Rhetoric and Reality

(Note: This article got published in Republica with minor edits)

If a newly diagnosed diabetes patient came to see me at Patan Hospital’s general medicine clinic, I would perform several tests to ensure proper care. I would check hemoglobin A1c to assess her severity of diabetes, test her kidney function, evaluate if she is throwing out protein in urine, test if liver is functioning properly, and measure cholesterol levels in the blood. For this visit, she would pay NRS 25 for registration but about NRS 2310 for the basic minimal testing that she requires for appropriate diabetes care. After all this, she will have to go home with a bag of medications that comes with obvious cost. Patan Hospital might take a pride in saying that it charges a meager 25 rupees for a patient visit, but that is just a miniscule portion of the patient’s actual healthcare cost.

The point is, doctor’s fee is a rather small portion of a patient’s healthcare cost. Main drivers of cost are tests, medications and medical devices. It gets especially ugly if unnecessary tests are performed and medications prescribed. And it is no news that our healthcare providers are incentivized to do exactly that. We have heard of our doctors receiving “cuts” for sending lab tests, prescribing certain medications and even referring patients to certain institutions or providers.

So, if I were a deliberating patient, I would choose a doctor based on how unlikely she is to order unnecessary tests or medications while not missing what are absolutely essential. I would like her not to have incentives tied to prescriptions and lab orders. I would happily pay a much higher fee than NRS 25 if these were ensured, because that extra cost is just one unnecessary test away.

Lately, newspapers have reported that the Ministry of Health and Population (MoHP) is planning to cap and enforce doctor’s fee. Furthermore, Republica reports that even the prevailing fees are lower than the cap. Why is this non-issue taking a front row seat? One has to concede, the MoHP officials are either very disconnected from patients’ realities or they are plain and simple stupid.

Even this cursory exercise tells us, doctor’s fee is not the biggest determinant of a patient’s healthcare cost. Accordingly, there are multiple high-impact potential targets for cost control. We have to ask, how we can cut down the cost of lab and radiological testing. How we can reign in an unethical practice of ordering unnecessary tests and medications for financial incentives. How we can make equipment and medical devices more accessible and affordable. In addition, we need to ensure that the cost of medications is reasonable. While the remedies are not as obvious or simple, any genuine cost cutting effort cannot circumvent debating and deliberating these issues.

Furthermore, whatever is a patient’s financial means, what matters ultimately is the health outcome. We want to get better at any cost. We sell our cattle, our land, and our hard-earned savings to seek treatment. When we put so much trust in these medical interventions, what should matter most is that the healthcare system delivers to that trust. We are not just seeking a cheap treatment but also an effective treatment. Quality medical care is actually what we seek. Of course we would like to pay less for it.

Unfortunately, our public debate hardly acknowledges the intricacies of patients’ needs and the corresponding complexity of delivering to that demand. It is no surprise that rhetoric of  “free health care” is so rampant. Anyone pausing for a moment and thinking can realize that there can be no “free health care.” Delivering health care needs infrastructure, personnel, medications and equipment that come with a cost. The best we can do is pool our risks and minimize the cost for the victims of diseases and injuries. It would indeed serve us well if we root ourselves on practical realities than rhetoric. This proposal of capping a doctor’s fee is a rhetorical exercise disconnected from the real needs of our patients. It is far detached from the potential to bring down costs.

Finally, it is about time that we are done with doctor bashing. The reality is, after we pass past the dreamy aspirations of medical school, we doctors walk a blurred line amidst necessities, greed and professional obligations. Larger structural issues, checks and balances in the system largely determine how we behave in our daily practice. The society in general and government in particular has the responsibility to address these structural issues and ensure effective regulatory mechanism. Yes, some of us have crossed professional ethical boundaries and behaved poorly. Where are those regulatory processes? Where is our government to hold us in check at those instances? More importantly, we should not forget that numerous of our junior doctors work in the muggy air of crammed emergency rooms with air laden with tuberculosis, intensive care units with bare minimum support and protection, medical wards with surfaces laced with resistant bacteria and filth, deprived of sleep, and for exhaustive hours that is inconceivable in any other profession. They work at incredible personal risks. While their peers, who work in lucrative development jobs, writing reports and policies that never see the light of the day, come home with a six-figure salary, these doctors satisfy themselves with NRS 10,000 per month. Vilifying these doctors in the process of lumping doctors for rhetoric’s shake would be an utter injustice.

