In the 1960s, China saw a phenomenon of "barefoot doctors." Named after barefoot farmers in southern China who worked at the paddy fields in a commune and also practiced medicine, these were farmers who underwent short-term training of three months to a year and delivered basic health services to the community. This offered decentralized basic health care services which focused on prevention and was sustained locally.
Despite quite a low per capita income, China achieved infant mortality rates comparable to developed nations by the 1980s.
Although, there were concomitant social and economic progresses, many people credit improved access to basic health services provided by barefoot doctors for this phenomenal reduction in infant mortality rate. Carl Taylor writes in Reaching Health for All:
"The Chinese experience shows that with equitable distribution even the simplest
and lowest-cost health measures can have great impact. It is more important that
care at community level be readily available to all with no barriers of cost or
social constraints than that it be of the highest quality...."
This should be an illuminating lesson for our policy makers who seem so hung up on coercing doctors to stay in remote areas, as if the presence alone of half-hearted doctors in these desperate places is going to solve all our health woes. This experience suggests that what we actually need is ensuring unimpeded access to basic health services. And this is best provided by locals who receive short-term targeted basic healthcare delivery training.
While Mr. Taylor emphasizes access over getting obsessed with high quality care at community level, it does not mean that quality of care is a dispensable luxury. As much as our community suffers from access issues, our so called tertiary care centers suffer from quality issues. And, I think, lack of quality in these higher centers is as much of an issue as access is for the communities.
Few days ago, my father asked if I knew anyone at Tribuhuwan University Teaching Hospital (TUTH). One of my villagers had brought his daughter to the emergency room there and knowing that I was around, he was trying to check with my father if I could put in some words to the doctors in that hospital. First off, I do not know many people at TUTH. Secondly, why should one seek relations when there may be tens of other patients who might be going through the same process of patient care? Still, I half-heartedly called one of my friends at TUTH, just to satisfy my father, and asked him to see if he could ask a resident in the emergency room to check on that particular patient.
Two days later, when I arrived home in the evening, I found the patient, her father and her cousin camped at my living room. They had left the hospital against medical advise, one of the notorious LAMAs (Left Against Medical Advice). Frustrated, father explained his dissatisfaction thus:
They were in the emergency room, a place akin to goat shed (in his own words). Nobody seemed to know what was going on with her. Students poked on her eight times drawing tube after tubes of blood as if the sole purpose of her presence was to offer a practice opportunity for these students. They were told that she needed blood and she needed to be admitted. Somebody told she would need a bone marrow biopsy; another person told she did not. After less than a 1/2 of the first unit of blood was transfused, the catheter clogged and blood was not transfused for several more hours. When asked why the catheter got clogged and blood was not running, they were told an inexperienced person had put in a catheter. So what is the purpose of staying in the hospital, if she is not getting the treatment and is a subject of experimentation every step of the way? That's why we left the hospital.
I flipped through a sheaf of medical documents. She had gone there with a feeling of weakness and shortness of breath. During evaluation, her hemoglobin was found to be quite low at 6 g/dL (normally it is around 12). All other testings were normal.
I can imagine of a rich academic discussion that might have happened amongst the doctors participating in her care. A senior doctor must have asked, "What's the cause of isolated anemia with normal WBCs and Platelets?" An apt among the herd of the learners must have purged out a list of differential diagnosis astonishing the less well-read ones. To that list, the senior doctor must have added some sharp criticisms or comments. Everyone must have been quite appeased by such a rigorous academic exercise, ready for a round of momos, tired by the effort of recalling data that are normally transcribed in the books.
But what of the patient?
She left the hospital with hemoglobin of 6 g/dL. This condition is perhaps not acutely life-threatening, but a teenage girl leaving a hospital in critical condition is a big failure of the system. We tend to blame patients for these kind of failures: LAMA is a patient responsibility, what can a doctor do? We say. But if this person was my daughter, I would have done the same. Perhaps piqued by such repetitive lame arguments, Paul Farmer, a doctor of deeds for the neediest, had a simple thing to say about such non-compliant patients:
"The only non-compliant people are physicians. If the patient doesn't get better, it's your
own fault. Fix it." (In: Mountain Beyond Mountains)
Dr. Farmer is talking about a patient who is not getting better despite some efforts and is asking for increased effort. But we are talking about owning some responsibility for at least critical and acute care.
