Patan Hospital is host to a government facility of telemedicine. This is housed in a small building amidst the crammed infrastructure of the hospital. It is a relatively elegant facility in sharp contrast to the clutter of the patient care areas. Floor is carpeted, windows have nice shades, partitions are orderly. Adorning this nice setup are several sleek computers of modern make and built. They stand atop reasonable quality furniture. Gracing this elegance are swivel chairs to go around!
This facility is linked with several district hospitals. They have also been setup with computers apparently, where they can plug in patient information and get answers from specialists at the central level: in this case Patan Hospital. These are meant to support the doctors who are in the wild. To give them a back up of expertise where they find deficient. To keep them connected to the center (apparently everyone aspires to stay in the center). I presume this is one of the solutions someone has devised to confront the distressing difficulty of staffing these remote facilities and getting them to stay. These doctors complain: we are alone, we don't get updated, we have no help. Here it is: type it away in this computer!
I am one of the physicians assigned to type out replies to these ghost messages that pop up in the computer screens: lifeless sentences that probably represent a soul in distress. However, I should confess I am not honored this exercise too often. There are few gentlemen from the Ministry of Health (MOH) who coordinate calling doctors to reply those messages. It depends on factors beyond my comprehension that determines their appetite to summon me. So I am a sporadic guest to this enterprise. When invited, I come to this bustling room. There are junior doctors downloading Hindi movies in the computer, some other people unknown to me glued to the Facebook. Each time I see new changes. Earlier there was a bed added to the room- inviting in the hassle of this public hospital! In a more recent visit, a partition had separated this bed converting it into a cozy enclave. Maybe someone is supposed to answer at night too. I do not know the purpose of the bed. The junior doctors apparently answer to phone calls from public. I hear them telling these callers: go take cetamol, don't worry too much. The gentleman from MOH scrambles as I arrive, to close down whatever he was surfing, and then opens up the software for me. Some of these guys have a decent dexterity with the computers, others are clumsy. Finally, after the screen is up, he tells me you can do this many today. I comply. There is a pattern to all the cases that I see. Perhaps doctors have a tendency to narrow down problems to their capabilities, most of these are COPDs, UTIs, Enteric fevers. I search for deviations to gather clues to the patient's problem. I try my best to give honest opinion from whatever information is available. One of my colleagues, who is also assigned to reply, asked the other day, "do you think this is helpful to them?" That is a question I ask myself too.
A few days ago, I received a call from one of the more active and enterprising MOH gentleman to schedule a video conference with a doctor at a remote district. Now you have video capability too? I agreed with a timetable for the afternoon. This time, the room welcomed a nice computer through which you could see and talk with the district folks! It was the same brand and type that I used to see at the VA hospital affiliated with my university at the US. You do have some spare change people, I told myself!
After some back and forth, the screen was up. They wheeled in a patient and the doctor showed up. All this was happening because this doctor apparently persuaded all these folks. This doctor was a young lady. Her dress-up, accent made it amply clear she was from a city. Perhaps someone who had never before been to the villages. She stood out as an odd existence in the village crowd that had already gathered by now. A young city girl amidst the shabbiness of village. What was she doing there?
She was one of the folks who have been mandated to serve in the remote government facilities. She went to one of the private medical colleges under the scholarship of the Ministry of Education. Having signed a bond to serve as ordered by the government, here she was fulfilling the requirements of her bond.
After our brief introduction, I asked her to tell me about the patient. This patient had breathing issues and diabetes. Blood sugars were out of control due to a medication being used to control the breathing problem. She told me what medications were available there to treat diabetes. She was doing the best possible with the available medications. I just agreed to her management plan. Then we moved on to a second patient. This patient had tuberculosis with pus in his chest. He had been treated at Kathmandu. A tube was placed in to drain the pus and he was sent home with tube in place. He came to the hospital requesting that the chest tube be taken out (he had been told that the tube should be taken out at this time). But the tube was still draining significant amount of fluid and if taken out, fluid would accumulate again causing breathing trouble. So this young lady doctor advised him that the tube should stay in place. However, he was not convinced so she decided to bring him up to the screen. I told the patient that his doctor was absolutely right, the tube should stay. He agreed. This doctor was doing a very capable job. I made this known to both of these patients.
Throughout all these interactions, I could not escape noticing a melancholy, anguish in this young doctor. She does not belong here, I told myself. Will she stay here once her two years is up? I do not know. Will the community benefit from her presence? I am sure they will having this capable person around. But is this arrangement just where a young woman is working in anguish by force of circumstances and rules to serve a community?
That is a complex question. However, the details of this arrangement has some brazen violation of a sense of justice which are worth discussing.
