On the NHS frontline: 'being a doctor in A&E is like being a medic in a war zone'

Doctor explains why she decided to make a film depicting the real-life drama of targets and staff pushed to the limit

• 
• • Saleyha Ahsan
  • The Guardian, Wednesday 5 March 2014

The start of a shift and I brace myself as I walk into the waiting area. A huge number of people are already there, waiting to be called. I try to avoid eye contact. It's like entering an arena but I feel more like the sacrificial lamb than a gladiator. Entering the main area of the emergency department, a scene of chaos. All available space to see patients is occupied. Staff shout instructions to each other above the noise. I hear a patient vomiting, another is crying out in pain and an elderly woman's voice cuts through, confused and repeating that she wants to go home. "So do I," I whisper to myself.

Colleagues run between cubicles with clean sheets, urine pots and trays for taking blood. Ambulance sirens heard above the noise signal that more patients are coming. A cardiac arrest case is sped into the resuscitation room with paramedics pumping the chest of a patient as the rest of the crash team run through. The atmosphere is explosive and adrenaline charged.

A senior doctor in the middle of the storm tries to bring order in a place that refuses to be controlled. Junior doctors are flushed, red in the face, eyes wide with a hint of panic. I find a tearful one at the computer. She is new and hating every second of it. There isn't time or even space to console her with a pep talk. Give her a few more weeks and the hard outer shell will develop like body armour.

My first patient of the shift needs a full neurological exam. I hunt around for a pen torch to shine into her eyes. "Make sure you have your weapons before you go to war," says a fellow registrar, wryly, handing over the torch. I smile. This is not Palestine, Libya or Syria. This is a hospital on the eastern outskirts of London.

 The A&E department at Queen's hospital in Romford deals with 400 patients a day.

Being a doctor in accident and emergency has at times resembled being a medic in a war zone. I have worked as a doctor in various conflicts and yet some of my most stressful moments, facing a tidal wave of pressure, have happened closer to home, in Queen's hospital, Romford.

The UK's A&E departments have been described by the College of Emergency Medicine (CEM) as facing a crisis. The term was specifically chosen to describe the situation that everyone from the most senior consultant to the most junior nurse is experiencing. Last year Dr Cliff Mann, the CEM president, wrote in a press release: "A lack of a plan for resolution [is] an existential threat to emergency medicine."

There are recurrent themes causing the crisis: more people are coming to A&E; a falling number of doctors want to work there because of the pressures involved and the poor work/life balance; and hospitals are increasingly full – resulting in bottlenecks that back up into the emergency department.

Over the past four progressively worse winters I came to a tipping point. Nothing in the media was reflecting the daily realities of being a doctor on the shop floor. Last April, when the CEM's press release hit the headlines, I took my cue.

I divide my time as an A&E doctor and film-maker. I wanted to make something honest and reflective of the reality.

After a year's worth of access negotiation, I began filming with the Guardian this winter in two hospitals – Queen's where I work as a middle-grade locum, and Musgrove Park, in Taunton, Somerset, where Cliff Mann also works.

"For a long time we were like John the Baptist, crying into the wilderness and no one was listening," Mann said to me, while on shift at Musgrove Park. The most senior consultant within emergency medicine leads from the front, including a Friday shift that runs from 3pm to midnight. "No one goes into emergency medicine thinking it's going to be easy and calm – that would be bizarre. But if you push the individual with persistently increasing intensity levels they will start to fade."

The TV stories of George Clooney and the ER cast don't come close to reality. My research into the speciality obviously went beyond watching medical dramas but nothing prepared me for what it was actually like.

Attending conferences in emergency medicine becomes almost therapeutic in its sharing of experiences. At an emergency medicine conference, Expanding Scientific Horizons, held in Twickenham, south-west London, last year, it was telling that the sessions entitled Creating Satisfaction and Maintaining Wellbeing in Emergency Medicine were standing room only.

One of the speakers, Susie Hewitt, a consultant from Derby, spoke about her battle with depression during the time she was appointed head of service for the introduction of the four-hour target – the government's instruction that 95% of patients should be seen within four hours of arriving at A&E.

The culmination of work and personal pressures resulted in what Hewitt describes as being "hit with what felt like a big freight train".

Many of us recognised ourselves in that. At the conference leaflets for well-being support and therapies were being distributed widely. We are clearly not a very healthy bunch right now.

The CEM warned the government three years ago that there was a problem with falling numbers of staff, but no concrete solutions emerged. I began to see my own consultants and middle-grade colleagues make plans to fly to the other side of the world.

 Medics with a patient at Queen's hospital. The hospital was built for 90,000 patients a year but receives 140,000.

Queen's A&E, part of the Barking, Havering and Redbridge University Trust, sees about 400 patients a day and its sister hospital, King George's, sees 200. The trust serves a population of 750,000 and is one of the UK's largest. It also has one of the highest elderly populations in London. Following a report by the Care Quality Commission (CQC) that its A&E was "at times unsafe because of the lack of full-time consultants and middle-grade doctors", Queen's became the 14th hospital to be put into special measures last December. Filming with the Guardian inside its A&E began the next day.

The hospital was built for 90,000 patients a year but receives 140,000. Ironically, King George's A&E, which performs better against targets, is scheduled for closure in 2015, after a unanimous vote by local primary care trusts. Queen's is expected to absorb the extra numbers. Queen's is understaffed, with only eight full-time consultants where it requires 21 in order to provide 24-hour cover, seven days a week. Four consultants left last year.

One of them, Dr Rosie Furse, described the pressure of targets. Battles with certain specialities to accept patients on to their wards are also a common complaint. She left for a post on the island of Mustique before being recruited to a hospital in Bath.

David Prior, chairman of the CQC, was reported in the Guardian in May 2013 as saying too many patients were arriving at hospital as emergency cases, and improved earlier care in the community was needed. He suggested more acute beds should be closed. "Emergency admissions through accident and emergency are out of control in large parts of the country," he said.

That prompted memories of a recent bed-blocked day in Queen's. Matron Mary Feeney rushed into A&E having secured a bed on the intensive therapy unit for an unwell patient in an A&E cubicle.

"They say bring him in half an hour – half an hour we have not got," and with that the patient was out of the door on the way with matron off to negotiate access at the hallowed gates of ITU.

