medical journals and penalize those that subscribe instead to online editions.
Charged with maintaining "excellence in medical education" is the Medical Council of India (MCI). But this government body is itself mired in controversy. Its prior president currently faces bribery allegations. The council is the subject of a mountain of lawsuits, many of them pitting it against medical schools challenging its findings. The cases often drag on for years.
"The best medical schools in India are absolutely world class," said David Gordon, president of the World Federation for Medical Education. But, he added, the Indian government's process of accrediting a "huge" number of recently opened, private medical schools "has at times been highly dubious."
India has been rocked by a series of recent medical scandals, including doctors accused of serious crimes. In November, a group of junior doctors at a medical college in the eastern city of Kolkata allegedly tied a suspected mobile phone thief to a pillar, slashed him with a razor and beat him to death with bamboo sticks, according to local police. Nine of the accused men remain in jail; they deny murder charges, say lawyers involved in the case. Three suspects remain at large.
The scalpel thrower
The system's problems are felt abroad, too. Tens of thousands of India's medical graduates practice overseas, particularly in the United States, Britain, Australia and Canada. All of these countries require additional training before graduates of Indian medical schools can practice, and the vast majority of the doctors have unblemished records.
But regulatory documents show that in both Britain and Australia, more graduates of Indian medical schools lost their right to practice medicine in the past five years than did doctors from any other foreign country.
In the United Kingdom, between 2008 and 2014, Indian-trained doctors were four times more likely to lose their right to practice than British-trained doctors, according to records of Britain's General Medical Council. (The U.S. and Canada lack publicly available centralized databases of disciplined doctors.)
The British cases include that of Dr. Tajeshwar Singh Aulakh, who received his medical degree in 1999 from Punjabi University in Patiala, India, according to Indian government records. He was assisting during a hip operation in 2008 in Shropshire, England, when he allegedly grabbed a scalpel, slashed the patient's stitches and threw it toward a nurse, according to British government records. The United Kingdom later struck him off its list of approved physicians. He could not be reached for comment.
The Australian cases include that of Dr. Suhail Durani, who graduated from an Indian government medical college in the northern city of Jammu in 2003. He was imprisoned in Perth for more than 18 months after being convicted in 2011 of sexually assaulting a female diabetic patient who had shown up in the emergency room with symptoms of a potentially serious illness.
In an interview, Durani maintained his innocence and described his medical training in India as excellent. He currently is not practicing medicine.
Dr. Ramesh Mehta, vice president of the Global Association of Physicians of Indian Origin, said there are "major problems" with some private Indian medical schools. But he added that a doctor's success depends as much on "personality and attitude" as on his or her college training.
About 45 percent of the people in India who practice medicine have no formal training, according to the Indian Medical Association. These 700,000 unqualified doctors have been found practicing at some of India's biggest hospitals, giving diagnoses, prescribing medicines and even conducting surgery.
Balwant Rai Arora, a Delhi resident in his 90s, said in an interview that he issued more than 50,000 fake medical degrees from his home until his forgery ring was broken up by the police in 2011. Each buyer paid about $100 for a degree from fictitious colleges. Arora was twice convicted and jailed for forgery.
"There is a shortage of doctors in India. I am just helping people with some medical experience get jobs,'' said Arora. "I haven't done anything wrong."
India currently has about 840,000 doctors – or about seven physicians for every 10,000 people. That compares with about 25 in the United States and 32 in Europe, according to the World Health Organization.
The shortfall has persisted despite India having the most medical schools of any nation. That's because the size of graduating classes is small – typically 100 to 150 students.
Indeed, gaining admission to India's top medical schools is akin to winning the lottery. The All India Institute of Medical Sciences in New Delhi has been rated the best medical school in India Today magazine's past five annual surveys. According to the registrar's office, it takes in only 72 students for its undergraduate course each year out of about 80,000 to 90,000 who apply – an acceptance rate of less than one-tenth of one percent. As in the United Kingdom, most medical school students attend an undergraduate program.
Similarly, Christian Medical College, a top-ranked school in the southern city of Vellore, received 39,974 applications this year for 100 places, according to a school official – an acceptance rate of 0.25 percent. By contrast, the acceptance rate at Harvard Medical School for its entering class in 2014 was 3.5 percent.
Health ministry officials and doctors say India's medical-education system began to falter following a surge in new, private medical colleges that opened across the country during the past few decades, often in remote areas.
In 1980, there were 100 government-run medical schools and 11 private medical colleges. Thirty-five years later, the number of government medical colleges has nearly doubled. The number of private medical schools, meanwhile, has risen nearly twenty-fold, according to the Medical Council of India. There are now 183 government medical colleges and 215 private ones.
'Little better than quacks'
Many of the private colleges have been set up by businessmen and politicians who have no experience operating medical or educational institutions, said MCI officials. Sujatha Rao, who served as India's health secretary from 2009 to 2010, said the boom in private colleges was driven by a change in the law in the early 1990s to make it easier to open new schools because the government was struggling to find the money to build public medical schools.
"The market has been flooded with doctors so poorly trained they are little better than quacks," Rao told Reuters.
Not that a legitimate degree necessarily makes a difference.
A study in India published in 2012 compared doctors holding medical degrees with untrained practitioners. It found "no differences in the likelihood of providers' giving a diagnosis or providing the correct treatment." The study, funded by the Bill & Melinda Gates Foundation, concluded that in India, "training in and of itself is not a guarantor of high quality."
