The Mess at CGHS

While the government has ambitions of running and efficiently managing the world’s largest public healthcare program called Ayushman Bharat, the much smaller and much older healthcare scheme meant for the employees of the Central Government is in a complete mess. The Central Government Health Scheme (CGHS) website loftily proclaims that it” is the model Health care facility provider for Central Government employees & Pensioners and is unique of its kind due to the large volume of beneficiary base, and open ended generous approach of providing health care”. It is anything but that.

CGHS is over six decades old and is run under the Ministry of Health and Family Welfare of the Government of India. It is meant to provide subsidized healthcare to government servants through a network of primary clinics, dispensaries and em-paneled hospitals, which are mostly in the private sector. The private hospitals are required to treat the CGHS beneficiaries in a cashless mode and claim reimbursements at subsidized and pre-agreed rates from the CGHS organisation. The participation of the hospitals in the scheme is voluntary.

Recently, on July 2nd, the Minister of State for Health and Family Welfare, GoI, Ashwini Choubey, stated in the Rajya Sabha (the upper house of the Indian Parliament), that the government has received some complaints regarding private hospitals em-paneled with CGHS refusing to admit the CGHS beneficiaries and that show cause notices have been issued to these hospitals and strict action is contemplated against them. As usual, the government is stating only one side of the story.

Here is the other side.

CGHS had entered into an agreement with private hospitals in 2014. The agreements were valid for 2 years. Since 2016, the CGHS organisation has been arbitrarily extending these agreements for a period of 3 months. Fresh agreements that should have been signed in 2016 have not been floated and the em-paneled hospitals just receive a communication from the CGHS organisation that the agreement is extended by 3 more months.

Interestingly, the agreements signed by the hospitals in 2014 were sent to CGHS for the signatures of CGHS officials. These have not even been returned to the hospitals. This essentially means that the hospitals do not hold with them any legally valid agreement duly signed by both the parties.

To make matters infinitely worse, the pricing that the hospitals had agreed to in 2014 for a period of 2 years remains unchanged even in 2019. Thus, the CGHS organisation has not increased the price that they pay to the hospitals in the last 5 years. The price of a consultation with a specialist is fixed at INR 150 (approx. USD 2) !!!! The hospitals’ costs of course keep going up year on year. There is no justification offered for this stasis.

If this was not bad enough, the CGHS never pays the hospitals on agreed credit period. The payments are delayed for months, while the hospitals are expected to continue treating CGHS patients without a pause. One clause in the CGHS agreement states that 60% of the bill will be reimbursed by the CGHS with-in one week of the submission of the bills. This, of course remains only on paper. The CGHS owes hundreds of crores of rupees to private hospitals in the National Capital Region of Delhi alone. Effectively, the private hospitals end up locking their working capital in treating CGHS beneficiaries.

A small industry thrives on recovering dues from the CGHS. Sundry companies offer their services to private hospitals to help get their bills cleared by the CGHS. Many hospitals employ a small army to chase their bills across the dusty desks of the CGHS mandarins. They literally move the files in the CGHS corridors, from one desk to the other and from one office to the other. All this means additional expenses for the private hospitals, just to recover their legitimate dues.

Finally, when the money arrives after a valiant effort stretching over months, the hospitals discover that their bills have not been paid in full and deductions have been made for reasons, never specified. The hospitals often make representations to the CGHS to understand the reasons for these deductions and seek the recoveries, which of course is another herculean task. Some simply do not bother and accept whatever CGHS deigns to pay them.

The genesis of the problem lies in the fact that CGHS is under-funded and monumentally inefficient. No one is actually bothered to take a broom and clean up the mess. No one has a real incentive to do that. While, perverse incentives to let things be, continue unabated.

Rather than threatening private hospitals, Minister Choubey will perhaps do well to have a look right down the corridor from his office and do something about the mess in CGHS.

The views expressed are personal and do not necessarily reflect those of my employers.

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Bharat Inder Singh

Dr Bharat Inder Singh, who passed away yesterday night was one of the most warm and jovial person I ever met. He was always laughing, mostly at himself or while cracking hilarious sardarji jokes. I had met Bharat for the first time a little over 17 years ago at our office (Max Healthcare, Okhla). He had recently joined the Max Medcentre Panchsheel Park as the centre head and he was going through his induction. I was the young and somewhat brash brand manager of the company.