A significant contributor to breaches of the four-hour target is the quest to find a bed for someone who is clearly not well enough to go home. Over Christmas one woman was brought in with diarrhoea and a ruptured bowel requiring a surgical side room. She waited in A&E for 17 hours until a room became available. Another woman was brought in with high blood sugars and needed an acute medical bed. I saw her when she arrived in the evening and then met her the next morning when I came back to work. That's when A&E becomes a ward.

On the first day of filming we had four intubated, unconscious patients in the resuscitation room at the same time, all of them requiring critical beds. The rest of the room was full of acutely unwell patients being redistributed around A&E as more room was needed with each new ambulance arrival.

Finding alternatives to A&E through improved care in the community is essential but if more acute beds close the A&E waits will get longer for sick patients requiring admission.

 Staff at work at Queen's hospital. The hospital has only eight full-time consultants.

I went through a period of having palpitations during a stretch of extremely challenging shifts last winter. It was when I had a palpitation and nearly passed out while driving that I decided to step down my intensity of work. I had further investigations but the remedy was obvious. I reduced my shifts and the palpitations have stopped.

Over the past three years I have worked harder than in my previous life in the army. I went through the Sandhurst commissioning course, renowned for its tough schedule, but in accident and emergency medicine at its peak, the intensity is tougher.

The CEM published an aptly named report – Stretched to the limit – in October last year. It described a consultant workforce under pressure. As a middle grade I wonder if actually I can physically do the job of a consultant.

The report said: "Evidence confirms that burnout among physicians in emergency medicine occurs at the highest rate of all medical specialities. There is also a very worrying trend developing of consultants seeking to move abroad after having been trained in the NHS."

The report details 21 consultants having left the UK in 2013 with an overall exodus of 78 since 2008.

Within the report details of a survey reveal that consultants on average plan to retire at 60 with the current job not compatible with advancing age. "Doing four nights in a row when you are 50 or 55 is physically impossible," said Dr Antoine Azzi, a specialist registrar working at Queen's at the very end of his training and soon to be a consultant.

He hopes for a less intense workload as a consultant, but it appears that is not going to be the case. The report said that 40% of the consultant workforce were on call one night in every six. The average age of emergency medicine consultants is 43 and the survey showed most plan to retire at 60.

The things that make a difference include access to training, which provides juniors with skills they need and reduces a layer of stress.

Before she left, Furse, like many other consultants, was dedicated to improving the working lives of her trainees and colleagues.

On one occasion I placed a chest drain into a patient with a spontaneous pneumothorax – a collection of air between the lung and the chest wall. If I failed, he could go into respiratory arrest, which could lead to death.

Furse stood by, calm and instructive. "Get it in quick, Saleyha," was all she said. I urged the drain's tube into his chest and the moment I saw the swinging bubble of the drain, signalling a successful placement I allowed myself to breathe and the patient was stabilised.

Moments like that are what makes being a doctor count but opportunities for training are few as workload grows.

The constant turnover of new junior doctors hits the department, too. Most junior doctors who spend six months in A&E leave at the end of their assignment with a lot of experience, but they are relieved to be going and they won't be coming back.

Mann says: "They come and do their six-month attachment and at the end say, "Thank you very much, it was interesting but I am moving on because it nearly killed me.'"

There is a quote from Hippocrates that says: "Where there is a love of medicine, there is a love of humanity." I see this every day to some degree in A&E. Before she left Furse reminded us during a teaching session: "Patients are key to everything we do and if you stop caring about them – well you should not be here any more."

Looking back on diary entries related to shifts I did last year during the spell when I was having palpitations I was reminded why I put myself through it. It's what makes us go back the next day no matter how awful the shift has been.

I wrote: "It was hard, I am tired and I was pushed but I feel alive. Today counted. I cared for patients and they remained the main focus of my day. Nothing else. Patients arrive here to be seen on possibly the worst days of their lives and through them we learn so much about our art. They teach us how to be doctors. As I walked into work today I was hit by reflection of all the patients who have left their mark – the ones that didn't make it.

"They stay with you, like companions. I shared the last few hours of their lives with them … forming a bond that transcends into something almost spiritual even for those that don't believe. Above all else, that is what counts and it remains a privilege."

"We Need Ambedkar--Now, Urgently..."

Saba Naqvi's interview of Arundhati Roy in Outlook India

In 1936, Dr B.R. Ambedkar was asked to deliver the annual lecture by the Hindu reformist group, the Jat-Pat-Todak Mandal (Forum for Break-up of Caste) in Lahore. When the hosts received the text of the speech, they found the contents “unbearable” and withdrew the invitation. Ambedkar then printed 1,500 copies of his speech at his own expense and it was soon translated into several languages. Annihilation of Caste would go on to have a cult readership among the Dalit community, but remains largely unread by the privileged castes for whom it was written.

Ambedkar’s landmark speech has now been carefully annotated and reprinted. What will certainly draw contemporary public attention to it is the essay written as an introduction by the Booker prize-winning author Arundhati Roy, titled The Doctor and the Saint.
Almost half of the 400-page book is Roy’s essay, the other half Annihilation of Caste. Roy writes about caste in contemporary India before getting into the Gandhi-Ambedkar stand-off. Taking off from what Ambedkar described as “the infection of imitation”, the domino effect of each caste dominating the ones lower down in the hierarchy, Roy says, “The ‘infection of imitation’, like the half-life of a radioactive atom, decays exponentially as it moves down the caste ladder, but never quite disappears. It has created what Ambedkar describes as the system of ‘graded inequality’ in which even the ‘low is privileged as compared with lower. Each class being privileged, every class is interested in maintaining the system’”.

However, the thrust of Roy’s powerful but disturbing essay deals with her exploration of the Gandhi-Ambedkar debate, and the man deified as the father of the nation does not come off well in this book. She writes: “Ambedkar was Gandhi’s most formidable adversary. He challenged him not just politically or intellectually, but also morally. To have excised Ambedkar from Gandhi’s story, which is the story we all grew up on, is a travesty. Equally, to ignore Gandhi while writing about Ambedkar is to do Ambedkar a disservice, because Gandhi loomed over Ambedkar’s world in myriad and un-wonderful ways.”