The problem at hand does not lend to a simplistic assessment and equally cavalier attitude of using the governmental power. People do have a choice in whether they want to see a doctor who charges NRS 1000. We don’t need our government to father us in making that choice. What we do want is help in ensuring that we are getting our money’s worth. That is and should be the purview of a democratic government. But it is also exactly where our government is utterly ineffective and our government officials have no wit, will or ability. For starters, our tax paid government officials would do much service in cutting cost if they even just focused on stocking low-priced quality medications, performing quality affordable lab tests, and consistent and reliable radiological tests at public institutions. Instead of coming up with these wacky ideas!

Kafal Sellers of Sworgadwari

Whose Kafal (Bayberry) should I buy?

Pardon my business acumen, but would it make more sense to spread out and sell? Wouldn't that increase your likelihood of making money for your own?

There is a certain innocence and cuteness in this group of Kafal sellers huddled together at the same place. With their baskets, wrapped in cloth, stashed with the produce from the wild. In their Kurthas, Surwals, Pachhyauras and Chappals.

These shy girls are huddled together, perhaps for each other's company. To survive strangers' exoticism. What will happen if they overcome this shyness and decide they want to make profits by competing with the other Kafal sellers? There's a certain harshness associated with this change. Cute innocence is trampled over by selfish motives. It feels as if something precious is lost in the process.

But that is a sentimental observation of an outside observer. Their act of Kafal trade is hardly cute. It is a chore you need to endure, fighting the glare and foreignness of strangers, in hopes of making some money that stoke vivid dreams. Cuteness and innocence are not what is celebrated here, not even remotely.

Mr. Maharjan

Amidst a patient visit I received a call on my cell phone. I ignored. But it rang again. So I excused myself from the patient and answered the call. On the other end was the daughter of a patient I used to see while working at a public hospital. The patient, Mr. Maharjan, had a long-standing diabetes. It had damaged his kidneys. The damage had now progressed to a stage where he was no longer able to throw out enough water and toxins through urine. As a result, fluid built up in his body. He had difficulty breathing and extreme weakness. They had brought him to this public hospital. He underwent emergent dialysis to remove fluid and toxins from his blood. 

"They have told us that we will be discharged. And they have asked us to find a place to have dialysis two times a week because there is no empty dialysis slot at the hospital. What are we to do?" she pleaded. With a shaken up voice, she continued, "we are poor, there is no way we can pay for dialysis unless we do it in government-subsidized place." "How can they just ask us to find a place when this is the only place we have been for all these years for his diabetes treatment?" she lamented. 

"I didn't know what to do and remembered you because you had treated us nicely at the hospital. Would you be able to help us?" she asked. 

What must it be like: to be drowning in your own water, gasping for breath, knowing that there is a way to relieve it, and yet being left alone to your own devices? As a society, we have actually already agreed to help out those who are in such needs. Government pays for dialysis at several government and non-governmental facilities. We tax payers, including Mr. Maharjan, are paying for this assistance. Multitudes of dialysis centers have popped up in Kathmandu. So why is Mr. Maharjan, amidst dire health condition, given a violent sentence of uncertainty?

Our doctors become quite animated about larger political, structural influences in health care systems. Many of the concerns are very legitimate and valid. And larger, systemic, political and structural issues do need to change for this health care system to be more accessible, just and fair. But many of these issues do not fall under our daily activities of patient care and doctoring. What we don't realize is that there are much more urgent issues directly under our power and capacity that we ignore. And to a ruthless extent. Which bureaucrat or politician will be able to understand the plight of Mr. Maharjan, real time, better than a doctor treating him? Yet, we choose to ignore to act. Rather, we take a delight in pronouncing dooms, telling this patient, good luck brother: find a place to get dialyzed on your own. Did they even consider what kind of ordeal it might be to the patient, a simple man without much education and means, to find a place where government offers subsidies for dialysis? Would it be easier for us who know hospitals and health care system to look around or it is best left to the patient? How can we just open the door and tell a gasping patient: out you go, do whatever you want? Is it even moral to dispose a patient to his means when we know that there is a solution, or at least an attempt could be made? 