In our very first meeting Bharat told me that he never understood why the organisation needed a brand manager. He explained that he had been practicing medicine for the last two decades and in his experience the only marketing he had ever needed was a board bearing his name outside his clinic. Lest, I become uncomfortable, he quickly added that things are changing now and maybe he needs to learn a few things from me.

Bharat had a unique way with his patients. He would connect with them in an instant, make them comfortable with humorous asides or simply laugh away their concerns about their illnesses, reassuring them that all will be well soon. He had a particular charm, which worked so well with the ladies, particularly elderly ladies, who were mostly his patients. He would always listen to them with great attention (or at least pretend to be listening), talk about their grand-children or dogs or husbands and be ready with his prescriptions. Bharat, always had time for his patients and he was never in a hurry for anything.

While, Bharat was a very good physician, he made no bones about the fact that he knew nothing of managing a facility. Thus, while Max Medcentre in Panchsheel Park was his responsibility, he had happily delegated the running of the centre to Dr Dilpreet Brar. He would often laugh at himself at his lack of ability as well as interest in anything, which required meetings, excel sheets or power-point presentations. He would show up at the last minute for reviews, quickly understand the drift of what was being presented and wink his way through it all. He made hilarious gaffes and we would all be hard pressed to keep straight faces, it really didn’t matter much to him.

Bharat was passionate about Squash. He was supremely fit and even coached youngsters in the game. I recall that once we had participated in a corporate Squash tournament. Our team comprised of Bharat and Dr Nitiraj Oberoi, an Orthopaedic surgeon who also worked at Max Medcentre in Panchsheel Park. Bharat and Nitiraj made their way to the finals without difficulty and invited Pallavi Das (who headed Corporate Sales at Max Healthcare) and me to watch them win the tournament. Pallavi and I drove across Delhi to Gurgaon to watch the match. The other finalists were two youngsters representing Amex. They were on the court, warming up, shadow practicing their shots and had quite a lot of supporters who had come to watch the match. They looked young, confident and were a bit cocky, prancing around the court. Bharat and Nitiraj were no where to be seen and I told Pallavi that these youngsters will probably whip Bharat and Nitiraj.

Our team showed up at the last minute, Bharat in his graying beard and Nitiraj too looking much older than the competition. I went and wished our team luck and also mentioned that these youngsters appear to be quite a handful. Bharat, looked at me scornfully and said ”watch the fun begin”.

Bharat and Nitiraj made the Amex team run around the court with such great ease that by the end of the first set itself the youngsters were sprawled flat on the court and Bharat had hardly broken into a sweat!!! That day, I learnt never ever to look at men with gray beards as old.

I last met Bharat two months ago. My mother had an appointment with her cardiologist at Max Medcentre, and while I waited with her for him to arrive, I noticed Bharat’s familiar name-plate outside his clinic at the centre. I learnt that he was in and relatively free. We chatted about old times for close to half an hour. He did appear a little frail and I did know about his illness, yet he looked in good spirits and was doing what he loved most, seeing patients. He joked with me about my paunch and advised me a diet and walking regimen that should help me reduce weight. We never spoke about his own health.

Rest in peace, Dr Bharat.

Resisting the advance of Medical Value Travel is Futile

As I travel to various parts of the world promoting Medical Value Travel (MVT) to India and Max Hospitals, in New Delhi, I am increasing becoming aware of a certain kind of resistance bordering on hostility in different quarters. The last time I was in Kenya I happened to meet a local parliamentarian in Nairobi. The parliamentarian articulated this phenomenon rather well. As per his world view MVT entails a significant leakage of foreign exchange from impoverished sub-Saharan African nations to wealthier nations with fancier (and not necessarily better) healthcare systems. He felt that hospitals chains from India and Thailand and elsewhere tend to ”lure” away gullible patients to their shores even though the patients can be treated locally as well. The MP was of the view that only those patients should be allowed to travel abroad, who cannot be treated in Kenya itself.