The Doctor and the Saint, your introduction to this new, annotated edition of Dr Ambedkar’s Annihilation of Caste, is also a deeply disturbing critique of Gandhi, especially to those of us for whom Gandhi is a loved and revered figure.

Yes, I know. It wasn’t easy to write it either. But in these times, when all of us are groping in the dark, despairing, and unable to understand why things are the way they are, I think revisiting this debate between Gandhi and Ambedkar, however disturbing it may be for some people, however much it disrupts old and settled patterns of thought, will actually, in the end, help illuminate our path. I think Annihilation of Caste is absolutely essential reading. Caste is at the heart of the rot in our society. Quite apart from what it has done to the subordinated castes, it has corroded the moral core of the privileged castes. We need Ambedkar—now, urgently.

Why should Gandhi figure so prominently in a book about Ambedkar? How did that come about?

Ambedkar was Gandhi’s most trenchant critic, not just politically and intellectually, but also morally. And that has just been written out of the mainstream narrative. It’s a travesty. I could not write an introduction to the book without addressing his debate with Gandhi, something which continues to have an immense bearing on us even today.

Caste is at the heart of the rot in our society. Quite apart from what it has done to the subordinated castes, it has corroded the moral core of the privileged castes. We need to take Ambedkar seriously.

Annihilation of Caste is the text of a speech that Ambedkar never delivered. When the Jat-Pat-Todak Mandal, an offshoot of the Arya Samaj, saw the text and realised Ambedkar was going to launch a direct attack on Hinduism and its sacred texts, it withdrew its invitation. Ambedkar publi­shed the text as a pamphlet. Gandhi published a response to it in his magazineHarijan. But this exchange was only one part of a long and bitter conflict between the two of them...when I say that Ambedkar has been written out of the narrative, I’m not suggesting that he has been igno­red; on the contrary, he is given a lot of attention—he’s either valorised as the ‘Father of the Constitution’ or ghettoised and then praised as a “leader of the untouchables”. But the anger and the passion that drove him is more or less airbrushed out of the story. I think that if we are to find a way out of the morass that we find ourselves in at present, we must take Ambedkar seriously. Dalits have known that for years. It’s time the rest of the country caught up with them.



Have you always held these views about Gandhi, or did you discover new aspects to him as you explored him vis-a-vis Ambedkar?

I am not naturally drawn to piety, particularly when it becomes a political manifesto. I mean, for heaven’s sake, Gandhi called eating a “filthy act” and sex a “poison worse than snake-bite”. Of course, he was prescient in his understanding of the toll that the Western idea of modernity and “development” was going to take on the earth and its inhabitants. On the other hand, his Doctrine of Trusteeship, in which he says that the rich should be left in possession of their wealth and be trusted to use it for the welfare of the poor—what we call Corporate Social Responsibility today—cannot possibly be taken seriously. His attitude to women has always made me uncomfortable. But on the subject of caste and Gandhi’s attitude towards it, I was woolly and unclear. Reading Annihilation of Caste prompted me to read Ambedkar’s What Congress and Gandhi Have Done to the Untouchables. I was very disturbed by that. I then began to read Gandhi—his letters, his articles in the papers—tracing his views on caste right from 1909 when he wrote his most famous tract, Hind Swaraj. In the months it took me to research and write The Doctor and the Saint I couldn’t believe some of the things I was reading. Look—Gandhi was a complex figure. We should have the courage to see him for what he really was, a brilliant politician, a fascinating, flawed human being—and those flaws were not to do with just his personal life or his role as a husband and father. If we want to celebrate him, we must have the courage to celebrate him for what he was. Not some ima­gined, constructed idea we have of him.

You could be accused of selectively picking out quotes from his writing to suit your own imagined, constructed idea of Gandhi....

When a man leaves behind 98 volumes of his Collected Works, what option does anybody have other than to be selective? Of course I have been selective, as selective as everybody else has been. And of course, those choices say a lot about the politics of the person who has done the selecting. My brief was to write an introduction to Anni­hilation of Caste. Reading Ambed­kar made me realise how large Gandhi loomed in Ambedkar’s universe. When I read Gandhi’s pronoun­cements supporting the caste system, I wondered how his doctrine of non-violence and satyagraha could rest so comfortably on the foundation of a system which can be held in place only by the permanent threat of violence, and the frequ­ent application of unimaginable violence. I grew curious about how Gandhi even came to be called a Mahatma.

I found that the first time he was publicly called Mahatma was in 1915, soon after he returned to India after spending 20 years in South Africa. What had he done in South Africa to earn him that honour?

Ambedkar challenged Gandhi not just politically and intellectually, but also morally. To excise him out of the mainstream narrative is a travesty.

That took me back to 1893, the year he first arrived in South Africa as a 24-year-old lawyer. I followed Gandhi’s writings about caste over a period of more than 50 years. So that answers questions like—“Did Gandhi change? And if so, how? Did he start off badly and grow into a Mahatma?” I wasn’t really researching Gandhi’s views on diet or natural cures, I was following the caste trail, and in the process I stumbled on the race trail, and eventually, through all the turbulence and mayhem, I found coherence. It all made sense.


It was consistent, and consistently disturbing. The fact is that whatever else he said and did, and however beautiful some of it was, he did say and write and do some very disturbing things. Those must be explained and accounted for. This applies to all of us, to everybody, sinner and saint alike. Let’s for the sake of argument imagine that someone driven by extreme prejudice ransacks the writings of Rabindranath Tagore. I am not a Tagore scholar, but I very much doubt that he or she would find letters, articles, speeches and interviews that are as worrying as some of the writings in the Collected Works of Mahatma Gandhi.

You say that Gandhi harboured attitudes that can only be described as racist towards the Blacks during his years in South Africa, you seem to see his positions as flawed and hypocritical. Would you agree with that?

I have not used those adjectives. I think you have inferred them from Gandhi’s speeches and writings reproduced in my introduction, which is perfectly understandable. Actually I don’t think Gandhi was a hypocrite. On the contrary, he was astonishingly frank. And I am impressed that all his writings, some of them—in my view at least—seriously incriminating, have been retained in the Collected Works.

