Global Nephrology- Dialysis in India

I am back in India again for meetings with the Indian government. There have been a number of recent press articles about for-profit dialysis providers moving into the Indian market (link1, link2). These articles send a chill down my spine. Already we know that 90% of patients who develop end-stage renal disease die because dialysis is either too expensive, or is unavailable. Having for-profit dialysis providers move into India might be good for the rich but what about the poor? As well, is the Indian Government providing a foot-hold to these dialysis companies without ensuring that quality of dialysis is monitored and that there are processes for improvement?

In a prior article I discussed the financial motives of these dialysis companies: using the dialysis procedure as a loss leader in order to sell hyped up and overly expensive drugs like epo and vitamin D analogues. Moving into the global market is attractive since the US market looks increasingly saturated, margins have become tight because profits from epo and other drugs are down, and markets such as India are poorly regulated with a growing middle class.

No-where in the reports did I see any attempt by DaVita or Fresenius or others to think about how they might innovate to provide dialysis more cheaply to the poor in India that still represent 80% of the population. Or how these providers would be opening dialysis units in more remote regions of India rather in only the big cities.

Wait there is more. In none of the articles in the press was there discussion about better monitoring of dialysis quality. The quality issue reminds me of a meeting I had with the late former prime minister of India, his honorable (Shri) VP Singh. He wrote on his blog about art and being on dialysis: “By the end of March 1997, I was on dialysis. My efforts to paint became erratic. For months I could not pull myself up to paint. Then I would get a spell of few months in which I could.”

The late honorable Mr. V P Singh
Former Prime Minister of India

When I met Mr. Singh about 10 years before he passed away, he told me that he had discovered why he felt so weak in spells. These spells were when he was dialyzing in India, he said. In fact, it was quite remarkable that when he travelled to England or elsewhere outside India he felt well after a few sessions of dialysis. He said that he had discovered through his own research that in India he was being dialyzed on untreated water (i.e., tap water). By using treated purified water that had been purified through an RO system he felt stronger and healthier. The effects, no doubt, of endotoxin contamination of the dialysate.

Of course, Mr. Singh’s example about exposure to untreated water cannot be generalized. In fact, I have visited many dialysis units who all have RO systems in place. Their dialysis procedure is comparable to units in the west. However, dialysis quality is not monitored or reported in India in a systematic way and there is no national quality system in place like one that exists in the US or in Europe.

In summary, my advice to policy makers in India: tread carefully, regulate, and demand much before allowing the entry of dialysis providers whose main motive is profit.