Last year, an individual described as a "concerned" student at a rural government medical college in Ambajogai, in western India, posted a letter online with a litany of allegations about the school, Swami Ramanand Teerth Rural Medical College.
There were professors who existed only on paper, he alleged, and "no clinics and no lectures" for students in the medicine and surgery departments. Conditions were unsanitary at the hospital, and pigs and donkeys roamed the campus, he wrote. The writer also alleged that students had to pay bribes to pass exams.
"We are not taught in this medical college," the letter stated. Students have graduated "without even attending a single day." The writer said the letter had been sent to various government agencies and health officials.
Records from the Medical Council of India, the body charged with maintaining the country's medical education standards, show that an inspection of the college this January found numerous deficiencies, including a shortage of faculty, residents and lecture theaters.
Dr. Nareshkumar S. Dhaniwala, who served as the principal of the college between 2011 and 2013, said "there is some truth in the letter." Animals, such as pigs and cows, do roam the campus, teachers and students don't turn up for lessons, and there is a scarcity of running water in the dormitories, he said. And before he joined, he said, he heard students had to pay to pass final exams.
"I found the students were not very interested in studying, they don't come to classes, they don't come to clinics," Dhaniwala said. "Medical education has gone downhill all over the country because the teachers are not as devoted as they used to be."
Sudhir Deshmukh, the college's current principal, did not respond to requests for comment.
The Medical Council of India, which was established by the government in 1934 and oversees medical education, has itself been swirling in controversy. Dr. Ketan Desai, the council's former president, faces criminal charges related to his arrest in 2010 for allegedly conspiring to receive a bribe to recommend authorizing a private medical college to accept more students. The case is still pending; Desai has denied the charges.
In interviews, medical school officials complained that the MCI had onerous inspection requirements that were outdated and arbitrary.
"The Medical Council of India is a junk body," said Dr. A. K. Asthana, principal and dean of Subharti Medical College in the northern city of Meerut, which has been accused of demanding illegal fees for admission. Asthana denies the allegations. The council has tried – unsuccessfully so far – to close the school. "I'm totally frustrated with the MCI. Totally frustrated," he said.
Dr. Vedprakash Mishra, the head of MCI's academic committee, told Reuters that the agency has created "discipline and accountability" among medical colleges by imposing fines and, in several cases, prohibiting schools from admitting students for up to two years. "We don't compromise and mitigate on the requirements," he said.
Asked about allegations of corruption within MCI itself, Mishra abruptly ended the interview. "This is not what I want to be discussing," he said.
Under the government's current regulations, private medical colleges generally must have campuses on at least 20 acres of land. Because urban real estate in India is expensive, many schools open in rural areas where recruiting qualified, full-time doctors to teach is difficult because pay scales are low and living conditions are tough.
Interviews and MCI records show that some private colleges solve the problem by cheating – they recruit doctors to pose as full-time faculty members during government inspections. The physicians work there for just a few days or weeks. Two MCI officials estimated that there are several hundred Indian companies involved in recruiting them.
In October, a doctor in New Delhi received an email from a local company called Hi Impact Consultants with the subject line: "Urgent requirement of doctors for MCI Inspection in Ghaziabad"
The email offered up to 20,000 rupees a day (about $310) if the doctor appeared for an inspection at Saraswathi Institute of Medical Sciences in Hapur, east of New Delhi. The doctor, who requested anonymity, has no connection with the college.
"If interested please revert back ASAP," the email concluded. The sender described itself as "a Medical Executive Search firm."
In an interview, Sanjeev Priyadershi, Hi Impact's executive director, confirmed that the firm had tried to recruit doctors to appear during government inspections at medical colleges where they don't normally work.
"My client wanted to hire full-time faculty members for inspection purposes," he said.
Dr. Shailendra K. Vajpeyee, the principal of Saraswathi, said the college is constantly struggling to recruit qualified professors. Vajpeyee said he knew of Hi Impact Consultants, but denied he had employed them during his 18-month tenure.
"I don't know why that email was sent" by the company, he said. He declined to comment further about the matter.
At Muzaffarnagar Medical College, where electrician Dilshad Chaudhry was taken in December, students can read medical journals and books in a sprawling, circular library and take classes in clean and modern lecture halls.
But finding enough patients to provide students with clinical experience at rural, private teaching hospitals like Muzaffarnagar is a challenge. Many people in rural India simply can't afford the cost of treatment.
School principal Agarwal denied the allegations by MCI inspectors that the college's hospital had inflated its number of patients during a 2013 inspection. "Sometimes the inspectors are biased, that is for sure," he said. He also denied the hospital had ever recruited local villagers to pose as patients.
But Dr. Vaibhav Jain, a former student at the college, told Reuters that the hospital would conduct "free check-up camps," to lure rural villagers to the facility on inspection days. He said the hospital sometimes would promise free ultrasounds, but only a small number of people would be tested. Villagers often later complained about it to students at a clinic in Bilaspur where he worked, he said.
"We used to say we can't do anything, the machine was not working," he said.
Medical education is in trouble across India, said Jain. "The truth is that many medical students aren't prepared to be doctors when they finish" college. "And the result is the patient suffers."