That really is a courageous thing. I have written at length about Gandhi’s years in South Africa. I’ll just say a couple of things here about that period. First, the famous story about Gandhi’s political awakening to racism and imperialism because he was thrown out of a ‘whites only’ compartment in Pietermaritzberg is only half the story. The other half is that Gandhi was not opposed to racial segregation. Many of his campaigns in South Africa were for separate treatment of Indians. He only objected to Indians being treated on a par with ‘raw kaffirs’, which is what he called Black Africans. One of his first political victories was a ‘solution’ to the Durban post office ‘problem’. He successfully campaigned to have a third entrance opened so that Indians would not have to use the same door as the ‘kaffirs’. He worked with the British army in the Anglo-Boer war and during the crushing of the Bambatha rebellion. In his speeches he said he was looking forward to “an Imperial brotherhood”. And so it goes, the story. In 1913, after signing a settlement with the South African military leader Jan Smuts, Gandhi left South Africa. On his way back to India he stopped in London where he was awarded the Kaiser-e-Hind for public service to the British Empire. How did that add up to fighting racism and imperialism?

But ultimately he did fight imperialism, did he not? He led our country to freedom....

What was ‘freedom’ for some was, for others, nothing more than a transfer of power. Once again, I’d say the Gandhi-Ambedkar debate deepens and complicates our understanding of words like “imperialism” and “freedom”. In 1931, when Ambedkar met Gandhi for the first time, Gandhi questioned him about his sharp criticism of the Congress, which at the time amounted to criticising the struggle for the homeland. Ambedkar’s famous, and heart-breaking, reply was: “Gandhiji, I have no homeland. No untouchable worth the name would be proud of this land.”

Even after he returned from South Africa, Gandhi still saw himself as a ‘responsible’ subject of Empire. But in a few years, by the time of the first national non-cooperation movement, Gandhi had turned against the British. Millions of people rallied to his call, and though it would be incorrect to say that he alone led India to freedom from British rule, of course he played a stellar part. Yet in the struggle, though Gandhi spoke about equality and sometimes even sounded like a socialist, he never challenged traditional caste hierarchies or big zamindars.

The rise of Dalit parties has been dazzling. The real worry is that even as Dalits become more influential in parliamentary politics, democracy itself is being undermined in serious, structural ways.

Industrialists like the Birlas, the Tatas and the house of Bajaj bankrolled Gandhi’s political activity and he took care never to cross swords with them. Many of them had made a lot of money during the First World War, and had now come up against a glass ceiling.


They were irked and limited by British rule and by their own brushes with racism. So they threw their weight behind the national movement.

Around the time Gandhi returned from South Africa, mill workers who had not benefited from the managements’ windfall profits had become restive and there were a series of lightning strikes in the Ahmedabad mills. The mill-owners asked Gandhi to mediate. I have written about Gandhi’s interventions over the years in labour disputes, his handling of labour unions and his advice to workers about strikes—much of it is very puzzling. In other areas too, the famous Gandhian ‘pragmatism’ took some very strange turns. For example, in 1924, when villagers were protesting against the Mulshi Dam being built by the Tatas some distance away from Pune, to generate electricity for the Bombay mills, Gandhi wrote them a letter advising them to give up their protest. His logic is so very similar to the Supreme Court judgement of 2000 that allowed the construction of the World Bank-funded Sardar Sarovar Dam to proceed...so Ambedkar was spot-on when he said, “The question whether the Congress is fighting for freedom has very little importance as compared to the question for whose freedom is the Congress fighting?”

Photograph by Corbis, From Outlook 10 March 2014

In the past you have written powerful political essays based on reporting from the field or on contemporary events as they unfold. But in this work, you seem to have done some very serious historical research and drawn very different conclusions from many known historians who have worked on the national movement, Gandhi and Ambedkar. You are obviously going to be challenged. Do tell us about the journey that writing The Doctor and the Saint involved.

You say I’ll be challenged? Oh, and here I was imagining that it was me that was doing the challenging! Several years ago, S. Anand, the publisher of Navayana, gave me a spiral-bound copy of Anni­hilation of Caste and asked me if I would write an introduction to it. I read it and found it electrifying. But I was intimidated by the prospect of writing an introduction to it—a real introduction, not just some quotes patched together with praise and banalities. I didn’t feel that I was equipped to do that. I knew it would mean swimming through some pretty treacherous waters. Anand said he would wait, and he did.

On the issue of Muslims, there were serious differences between Gandhi and the Hindu Right. But on the issues of caste, religious conversion and cow protection, Gandhi was in stride with the Hindu Right.

Meanwhile, he began work on the annotations which placeAnnihilation of Caste in a context and make it an extraordinarily rich resource for scholars interested in the subject. I was writing fiction and had promised myself that I wasn’t going to write anything that involved footnotes anymore. But of course, when I started writing the introduction, given the way my argument developed, I had to reference almost every sentence. After a while I began to enjoy myself. The notes are not just references, they’re almost a parallel narrative, in and of themselves. I hope at least some people take the trouble to read them....


But coming back to your question of The Doctor and the Saintbeing a challenge—many historians have criticised Gandhi before, for other reasons, so I don’t think I am alone on this one at all. Many Dalits and Dalit scholars have, over the decades, been very sharply critical of Gandhi and Gandhism. Having said that, if this book begins another debate, a real debate, it can only be a good thing. I think it’s high time that there was one. I’m sure there are plenty of people who would be happy to weigh in on it.

Given what happened to Wendy Doniger’s book, are you worried?

Not about this book in particular, no. It’s Ambedkar’s book. But it’s true that we are becoming less and less free to write and say what we think. What the irreverent Mirza Ghalib could say in the 19th century about his relationship with Islam, what Saadat Hasan Manto could say about mullahs in the 1940s, what Ambedkar could say about Hinduism in the 1930s, what Nehru or JP could say about Kashmir—none of us can say today without risking our lives. The argument between Gandhi and Ambedkar that followed the publication of Annihilation of Caste was a harsh, intense debate between two extraordinary men—they were not afraid of real debate. Unlike contemporary bigots who demand book-banning, Gandhi—who found the text of Ambedkar’s speech disagreeable—actually wanted people to read it. He said, “No reformer can ignore the address.... It has to be read only because it is open to serious objection. Dr Ambed­kar is a challenge to Hinduism.”

Your introduction begins with a powerful critique of the all-pervasive domination of traditional upper castes in the establishment, including the media, and you suggest that there has been a ‘project of unseeing’ across the political establishment. Don’t you think that the post-Mandal realities of contemporary India have actually made caste a fundamental unit of all politics?