Sadly, a similar view is also being articulated by many local clinicians as well as various Medical Associations and regulatory bodies in several parts of the world. They are making it difficult for foreign clinicians to come and work in their countries by raising inappropriate barriers such as the requirements of multiple licenses and permissions from sundry agencies. Essentially, behind all this lies fundamental insecurities and an almost cavalier disregard for what might be the best for the patient.

People travel far away from their homes in search of quality medical care for three main reasons.

  1. The Services are not locally available or are scarce.
  2. The services are available but are too expensive.
  3. The services are available but are not easily accessible to patients.

Unless a nation addresses these issues, MVT is unlikely to go away.

By being mean spirited and denying foreign doctors and hospitals to collaborate with local medical establishments is clearly foolhardy. International medical collaboration leads to exchange of knowledge and transfer of skills. That is usually the quickest way to upgrade local expertise and instill confidence in local clinicians to take up difficult cases initially under the guidance of foreign experts and later, on their own. There is nothing shameful in learning from someone who has greater knowledge or expertise.

Moreover, such practices are against the best interests of the patients, which all doctors are under oath to protect. ”As a father of a sick child with a congenital heart problem, why should I be denied the opportunity of seeing a foreign expert if he is willing to travel and visit me in Nairobi? Why should I not have the opportunity to take his opinion and compare it with what is available locally and decide for myself, what might be the best for my son?” asked John Kutolo, whom I met in Nairobi in October 2018.

The argument that people should not be allowed to travel abroad if the clinical service is available locally is quite disingenuous. The availability of service is just one aspect of the decision to travel abroad for treatment. The big question really is the quality of the service available and more importantly the trust that one has in the local medical services. Thus, it is possible that Kidney Transplants may be happening in Nigeria, however if I, as a patient or a care-giver do not trust the local hospital, why should I be forced to get my transplant done there?

Often people travel abroad for treatment because healthcare costs in many countries are humongous and insurance coverage either non-existent or severely limited. If the patients and the care-givers have confidence in their decision of traveling abroad, where they can possibly afford good quality healthcare, they should certainly have no difficulties in accessing such services. Similarly, if one chooses to get treatment done at low costs in a foreign country rather than wait for months in some places like Canada, UK or Russia, they should be able to do so unhindered. False pride in one’s country’s medical systems should not come in the way of offering foreign treatment options to patients who can than decide what might be the best for them.

While, I do realize that most hospitals sending their doctors and medical teams to war ravaged countries like Iraq or under-developed nations like those in the Sub-Saharan Africa clearly have a profit motive in encouraging patients to travel, the fact is that patients travel only when their clinical needs are not satisfactorily met locally. No one really wants to be thousands of miles away from family and loved ones during a risky medical procedures.

Finally, it all boils down to a patient exercising a choice over who and where she gets treated. I believe that the patients should have complete access to information regarding all relevant options and they should be free to choose. If this means that they should get to interact with visiting clinical teams from foreign lands, than they must be able to do so without hindrance.

The only way to counter MVT is for the governments and private enterprises to invest in healthcare infrastructure, build world-class, technology led institutions and have a steady supply of trained and experienced clinicians. All this must also be easily accessible to most citizens and at competitive prices.

Unless that happens, MVT is here to stay.

The views expressed here are personal

The Aggressive Patient

Why are we intimidating and beating up our doctors ever so often these days?

Every other day one see’s newspaper headlines where doctors find themselves facing angry patients and their attendants who believe that misbehaving with hospital staff and doctors is no big deal at all. That breaking furniture and maybe a few bones will get them better service or perhaps the hospital will waive off a portion of their bills. Doctors and hospitals today are quite scared of such hooligans, who create a nuisance in the hospital demanding better treatment for their patients without realizing that their behavior is putting other patients at grave risk.

Part of the reason for this I suppose is that we are becoming a more aggressive nation. The road rage that one witnesses on the roads in Delhi everyday, the ugly fights among neighbors usually for parking spots, the crazy honking even on a red light are perhaps all a manifestation of this malaise. The medical profession too I suppose cannot escape its share of problems in a society becoming louder, more aggressive and more demanding. Everyone seems to be on a short fuse.

