National 6 (Spotlight Weekly)

Medical Morals

Does the quality of health care depend on the patient's socio-economic status?

By AKSHAY SHARMA

A mother and her child : Health insecurity

The quality of the health care you can expect to get depends on your place on the socio-economic ladder. That may be a sweeping indictment of the medical profession, but it is one some members concede they have a hard time disputing.

"I have been here for only six months, but I can see that doctors treat their patients considering their [social and economic] status," says Dr. Sameer Gharthi, who works at Bir Hospital. "If a person who looks rich walks in, he is given special attention. But if someone from a rural area enters, he is likely to be treated with disdain."

According to studies, educated and economically well off patients are receiving better health care compared to patients from rural areas. Even sporadic violations of patients' right to equal treatment are enough to give the entire medical profession a bad name, say experts.

One argument that is often heard is that the country's limited resources prevent doctors from providing full and equal attention to all the patients they see. For one thing, the patient-doctor ratio is extremely diverse. The number of people a doctor sees in rural areas is very high compared to urban centers. Explaining the diagnosis, prognosis and drug use in detail would take away valuable time of the doctor, and work to the disadvantage of the other patients he has to see. Moreover, in a country where the majority of the people are illiterate, what can a patient who lacks basic knowledge hope to understand and gain from such explanations?

However, critics contend that the problem is not so straightforward. "The current epidemic in the Terai stems from the fact that even drug distributors there act as doctors," says Dr. Bijay Kumar Sharma, ex-president of the Nepal Medical Council (NMC). "The problem has become bigger because the patients are prescribed drugs that sometimes are unnecessary or outright fake. They often need higher dosages of medicines. His Majesty's Government should take steps to protect the consumers of health services. The government should also formulate strong regulations to combat such problems," he says.

Medical ethics is often linked with the semantically nuanced and technologically advanced medical procedures of the developed world, says Ian Huntington, who has been working for the past year for a small patient advocacy group in Kathmandu. Experts say self-regulation through ethical medical practice may be the poor Nepalese patient's only hope of receiving quality care.

Principle 3.5 of the NMC's Code of Ethics requires a physician to seek, "informed consent prior to performing a diagnostic or treatment procedure". In a country where most of the people can barely stamp their thumbprints, is this feasible? "Ethics is the intersection of philosophical theory and real-world action," says Huntington.

Principle 3.5 gives decision-making authority to the patient's family, but this also has left a lot of people bewildered. Once the patient has been informed, is it the patient, the patient's family or the doctor who is the decision-making authority? "Often poor, illiterate Nepalese rarely question the educated doctors and would hesitate to take decisions," says Dr. Gharthi.

Dr. Praveen Mishra, president of Nepal Dental Association and vice-president for the South Asian Dental Association Federation, defines the scenario in another way. "We have a big problem concerning the fact that parents spend a huge amount of money on their children's medical education. The new doctor finds himself thinking about ways of recovering that investment." Regardless of the root causes and motives, this malady could assume epidemic proportions if left untreated.