When you look at India, through the prism of caste, at who controls the money, who owns the corporations, who owns the big media, who makes up the judiciary, the bureaucracy, who owns land, who doesn’t—contemporary India suddenly begins to look extremely un-contemporary. Caste was the engine that drove Indian society—not just Hindu society—much before the recommendations of the Mandal Comm­ission. A long section of The Doctor and the Saint is an analysis of how, in the late 19th century, when the idea of ‘empire’ began to mutate into the idea of a ‘nation’, when the new ideas of governance and ‘representation’ arrived on our shores, it led to an immense anxiety about demography, about numbers. For centuries before that, millions of people who belonged to the subordinated castes—those who had been socially ostracised by privileged castes for thousands of years—had been converting to Islam, and later to Sikhism and Christianity to escape the stigma of their caste. But suddenly numbers began to matter. The almost fifty million “untouchables” became crucial in the numbers game. A raft of Hindu reformist outfits began to proselytise among them, to prevent conversion. The Arya Samaj started the Shuddhi movement—to ‘purify the impure’—to try and woo untouchables and Adivasis back into the ‘Hindu fold’. A version of that is still going on today with the VHP and the Bajrang Dal running their ‘Ghar Vapasi’ programmes in which Adivasi people are ‘purified’ and ‘returned’ to Hinduism. So yes, caste was, and continues to be, the fundamental unit of all politics in India.

So how can you call it a ‘project of unseeing’?

The ‘project of unseeing’ that I write about is something else altogether. It’s about the ways in which influential Indian intellectuals today, particularly those on the Left, for whom caste is just a footnote—an awkward, inconvenient appendage of reductive Marxist class analysis—have rendered caste invisible. To say “we don’t believe in caste” sounds nice and progressive. But it is either an act of evasion, or it comes from a position of such rarefied privilege where caste is not encountered at all. The ‘project of unseeing’ exists in almost all of our cultural practice—does Bollywood deal with it? Never. How many of our high-profile writers deal with it? Very few. Those who write about justice and identity, about the ill effects of neo-liberalism—how many address the issue of caste? Even some of our most militant people’s movements elide caste.

Is there a version of Communism that I endorse? I don’t know, I am not a Communist. But we do need a robust, structural critique of capitalism.

The Indian government’s churlish reaction to Dalits who wanted to be represented at the 2001 World Conference against racism in Durban is part of the ‘project of unseeing’. In the same way, the Indian census entirely elides caste in its data collection—leaving us all in the dark about what’s really going on—the scale of dispossession and violence against Dalits is part of the ‘project of unseeing’. Here’s something to think about—in 1919, during what came to be called ‘The Red Summer’ in the United States, approximately 165 Black people were killed. Almost one century later, in 2012 in India—the year of the Delhi gang-rape and murder—according to official statistics, 1,574 Dalit women were raped. And 651 Dalits were murdered. That’s just the criminal assault against Dalits. The economic assault, notwithstanding the emergence of a clutch of Dalit millionaires, is another matter altogether.


You say that caste in India—“one of the most brutal modes of hierarchical social organisation that human society has known—has managed to escape censure because it is so fused with Hinduism, and by extension with so much that is seen to be kind and good—mysticism, spiritualism, non-violence, tolerance, vegetarianism, Gandhi, yoga, backpackers, the Beatles—that, at least to outsiders, it seems impossible to pry it loose and try to understand it”. You argue that caste prejudice is on a par with racial discrimination and apartheid but has not been treated as such. Many would argue that electoral politics and reservation are adequate to deal with historical injustice. But recen­tly a senior Congress leader, Janar­dhan Dwivedi, said reservation should be discontinued. How would you respond to such an argument?

It was an outrageous thing for anyone to say. Reservation is extremely important, and I have written at some length about it. To be eligible for the reservation policy, a Scheduled Caste person needs to have completed high school. Govern­ment figures say more than 70 per cent of Sche­duled Caste students drop out before they matriculate. Which means for even low-end government jobs only one in every four Dalits is eligible. For a white-collar job, the minimum qualification is a graduate degree. Just over 2 per cent of Dalits are graduates. Even though it actually applies to so few, the reservation policy has meant that Dalits at least have some representation in the echelons of power. This is absolu­tely vital. Look at what one Ambedkar, who had the good fortune to get a scholarship to study in Columbia, managed to do. It is thanks to reservation that Dalits are now lawyers, doctors, scholars and civil servants. But even this little window of opportunity is resented and is under fire from the privileged. And the track record of government institutions, the judiciary, the bureaucracy and even supposedly progressive ins­titutions like jnu in implementing reservation is appalling. There is only one government department in which Dalits are over-represented by a factor of six.

Almost 90 per cent of those designated as municipal sweepers—people who clean streets, who risk their lives to go down manholes and service the sewage system, who clean toilets and do menial jobs—are Dalits. Even this sector is up for privatisation now, which means private companies will be able to subcontract jobs on a temporary basis to Dalits for less pay and with no guarantee of job security. Of course there are problems with people getting fake certificates and so on. Those need to be addressed. But to use that to say reservation shouldn’t exist is ridiculous.

But surely you agree that the rise of Dalit parties like the BSP marks something close to a revolution in Indian democracy?

The rise of Dalit political parties has been a dazzling phenomenon.
But then our electoral politics, in the present shape, cannot really be revolutionary, can it? The book, and not just the introduction, deals with it in some detail. Ambedkar’s confrontation with Gandhi at the Second Round Table Conference in London in 1931 had precisely to do with that—with their very different views on the matter of political representation of and for Dalits.

Ambedkar believed that the right to representation was a basic right.

Reductive Marxist class analysis renders caste invisible. Very few high-profile writers deal with it. Our most militant people’s movements elide the issue. It finds no place in Indian census data. It’s a Project of Unseeing.