In hospitals, where life and death situations are routine, people are perhaps a lot more stressed and express their frustrations by mishandling the folks right in front of them. These are mostly doctors and nurses, who bear the brunt of their anger. Little do they realize that beating up the doctor won’t help them get better care. And that beating-up anyone is no solution to any problem.

The other reason that I find for all this anger in the hospital is a lack of communication between doctors and the patient’s attendants. Usually, the clinicians are very busy folks who have very little time for patient’s attendants. They believe that their primary duty is to look after the patients, without realizing that in today’s world they also have an equal duty towards addressing the attendant’s fears and concerns regarding the patients. Hospitals spectacularly fail in impressing on the clinicians that they must meet the attendants regularly and address all their queries as honestly and as transparently as possible. This must be a part of a process and not a random meeting in a corridor or when a patient’s attendant catches hold of a doctor fortuitously. Better communication will help reduce these unsavory episodes far more than more security guards manning the hospital doors.

I also look upon these incidents as reflective of a loss of respect and trust between patients and doctors. With the media awash with stories of profiteering hospitals and grasping clinicians engaged in dubious practices, no wonder that the relationship between patients and doctors have almost broken down. The noble profession has been reduced to no more than a transaction. There is no longer the old world courtesy and respect that clinicians commanded not so long ago. No longer are they the Gods of their realms. This is rather sad. The relationship between a doctor and a patient and their care givers has to be a a bond of great trust. The patient willingly allows the doctor to treat and operate upon him believing that he will do so to the very best of his skills and ability. The doctor on the other hand accepts this as a huge and crushing responsibility and does his best to ensure that the patient comes to no harm, while under his care. This is the covenant that has always existed between doctors and patients. This sacred bond is now stretched almost to the breaking point.

What is it that we can do to get back from the brink??

As hospitals and clinicians we have to understand that the patients are increasingly getting impatient and we must learn to deliver all that we commit. We must find more time to address their concerns and not just fob them off with some sarcastic remark about their limited understanding of medical matters. We must engage with them more, learn to treat them as equals and partner them in their treatment. A dialogue is essential.

As patients and their attendants we must understand the tremendous pressure and responsibilities each clinician carries. We must also have an unshakable faith in their good intent, skills and abilities. This has to be a given. We must also have the wisdom to realize that in medicine an adverse outcome is not necessarily the fault of the doctor or the hospital. Actually, at times it is no one’s fault. We must treat our doctors and nurses as fallible humans, just like ourselves.

Finally, there will always be those who believe that creating a ruckus helps get things done in the hospital. In my view the hospital must deal with them firmly and take whatever action is required to ensure orderly conduct.

Violence can not be justified, whatever the reason or the grievance. Beating up ones doctor is almost the most stupid thing imaginable that one can do.

The views expressed are personal

 

 

 

NHS and the dilemma of Outsourcing

A few months ago, a friend who lives in London visited his GP with a complaint of persistent headache. The GP advised him some medicines and asked him to follow-up in a week’s time. The head-aches continued and appeared to be getting worse, my friend visited the GP again, who referred him to a Neurologist. My friend managed to get an appointment with the Neurologist after 3 weeks. The neurologist examined him and suggested that he needed a MRI of the brain. A routine appointment for a MRI was given after another 3 weeks.

While waiting for his appointment, my friend had a seizure in his office. He was rushed to the A&E of a tertiary care hospital, an MRI was immediately conducted and a large vascular tumor was visualized. He was hospitalized and his family was informed that the he needed immediate surgery in a delicate part of his brain. The risks of the surgery included death because of uncontrolled bleeding or paralysis. Not operating meant certain death. They had little choice.

If, this would have been in India, my friend would have undergone an MRI the day after he had been advised by his neurologist. The tumor would have been diagnosed right-away and not after he had a seizure. His family would have been given some time to seek another opinion before deciding on surgery. They would also have had the time to visit a hospital of their choice and decide on a surgeon that they would have been most comfortable with. Essentially, this would have been an elective surgery rather than an emergency.

In England, the service was of course cashless at the point of delivery, in India, it would have been cashless as he would have been covered by an insurance policy.