One of the most reasonable arguments I have heard in favor of forcefully sending doctors to serve the districts comes from a colleague of mine. He argues thus:
To become a doctor, you have received a lot from the society. Allowing a novice to send a painful pipe down the throat when some other competent person could have put it in with much less pain cannot be measured in terms of material interactions. It is immeasurable. How can that person learn to put a tube down the throat practising in this community and just walk away as if he had no responsibility to those who allowed that opportunity?
And it is a compelling argument which makes a lot of sense. It makes a case for moral responsibility towards the society in which one learns the creed of doctoring. But should this moral responsibility be forced is an entirely different question. One obvious question is how do you limit and identify the society upon which you have drawn your learning and to which you should be responsible. Is it the city of Kathmandu that you are obligated to if you went to medical school in Kathmandu and saw no patients from Dolpa during all of your medical school? Is it Dolpa if you went to medical school there? And this will not be an abstract exercise as we are debating Federalism. Our country will be divided into states where these distinctions of societies will start to appear. At the fundamental level, once we start tying a doctor to distinct societies, a basis for your society and my society will emerge. Do we want our doctors to have their obligations defined primarily by societies and geographies? Because equally compelling basis of ethical responsibilities are possible: serving the neediest of humanities (a doctor from Kathmandu might want to serve in Dolpa), serving those in prisons because you were born in a prison and have seen appaling situation of basic health care in prison, serving those with limb amputations from motor vehicle accidents because you yourself had both your legs amputated after an accident... There are innumerable compelling reasons that can be the moral basis of responsibility. Identifying one and coercing it will at the least be an exercise that is blind to these possibilities.
The only situation where I can see coercion to be tolerable is if we identify absence of doctors in these geographical areas as crisis and use it as a temporary measure while we start rigorously to build long-term measures. This coercion has to be universal: every doctors should be forced to do it and not cherry picked based on some other identified criteria.
Sadly, the coercion as it exists now is far from being universal. It is bigoted, unjust and outrageous. Let me be more specific. If you have gone to a private medical school under government scholarship, after competing in an exam at the national level, you have to serve in the remote areas for 2 years. However, if your parents have paid for your medical school, you have no such obligation. The bottom line: if you happen to be born in a family who can afford to pay for medical school you are waived of any need to serve in the remote areas. Lesson: choose your parents. You may argue, well, when you signed a bond accepting the scholarship you knew you had to serve in the remote areas, so why the whining now? You could have opted not to sign up for the scholarship. These are teens (17/18 year old kids) who are deciding about their prospect of going to medical schools. Do they really know what it is like going to remote areas? Even if they knew, where would some of these bright kids find millions of rupees to finance their wish to become a medical doctor? At that age, I would have signed any papers that would ensure my possibility of going to a medical school! Well, parents would know though? But the parents do not live these kids' adult lives, they change during 5 years of medical school, an adult does not necessarily live on the judgements and decisions of their parents. The bases of selective coercion is shaky at the least. Furthermore, there are few government medical schools where you pay minimal fees but you are not obligated to serve. It makes absolutely no sense. The government is eager to force others to fulfill this obligation but not from its own institutions. To conclude, the current arrangement is unfair. It is not universal. And it is discriminatory. Almost cringe worthy.
Lack of human health resources at the community level is an urgent issue. But the solutions that have been adopted are coercive and unjust. It seems like these people think that forcefully sending doctors to the primary health care centers and district hospitals will solve all the health care woes of this country. Are these half-hearted coerced doctors really needed here? Are there alternatives to these coercive measures that are more just?
I am certain there are. One such example exists at Patan Academy of Health Sciences (PAHS) known as Collaborative Scholarships. In this, communities identify potential candidates from their communities, send them for a competitive exam at PAHS, provide full-scholarship and bond them to come back to their communities to serve. It is still coercive but a simpler and fairer arrangement. You would know that this is where you will be returning back. You have lived here and have been educated here, so you know what to expect. In addition, studies have shown that health care workers who come from that community have higher chances of long-term retention. It appears to be a better choice. Collaborative Scholarship is just an example, we can imagine of multiple other possibilities to make this fairer. Moreover, this focus on doctors only is off-target to the actual health care needs. More than these doctors what we need are mid-level providers who can carry out the local health care needs. We hear very little about that.
Is it a lack of imagination? Is it ruthlessness? Is it desperation that is driving these kinds of decisions? We talk about democracy and New Nepal. But are these our moral spheres where a certain callousness pervades our activities as if it is second nature to us. It is perhaps the same callousness that Nobel laureate and current National Cancer Institute director Harold Varmus was cadid enough to note and explicate about his Indian volunteer experience in The Art and Politics of Science. It is not something we can be proud of as a society.
At the end of the conversation, I told this young doctor in English, "Daktar saab, you have been serving in a remote place, you should know that we are proud you." She paused, almost choking, and replied, "Thank you, Sir."
(Did I tell you how much I despise that word Sir- either in hierarchical use here in Nepal or a customer service use in the US?)