And all his life he fought for untouchables to have that right. He thought and wrote a great deal about the first-past-the-post electoral system and how untouchables would never be able to emerge from the domination of privileged castes in such a system because the population was scattered in a way that they would never form a majority in a political constituency. Gandhi, who worked among untouchables with missionary zeal, was not prepared to allow them to represent themselves. And he explicitly worked against that possibility. His Harijan Sevak Sangh—funded by G.D. Birla—which fronted the Temple Entry movement was made up only of privileged caste members. In the Mahajan Mazdoor Sangh, the mill workers’ union that Gandhi started in Ahmedabad, workers, many of whom were untouchables, were not allowed to be office-bearers, they were not allowed to represent themselves. At the Second Round Table Conference in London in 1931, Gandhi said, “I claim myself, in my own person, to represent the vast mass of untouchables.” In S. Anand’s note on the Poona Pact at the back of the book, he writes of how Gandhi, in a reply to a question from an untouchable member of the Congress party asking if he would ensure that Harijans were represented in state councils and panchayat boards, said the principle was “dangerous”.


Gandhi played a great part in seeing to it that Ambedkar’s project of developing untouchables into a political community that was aware of its rights, that could choose its own representatives from among themselves, was thwarted and undermined. Even today Dalits are paying the price for that. Despite these odds, the Bahujan Samaj Party has emerged in UP. But even there, it took more than half a century for Kanshi Ram—and then Mayawati—to succeed. Kanshi Ram worked for years, painstakingly making alliances with other subordinated castes, to achieve this victory. The BSP needed the peculiar demography of Uttar Pradesh and the support of many OBCs. But if it is to grow as a political party, it will have to make alliances that will dilute its political thrust. For a Dalit candidate to win an election from an open seat—even in UP—continues to be almost impossible. Still, notwithstanding the charges of corruption and malpractice, I don’t think anybody should ever minimise the immense contribution the BSP has made in building Dalit dignity. The real worry is that even as Dalits are becoming more influential in parliamentary politics, democracy itself is being undermined in serious and structural ways.

Your account of the manner in which Gandhi prevailed over Ambedkar on the issue of the Communal Award, in which the British awarded a separate electorate for untouchables, is fascinating—the description of how Ambe­dkar had to give up his dream and sign the Poona Pact in 1932. But I have a question about the issue of separate electorates. Many histo­rians argue that this idea really was at the root of the problems that would lead to Partition. And many would argue against separate electorates. Do you think that India still needs separate electorates?

I think our first-past-the-post electoral system is gravely flawed and is failing us. We need to rethink it. But I think we should be careful of collapsing all these very contentious issues about separate electorates, the Communal Award and Partition into one big accusatory mess. As I said earlier, Ambedkar had thought out the demand for a separate electorate and separate representation for untou­chables very carefully. I really don’t want to restate what I’ve written...but let’s just say that he had come up with a brilliant and unique plan.
His idea really was to create a situation in which Dalits could develop into a political community with its own leaders. His proposal for a separate electorate was to last for only 10 years. And we are talking here about a people who were ostracised by the privileged castes for thousands of years in the most unimaginably crude and cruel manner—people who were shunned, who were not allowed access to public wells, to education, to temples, besides other things. People who were not entitled to anything except violence and abuse. But when they asked for a separate electorate, everybody behaved as though the world was ending.

Ambedkar speaks about the Adivasis in the same patronising way as Gandhi speaks about untouchables. It’s hard to understand how a man who saw the insult to his own people so clearly could have done that.

Gandhi went on an indefinite hunger strike and public pressure forced Ambedkar to give up his demand and sign the Poona Pact. It was preposterous. How can we possibly say that Ambedkar’s demand for a separate electorate led to Partition? The impulse was exactly the opposite. He was trying to bring liberty and equality to a society that practised a vicious form of apartheid. He was talking about justice, brotherhood, unity and fellow feeling—not Partition. But caste hierarchy means that only the privileged can close the door on Dalits.


When Dalits close the door on themselves, it is made out to be an act of treachery. Also, while we like to place all the blame for Partition on Jinnah—using the word ‘blame’ presupposes that everybody agrees that Partition was a terrible thing, but even that is not true—we forget that people like Bhai Parmanand, a founder-member of the Ghadar Party, a pillar of the Arya Samaj in Lahore, and later an important leader of the Hindu Mahasabha, suggested, as far back as 1905, during the partition of Bengal, that Sindh should be joined with Afghanistan and the North West Frontier Province, and should be united into a great Muslim Kingdom. Partition happened because a whole set of forces was set into play, and it all spun out of the control of the men who had positioned themselves at the helm of affairs.

You criticise Ambedkar quite harshly for his views on Adivasis.

Ambedkar speaks about Adivasis in the same patronising way that Gandhi speaks about untouchables. It’s hard to understand how a man who saw the insult to his own people so clearly could have done that.

Ambedkar was a man of reason, and a man with a keen sense of justice. I bel­ieve he would have taken the criticism seriously and would have changed his views. But that’s not the only criticism I have of him. In his embrace of Western liberalism, his support of urbanisation and modern ‘development’, he failed to see the seeds of catastrophe that were embedded in it. I have written about this at some length too.

You have also explored the great failure of Communists to address caste. You write that “they treated caste as a sort of folk dialect derived from the classical language of class analysis”. I think all Communists should read your precise take on the great trade union leader S.A. Dange. My question to you is this: Party communism has disappointed you. But is there any version of Commu­nism that you support and endorse?

My criticism of the way mainstream Communist parties have dealt with caste goes all the way back to The God of Small Things. When the novel came out in 1997, the Communist Party of India (Marxist) was extremely angry with the book. They were angry with my depiction of a character called Comrade K.N.M. Pillai who was a member of the Communist Party and his prejudices against Velutha, a Dalit who was one of the main characters in the book. Communists and Dalits ought to have been natural allies, but sadly that has just not happened. The rift began in the late 1920s, quite soon after the Communist Party of India was formed. S.A. Dange—a Brahmin like many Communist leaders tend to be even today, and one of its chief ideologues—organised India’s first Communist trade union, the Girni Kamgar Union with 70,000 members. A large section of the workers were Mahars, untouchables, the caste that Ambedkar belonged to. They were only employed in the lower-paid jobs in the spinning department, because in the weaving department, workers had to hold the thread in their mouths, and the untouchables’ saliva was considered polluting to the product. In 1928, Dange led the Girni Kamgar Union’s first major strike. Ambedkar suggested that one of the issues that ought to be raised was equality and equal entitlement within the ranks of workers. Dange did not agree, and this led to a bitter falling out. That was when Ambedkar said, “Caste is not just a division of labour, it is a division of labourers.” There is a very very compelling section in Annihilation of Caste in which Ambedkar writes about Caste and Socialism. Is there a version of Communism that I support and endorse? I’m not sure what that means. I am not a Communist. But I do think that we are in dire need of a structural and robust criticism of capitalism, and I do not mean just crony capitalism.