With private healthcare extremely expensive and insurance premiums being very high my friend had no choice but to rely on National Health Service (NHS). This is just one case out of probably thousands who have no choice but to access tertiary healthcare in England through the A&E. The thought itself is scary.

With the issues facing NHS being well-known (and we are again in the middle of a winter when horror stories mount) it is quite a shame that the NHS mandarins haven’t considered outsourcing some of the work to hospitals abroad. The least they can do is offer patients a choice. Something like, ”you can get your bypass surgery done in the local NHS Hospital in 6 weeks or you can travel to a hospital abroad and get the same surgery done the next week. Waiting entails some risks, traveling abroad entails some risks as well and the you can decide what you want.”

The reason that NHS is chary of outsourcing is largely because of the fear regarding the local backlash, which will follow if something ”goes wrong”. And than there is of course false pride that comes in the way as well.

In matters related to healthcare sometimes things will certainly go wrong, the outcomes will not always be the desired ones. This happens in every healthcare organisation including NHS. The key is of course working towards minimizing medical errors. Good hospitals everywhere in the world pay great attention to patient safety and reducing mishaps. They have stringent processes, multiple checks and now great technology that helps bring down medical errors. At Max Healthcare in New Delhi, India, where I work we have an ambitious program called ”Chasing Zero”, which aims at reducing medical errors to zero (or as close to zero as possible!!!). I am sure other hospitals elsewhere too have such process controls, which eliminate errors systematically. NHS can pretty safely outsource some of their work to hospitals, which report clinical outcomes similar to NHS. Additionally, they can set up an oversight mechanism for this outsourced network of hospitals pretty much like what Care Quality Commission (CQC) does to supervise and regulate healthcare services in England.

The NHS will also find that the cost of sending patients abroad for treatment is far less than providing similar services in England. This will be an add-on benefit in times where most Clinical Commissioning Groups (CCG’s) are running deficits and the government has limited funds to pour into NHS.

While, this is a sensible solution the biggest problem in implementing something like this is the lack of courage on the part of both NHS as well as the Clinical Commissioning Groups (CCG’s) and ultimately the political leadership in England. The fear of the unknown and the belief that hospitals outside of Britain/Europe do not offer high quality care (mis)informs such thinking.

In a connected world where patients can be monitored and even operated remotely, this is bizarre. The NHS needs to create an expert group that should evaluate hospitals across the world for their clinical quality, cultural affinity to England, languages spoken, easy connectivity to England and the regulatory environment prevalent in the remote country. It should reach out to these hospitals for collaboration in treating NHS patients, who may opt to travel outside of England for their treatment.

Once the hospitals are identified, NHS should set a tight regulatory frame-work, which allows them complete visibility regarding the care protocols for their patients in these hospitals. If need be they can even post ”care officers” in these hospitals to monitor the care being provided. The MIS related to clinical outcomes should be transparently shared with the CCG’s/NHS. A quarterly review involving NHS/CCG officials and the hospitals should help in smooth operations of the program.

This is quite doable. All it needs is courage, will power and some leadership to effect a change.

PS: My friend had his surgery and a reasonably good outcome. The surgery was quite challenging, took more than 8 hours and was fairly eventful. He had to spend many days in the ICU and a long stay in the hospital. He has no complaints regarding the quality of care he received. His only regret being that this need not have been an emergency.

The views expressed are personal

Medical Trafficking and Medical Value Travel are very Different

I was recently in Kenya and learnt about a new term called “medical trafficking”.

This came up in discussions with a member of the Kenyan parliament, who is also an eminent clinician of Indian origin. The MP is a prominent citizen of Kenya, owns a chain of hospitals and believes that what passes for medical travel in Kenya is mostly medical trafficking.

Well, I wouldn’t agree entirely but there is more than a grain of truth in what the lawmaker is talking about. Essentially, he defines medical trafficking as dubious agents persuading gullible and sometimes desperate Kenyan citizens looking for the medical treatment to countries like India. He believes that many of the problems for which the Kenyans are travelling can be treated in his own and other hospitals in Kenya. However, ordinary Kenyan citizens, when faced with a medical crisis are lured away by unscrupulous medical travel agents with promises of magical cures at jaw-dropping prices in faraway places. This is largely achieved through an unholy nexus between local clinicians, hospitals, medical travel agents and hospitals in India and other countries.