Barefoot doctors seem like an attractive option for basic healthcare in our communities but it does not justify footless doctors in our higher care centers. More than that, apathetic hospital administration that leaves patient care to the devices of mob dynamics needs to realize that its somnolence is a reason for much agony.
Despite quite a low per capita income, China achieved infant mortality rates comparable to developed nations by the 1980s.
"The Chinese experience shows that with equitable distribution even the simplest
and lowest-cost health measures can have great impact. It is more important that
care at community level be readily available to all with no barriers of cost or
social constraints than that it be of the highest quality...."
This should be an illuminating lesson for our policy makers who seem so hung up on coercing doctors to stay in remote areas, as if the presence alone of half-hearted doctors in these desperate places is going to solve all our health woes. This experience suggests that what we actually need is ensuring unimpeded access to basic health services. And this is best provided by locals who receive short-term targeted basic healthcare delivery training.
While Mr. Taylor emphasizes access over getting obsessed with high quality care at community level, it does not mean that quality of care is a dispensable luxury. As much as our community suffers from access issues, our so called tertiary care centers suffer from quality issues. And, I think, lack of quality in these higher centers is as much of an issue as access is for the communities.
Few days ago, my father asked if I knew anyone at Tribuhuwan University Teaching Hospital (TUTH). One of my villagers had brought his daughter to the emergency room there and knowing that I was around, he was trying to check with my father if I could put in some words to the doctors in that hospital. First off, I do not know many people at TUTH. Secondly, why should one seek relations when there may be tens of other patients who might be going through the same process of patient care? Still, I half-heartedly called one of my friends at TUTH, just to satisfy my father, and asked him to see if he could ask a resident in the emergency room to check on that particular patient.
Two days later, when I arrived home in the evening, I found the patient, her father and her cousin camped at my living room. They had left the hospital against medical advise, one of the notorious LAMAs (Left Against Medical Advice). Frustrated, father explained his dissatisfaction thus:
They were in the emergency room, a place akin to goat shed (in his own words). Nobody seemed to know what was going on with her. Students poked on her eight times drawing tube after tubes of blood as if the sole purpose of her presence was to offer a practice opportunity for these students. They were told that she needed blood and she needed to be admitted. Somebody told she would need a bone marrow biopsy; another person told she did not. After less than a 1/2 of the first unit of blood was transfused, the catheter clogged and blood was not transfused for several more hours. When asked why the catheter got clogged and blood was not running, they were told an inexperienced person had put in a catheter. So what is the purpose of staying in the hospital, if she is not getting the treatment and is a subject of experimentation every step of the way? That's why we left the hospital.
I flipped through a sheaf of medical documents. She had gone there with a feeling of weakness and shortness of breath. During evaluation, her hemoglobin was found to be quite low at 6 g/dL (normally it is around 12). All other testings were normal.
I can imagine of a rich academic discussion that might have happened amongst the doctors participating in her care. A senior doctor must have asked, "What's the cause of isolated anemia with normal WBCs and Platelets?" An apt among the herd of the learners must have purged out a list of differential diagnosis astonishing the less well-read ones. To that list, the senior doctor must have added some sharp criticisms or comments. Everyone must have been quite appeased by such a rigorous academic exercise, ready for a round of momos, tired by the effort of recalling data that are normally transcribed in the books.
But what of the patient?
She left the hospital with hemoglobin of 6 g/dL. This condition is perhaps not acutely life-threatening, but a teenage girl leaving a hospital in critical condition is a big failure of the system. We tend to blame patients for these kind of failures: LAMA is a patient responsibility, what can a doctor do? We say. But if this person was my daughter, I would have done the same. Perhaps piqued by such repetitive lame arguments, Paul Farmer, a doctor of deeds for the neediest, had a simple thing to say about such non-compliant patients:
"The only non-compliant people are physicians. If the patient doesn't get better, it's your
own fault. Fix it." (In: Mountain Beyond Mountains)
Dr. Farmer is talking about a patient who is not getting better despite some efforts and is asking for increased effort. But we are talking about owning some responsibility for at least critical and acute care.
Barefoot doctors seem like an attractive option for basic healthcare in our communities but it does not justify footless doctors in our higher care centers. More than that, apathetic hospital administration that leaves patient care to the devices of mob dynamics needs to realize that its somnolence is a reason for much agony.
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