Right now, the new player on the political scene, the Aam Aadmi Party, which is obviously inspired by Gandhian symbolism, is taking on crony capitalism. It has attacked Mukesh Ambani and RIL, who you wrote about in your last big essay Capitalism: A Ghost Story. What are your views on AAP?

It’s a little difficult to have a coherent view on AAP because it doesn’t seem to have a coherent view of itself. I am not an admirer of anti-corruption as a political ideology, because I think corruption is the manifestation of a problem, and not the problem itself. Of course, it gets a lot of political traction in an election year—after all even the corrupt are against corruption—but eventually it will lead us down a blind alley. But I was one of the people who cheered when AAP took on Mukesh Ambani. Suddenly everybody, the mainstream media as well as the social media, began to discuss the Ambanis and the gas-pricing issue—these are things that hardly anybody dared to even whisper about only a few months ago. We all remember how the news of the Ambani car crash in Mumbai was just blanked out. On this score, the Aam Aadmi Party has put a little steel into everybody’s spine. They identify themselves with the Gandhi cap, but going after industrial houses in this way is very un-Gandhian activity, and I’m all for it. I just hope it doesn’t end in a gladiatorial inter-corporate war, where a new monster takes the place of the old one. Mud-slinging and allegations about who has been bought over or bribed by whom is good entertainment, but the rot is deeper than corruption and bribery. The real problem as I see it is that the big corporations—Tata, Reliance, Jindals, Vedanta and several others—run so many businesses simultaneously. Mukesh Ambani is personally worth something like 1,000 billion rupees. But the Tatas, Vedanta, Jindals, Adanis are not all that different. Even if everything is completely above board there is a problem. Even if you are a hard-core classical capitalist you have to see there is a problem here. This kind of cross-ownership of businesses, this scale of profits—limitless profits—accruing to fewer and fewer people, the conflict of interest between corporates and the media—how can you have a free press that is owned and run by corporations? I understand that as a political strategy, AAP is singling out Mukesh Ambani and taking him on for the sheer spectacle of it. Having a 27-storeyed tower built as a personal residence—it’s hubris, he was asking, begging, to be taken down. But at some point I would be glad to see the problem being addressed in a more serious and structural way. Particularly since we are looking to AAP to put a few roadblocks in the way of what is being called the rise of Moditva—which is basically corporate capitalism fused with primitive fascism.

Many people will take issue with your interpretation when you say “there was never much daylight between Gandhi’s views on caste and those of the Hindu Right. From a Dalit point of view Gandhi’s assassination could appear to be more a fratricidal killing than an assassination by an ideological opponent”. You then go on to say that Narendra Modi is able to invoke Gandhi without the slightest discomfort because of this. Are you therefore handing Gandhi over to the Hindu Right? He is someone they have been eager to appropriate, so are you not playing into their hands?

Gandhi’s not a stuffed toy, and who am I to hand him over to anyone?
Let me just say this—on the issue of Muslims and their place in the Indian nation there surely were serious ideological differences between Gandhi and the Hindu Right, and for this Gandhi paid with his life. But on the issues of caste, religious conversion and cow protection, Gandhi was perfectly in stride with the Hindu Right. At the turn of the century—the 19th and 20th centuries—when various reformist organisations were proselytising to the untouchable population, the right-wing was, if anything, more enthusiastic. For example, V.D. Savarkar, a disciple of Tilak’s, and a hero of the Hindu Right, supported the 1927 Mahad satyagraha which Ambedkar led, for the untouchables’ right to use water from a public tank. Gandhi’s support was less forthcoming. Who were the signatories to the Poona Pact?

There were many, but among them were G.D. Birla, Gandhi’s industrialist-patron, who bankrolled him for most of his life; Pandit Madan Mohan Malaviya, a conservative Brahmin and founder of the Hindu Mahasabha; and Savarkar, who was accused of being an accomplice in the assassination of Gandhi. They were all interconnected in complex ways.

One cannot have a coherent view on AAP as it doesn’t have one of itself. But it has put steel in everyone’s spine. I just hope it doesn’t end in a gladiatorial inter-corporate war, where a new monster replaces the old.

Birla funded Gandhi as well as the Arya Samaj’s Shuddhi movement. When the RSS was banned after the assassination of Gandhi, Birla lobbied for the ban to be lifted. A recent report in Caravan about Swami Aseemanand, a major RSS leader and the son of a devout Gandhian, who is in jail, being tried for orchestrating a series of bomb blasts including the Samjhauta Express blast, in which about 80 people were killed, describes how boys in his ashram in Gujarat were made to chant the Ekata mantra every morning, an ode to national unity that invokes Gandhi as well as M.S. Golwalkar, the most important RSS ideologue.


Narendra Modi delivers many of his hissy pronouncements from a spanking new convention hall in Gujarat called Mahatma Mandir. In 1936, Gandhi wrote an extraordinary essay calledThe Ideal Bhangi which he ends by saying—“Such an ideal Bhangi, while deriving his livelihood from his occupation, would approach it only as a sacred duty. In other words, he would not dream of amassing wealth out of it.” Seventy years later, in his book, Karmayogi (which he withdrew after the Balmiki community protested), Narendra Modi said: “I do not believe they have been doing this job just to sustain their livelihood. Had this been so, they would not have continued with this kind of job generation after generation.... At some point of time somebody must have got the enlightenment that it is their (Balmikis’) duty to work for the happiness of the entire society and the Gods; that they have to do this job bestowed upon them by Gods; and this job should continue as internal spiritual activity for centuries.” You tell me—where’s the daylight?

When Arundhati Roy does a scathing critique of a man as revered as Mahatma Gandhi, it gets noticed around the world. Some would argue that keeping a beautiful idea alive is more important than undermining it with a certain reality.

That’s a good question. I actually thought about that quite a lot—as any writer would, or should. I decided it was completely wrong, completely unacceptable. That kind of a cover-up—and it would be nothing less than a cover-up—comes at a price. And that price is Ambedkar. We have to deal with Gandhi, with all his brilliance and all his flaws, in order to make room for Ambedkar, with all his brilliance as well as his flaws. The Saint must allow the Doctor a place in the light. Ambed­kar’s time has come.