I told her, "let's see what we can do." 

I first made a call to a friend who is a nephrologist at a medical school which houses a large subsidized dialysis facility. He told me there were no empty slots but asked to send the patient anyway to see if he could figure out a solution. I asked the daughter to go meet him. The best they could come up was an alternative way of dialyzing (called peritoneal dialysis) but it came with an upfront cost for tubings and devices to be connected to the belly, it was not an ideal option. So I searched out the contact for the chairman of a non-governmental organization which has been organizing dialysis facilities at multiple places. I told him the story and asked if he could help in any ways. He generously offered to do free dialysis at his private hospital. It was a big relief. We arranged an appointment for the patient at his clinic and I asked the daughter to go to that appointment. In the mean time, I wrote a letter to the chief of the service at the public hospital where the patient was admitted, and who I knew as a man who would go extra miles to help patients in need, detailing their plight and pleading, "you can very well imagine in what dire straits this patient is." In a few days, the chief of service from the hospital replied me saying that they were able to arrange dialysis within the hospital. 

Wow! That was it? There was not a magnanimous gulf separating possibility. But why did the patient have to undergo this distress of uncertainty while gasping for breath? 

The daughter called me to thank. 

After a few phone calls and few keystrokes of a computer, I will be able to get my good night sleep. But that can't be said of Mr. Maharjan and his daughter. Their ordeal has just begun  and it will end only with his death. 

Swami Ji

The hall was packed with people; the cleanly-dressed kind that have been sheltered from dust and soot that beclouds the majority. These were mostly doctors who had congregated to talk about spirituality. They were listening attentively. At the stage, Swami ji, adorned in yellow robes graced the throne. Throne, indeed! Long hair flowed out from his head, streaks of grey boosted elegance of his eminent beard. Energy was ebullient. Swami ji had captivated the audience. 

At the end of nearly an hour of his discourse, the message I gathered from Swami ji was: Thought is powerful. I felt that the discourse lacked any substance. It neither offered me any information about why recognizing thought as powerful was important nor it told me what next after recognizing the power of thought. It was an exercise of futility lacking in any direction or intent. It was as if someone spent an hour saying, "there is an apple in a tree."

But the Swami ji captivated the audience. He was a master at that. He had energy and charisma during the talk. Interjecting with rhetorical English statements during his monologue in Nepali, he convinced us that he was no traditional jogi. He would spit out a string of English names, who he informed us were philosophers. "Emerson knew that the East had already figured out two thousand years ago," he told us. "Big bang theory tells us that the world is going to end," he declared. He told us stories, simple ones in very easily understandable language, wrapped in humor, and we laughed heartily. "I consider myself philosopher and not a traditional jogi" he pronounced. He giggled wildly, laughed like a fool. Shouting at times, he toned down to a whisper like some musical exercise. He was a sight to behold.  

As he descended the stage and later walked out of the hall, he was surrounded by numerous young men from his organisation, clad in fluorescent jackets (like those of traffic police), people surrounded him, bowing, heaping praises, he was offered money and those young men in fluorescent jackets collected the money. Swami ji swaggered out the door smiling at a captivated audience, waving his hand, blessing perhaps. More young men started collecting many of the audio visual equipments that had been set up for Swami ji's discourse. It was a massive enterprise; the act of discourse. Even after the Swami ji left the premises, the young men lingered along with numerous video cameras and microphones, interviewing the attendees and taping the responses. 

There can be a discourse that transcends reasons: that of faith and things beyond reasoning. But that can be a coherent, meaningful discourse. There can be a discourse of matters using reasons and facts. His was neither of those. It was an entertaining talk by a charismatic man using pseudoscientific gibberish. 

And it had impressed the audience. It was terrifying that just the style of a substanceless  monologue had glossed over their critical reasoning. And it was furthermore terrifying that many in this audience claim the intellectual authority in this society. No wonder the Swami ji blankets Nepali TV stations in the mornings.