The Hon’ble MP believes that Kenyan government should take steps to prevent exploitation of Kenyan patients in this manner. He is sponsoring a private member’s bill in the Kenyan parliament, which will regulate medical travel from Kenya and allow only patients, who have serious medical conditions and for which treatment is currently not available in Kenya to travel abroad.

I believe this is good.

However, there are a few caveats.

More than restricting patient travel for better medical care, Kenya needs to invest a lot more in building capacity and appropriate skills enhancement in the medical centre. The hospitals in Kenya, while making progress are still far behind those in India and elsewhere. The government hospitals are overcrowded, filthy and struggling. The hospitals in the private sector, barring a few are at best secondary care centres equipped to handle only routine surgeries. There is an all-pervasive shortage of clinicians, nurses and para-medical staff. The problem is a lot more acute outside of Nairobi. Unless, Kenya bridges this gulf, patients will always seek to travel abroad in search of better care.

This cannot be done overnight. Building new hospitals and finding highly trained and experienced clinicians will take years. In the short run, some gains can be made through collaborations with foreign hospitals, who might be willing to share their expertise with local Kenyan hospitals. It might also be possible to import a team of highly trained clinicians and allied technicians to be able to work in Kenyan hospitals for short periods. This will help Kenyan patients get access to high-quality care closer home and the local clinicians will be able to learn while working together with foreign experts.

Sure enough, some clinical work, particularly for higher-end tertiary care specialities, may still not get done with-in Kenya. Patients for these conditions will still need to travel abroad. These patients must be guided through proper well-established medical travel operators governed by suitable rules and regulations. These need to be framed urgently.

The medical travel industry continues to be largely unorganized not only in Kenya but in almost all parts of the world. Small-time operators with very little understanding and knowledge of the patient’s needs or the capabilities of the hospitals that they are being referred to continue to thrive. This is the soft underbelly of medical travel that the Kenyan lawmaker referred to as ”medical trafficking”.  This, of course, needs to be rooted out. It will be possible only when well-established medical travel operators employing doctors and other experts come into play. The government of Kenya should establish guidelines on who can be a medical travel operator, give them incentives to set up their offices in Kenya and let them effectively collaborate with Kenyan Hospitals, the NHIF and other large public sector undertakings for patient referrals. Only authorized medical travel operators should be allowed to facilitate patients for treatment abroad.

Finally, I must make a point about patient choice. The fact that a particular treatment is available in Kenya should not mean that the patient must be treated in Kenya. This will be clearly wrong. Availability of treatment does not guarantee quality. If a patient prefers to go abroad for her own treatment, she must be allowed to do so. After all, it is a matter of her own health and if she has the necessary wherewithal to pay for the treatment at a place of her choice, she must be allowed to do so.

Medical Trafficking is a result of unorganized, mercenaries masquerading as medical travel operators being allowed to work unchecked in Kenya. It must be curbed through effective legislation. However, patients genuinely needing high-end medical care or those who wish to travel abroad for treatment must be allowed to do so. They should be guided to bonafide and licensed medical travel operators who may help them seek the best possible care anywhere in the world.

A Day in Khiva

272Pahalvan Mahmood is perhaps the only wrestler in history who has a beautiful mausoleum built for him, which he shares with his king. The Pahalvan apparently was a man of extraordinary talents. Apart from his herculean strength and skills as a wrestler he was a polyglot, philosopher and a poet. He was also known to be a Sufi and the patron saint of the city of Khiva in Khorezm (Khorasan) region of present-day Uzbekistan. As I stand agape at the beautiful monument, our guide Umeeda tells me that the most famous wrestling match that Pahalvan Mahmood had won was with a renowned Indian pahalvan in the city of Multan. Pahalvan Mahmood beat the Indian wrestler and was cleverly able to free over 500 Uzbek prisoners as a reward for his efforts.

The Pahalvan’s mausoleum is carefully kept in Khiva, has a magnificent tiled courtyard and a turquoise dome, which gleamed in the sun. The aquamarine dome is striking and the tiling on the walls and the sarcophagus are marvellous. The tomb was built-in 1326 and has been very well-preserved. Pahalvan Mahmud has the honour of sharing the mausoleum with the 13th-century ruler of Khiva.