What Does it Mean to be a Physician?

Whitcomb, Michael E. MD

 Extraordinary changes have occurred during the past few decades in the design and conduct of the medical school curriculum. To a great extent, this reflects a commitment by medical school deans and faculties to better prepare their students for the challenges they will face throughout their professional careers. The changes that have been adopted are truly impressive, yet there is still more to be accomplished. I have suggested on several occasions that in order for the medical education community to be clear about the kind of changes that are needed, the community needs to define more clearly the purpose of the educational program.^1,2 And I have suggested that in order to reach agreement on that purpose, the community must first answer a fundamental question: What does it mean to be a physician?

This approach reflects my belief that one of the primary purposes of the educational program is for students to learn, in depth, what it means to be a physician. After all, the title is bestowed upon them when they graduate from medical school, even though they are not yet prepared for the actual practice of medicine. Even so, shouldn’t they have an understanding of what it means to be a physician when they receive the title? In posing the question I am not seeking a formal definition of the term physician that one might find in a dictionary. My intent, instead, is to seek agreement within the medical education community on the attributes—that is, the personal qualities—that a physician should possess if he or she is to be capable of meeting the public’s expectations of a doctor.

Some have suggested that possessing a body of knowledge and a set of skills that can be applied in the practice of medicine defines what it means to be a physician. Now, there is no question that certain knowledge and certain skills are essential elements of being a physician. But it is also clear that the knowledge and skills required vary depending upon the particular career path a physician has chosen. So, while it is essential for physicians to be knowledgeable and skillful in order to engage in the practice of medicine, it is not possible to define what it means to be a physician by identifying a body of knowledge and a set of skills that all physicians must possess. On the other hand, there is a specific set of personal attributes that I maintain all physicians should possess if they are to meet the public’s expectations, and that it is those attributes that define the essence of what it means to be a physician.

First, a physician must be caring. One of the most famous quotes in the annals of American medicine comes from the address Francis Peabody gave to Harvard medical students in 1925.³ In that address, Peabody stated, “The secret of the care of the patient is in caring for the patient.” There are many texts that describe in eloquent terms the value that patients place on being truly cared for by a physician. But in modern times, members of the medical profession have too often equated caring with treatment, and have tended at times to limit their role to providing treatment leading to a cure. Unfortunately, this approach has too often meant that physicians ignored the importance of a caring manner, no matter what the treatment options were. Worse, once a patient could no longer be cured, too many physicians believed that there was nothing more to be done and attended in only a minimum way to the patient’s needs. In fact, it is now clear that caring for patients becomes more critical in situations in which the patient understands that treatment will no longer be useful and cure is no longer possible.

A few years ago, the Hastings Center initiated a project to define the goals of medicine.⁴ One of the four major goals that evolved from the project was called The Care and Cure of Those with a Malady, and the Care of Those Who Cannot be Cured. It is essential, therefore, that physicians understand clearly that to serve the goals of medicine, they have a responsibility to continue to care for their patients when they can no longer prescribe a particular form of treatment or offer the likelihood of a cure. If they do not continue to provide care under those circumstances—that is, by being caring—their patients will sense that they have been abandoned by their doctor at a critical time. Clearly, the essence of what it means to be a physician requires that a physician not allow this to occur.

Second, physicians must be inquisitive. Medicine has a long tradition of celebrating all that the members of the profession know about mechanisms of disease and the diagnosis and management of various clinical maladies. Indeed, admission to the study of medicine and advancement throughout the various stages of one’s career are often based solely on what one knows. But the fact is that there is a great deal about medicine that is not known, and there is a great deal that individual physicians do not know about what is known.

Given that, the value of physicians’ being inquisitive about medicine is clear. This attribute contributes in an important way to the quality of care provided by physicians by ensuring that they continue to acquire the knowledge and skills they will need to meet their professional responsibilities as the nature of medicine changes during their careers. But it is also important to recognize that this attribute contributes in a more immediate way to the quality of the care provided to individual patients.

In his new book, How Doctors Think, Jerome Groopman⁵ emphasizes that most of the diagnostic errors made by physicians result from cognitive mistakes. He points out that because of the uncertainty inherent in the practice of medicine, there is a tendency for physicians when encountering a patient to lock in too soon on a particular diagnosis or a particular approach to treatment. By doing so, the physician runs the risk of overlooking clues suggesting that the working diagnosis may not be correct. Even though a patient may present with the classic manifestations of a particular malady, the true physician will always pause before making a diagnosis and embarking on a course of therapy by asking himself or herself, What is there about this patient’s presentation that I don’t understand? Or, importantly, What is there about this patient that I should know before proceeding?

And finally, physicians must be civic minded. This is a confusing concept to grasp, because in modern times the civic responsibility of the individual physician tends to be obscure. Over the years, this responsibility has come to be viewed as an element of professionalism that is somehow embedded, at least implicitly, within the context of the social contract that defines the medical profession’s responsibility to the society as a whole—a responsibility manifested largely by how professional organizations relate to the public. But Bill Sullivan⁶suggests in Work and Integrity: The Crisis and Promise of Professionalism in America that it is critically important that individual physicians become more personally involved in meeting medicine’s responsibility to society. In his view, they must concern themselves with ensuring that the professional organizations to which they belong are focused on serving the interests of the public, rather than simply serving the interests of the organization’s members. But the civic mindedness of physicians should go beyond that to include consciously contributing in a variety of ways to the betterment of the communities in which they live by participating in community organizations and bringing their special talents to bear in volunteer efforts specifically aimed at improving the health of the public.

So, I suggest that although a physician who is not caring, inquisitive, and civic minded may be a highly skilled technician involved in the practice of medicine, such an individual will not truly reflect the essence of what it means to be a physician. Given this, it is essential that as medical schools continue to modify their educational programs, they ensure that those programs reflect a commitment to ensuring that their graduates be caring, inquisitive, and civic-minded physicians. Deans and faculties of medical schools must understand clearly that while their graduates will spend their residencies acquiring much of the knowledge and many of the skills they will need for the practice of their chosen specialties, it is in medical school that they must learn the essential attributes of a true physician.