224Khiva has a history going back to over 1000 years. The city is located on the banks of Amu Darya in the Khorezm region of Uzbekistan, west of the modern Uzbek capital Tashkent. The region is also famous as the birthplace of Al Biruni, arguably the finest scholar of the medieval Islamic era. Al Biruni knew physics, mathematics, astronomy and natural sciences. He was also a historian and linguist familiar with Khawarzemin, Persian, Arabic, Sanskrit, Greek, Hebrew and Syriac. Al Biruni travelled to India and published a famous study of Indian culture after studying Hinduism. In Khorezm, he is a national hero.

Fortunately, travel to Khiva is a lot easier in today’s time. Direct flights connect Tashkent to Amritsar and Delhi. The nearest airport to Khiva is Urgunch 70 minutes flying time from Tashkent. Khiva is a 40 minutes drive from Urgunch. A 4 lane modern highway took us from Urgunch to Khiva. The road on either side was lined with fields of cotton, sunflower and peach orchards. The land is fertile and well fed by a network of canals visible everywhere.

190Stepping into the walled city of Khiva is like entering a living and breathing medieval Islamic city. The inner part of the city called ”Ichan kala” is well laid out with beautiful madrasas, mosques and lovely minarets. The Kalta Minor, which is a huge blue and green tiled tower in the centre of the walled city is an incomplete minaret, which the Khan building it could not complete and his successors chose not to finish. Today, it is the most distinguished landmark of the walled city of Khiva.

We strolled across the thoroughfares of the lovely city on a mild afternoon. The streets were lined with shops selling curios, beautiful ceramic plates and fur huts made from authentic minx fur. We walked onto the roof of the king’s palace to have a great view of the city spread out beneath us. This is a city steeped in history and so well-preserved that it appeared as if we had actually travelled a few centuries and were looking at a real medieval city.  The silver throne of the king though was a disappointment. This is apparently a replica, the original one is now a part of the National Museum in Moscow.

242Opposite the King’s Palace stands a madrasa with a beautiful tree-lined courtyard and the rooms of the students around it. There is a museum there as well, where I came face to face in a painting with Pahalvan Mahmood standing victorious after his famous ”dangal” in Multan!!!

257A little later we walked into the Djama Masjid, the Friday prayer mosque. The mosque is now a monument with hundreds of carved wooden pillars supporting the roof arranged in rows. The mosque was built in the 10th century and rebuilt in 1788-89. Umeeda showed us some original columns taken from the earlier structure. From the place, where the imam stood, Umeeda pointed out to us that all the columns were clearly visible. With the sun filtering into the mosque, it almost looked divine.

277A small turn towards the right took us to the mausoleum of the famous pahalvan and the king Rakhmat Khan. Abutting the mausoleum is a tall minaret. Umeeda challenged us to climb to the top for the most magnificent views of the city. We accepted the challenge and entered the dark minaret through a flight of stairs leading to its entrance. Soon we were on a treacherous, winding, ancient staircase with polished wooden steps. We soon realised our folly but decided to continue up through the minar. A little light seeped through the openings cut into the wall of the minaret and we used the torch-light from our mobile phones. The journey up the minaret is arduous but the views from the top well worth it. I imagined seeing the Amu Darya glinting in the sun, far away to our east. We learnt that the minaret also served as the ancient gallows, with the condemned being flung to their deaths from the top.

The return to mother earth was even more treacherous. The stairs are uneven, slippery and there is just nothing to hold on to. We negotiated each step with a great deal of caution, holding on to the step above while taking the next step down. To make matters more difficult, we encountered people going up the same time. Stepping out of the minar, I took a deep breath and resolved never ever to try scaling a medieval minaret, whatever the reward!!!!

PS : The melons of Khurasm are something to die for. Pristine white slices dripping with the sweetest nectar, they are just out of the world. We saw these piled high up on the roadside, each melon the size of a football. Actually, they come in two shapes, oval like a rugby ball and round ones like a football. We had them for dessert that evening.

Pics by the author