The ethical dilemmas faced by health professionals in the developing world ultimately revolve around two main problems: not enough money, and not enough time. There is not enough money to do the job that needs to be done, and there is not enough time in which to do it. This means that the standard of care is often reduced far below what would be considered acceptable in more medically advanced countries. For example, Nepal has one physician for roughly every 20,000 people, and one dentist for every 100,000 people. These are among the lowest ratios in the world. Even if there were enough physicians and dentists, there would not be enough money to treat everyone.
The governments of many developing countries are committed, for political reasons, to the concept of free medical care for all of their people. However, the end result is that although it is free, very little medical care is provided. The government of Nepal spends less than US $2 per person per year on healthcare. Patients come to a government hospital or clinic where they might see a doctor or paramedical worker, but they will then have to go out and buy their medicine at a privately run medical shop at inflated prices.
In view of these problems, I consider two money management strategies to be essential in order to provide adequate healthcare in the developing world.
1. Charging patients
After observing medical care in Nepal, I am convinced that it is futile for the governments of developing countries to try to provide totally free health care for their people. I do not believe that people have a right to free health care, any more than they have a right to free food at the market. If they are able to pay something for their medical care, they should. In the developing world, the potential for abusing free health care is even greater than it is in the developed world. The well-to-do manipulate the system for their own benefit, demanding free medicine and treatment even when they don’t need it, and thus even less is left over for the really poor people.
Christian mission organisations run ten hospitals in Nepal which are self-supporting, as far as possible. This means that they charge for their services. Despite the fact that the average annual per capita income in Nepal is US $180 dollars (falling to a fraction of that in rural areas), most Nepalis can pay something, even if only a little. Those who cannot pay anything at all still receive healthcare. Although it is painful, in the long run I believe that charging patients is the only way in which developing countries are going to be able to provide consistently reliable health care to their people at the lowest possible cost.
2. Making compromises
Obviously the only way the poor are going to be able to pay for their medical care is by keeping the cost very low. This can be achieved by giving the lowest level of care possible which will still cure most patients. In other words, in order to stretch limited resources to benefit the most people, a tiny minority of patients whose treatment would be excessively costly or time consuming are deliberately sacrificed. In these situations I think that it is important to look at the needs of the majority as well as the individual. This is one of the hardest lessons that Western doctors coming out to the developing world have to learn.
In our hospital we are always making compromises in order to treat the most patients. For example, typhoid fever is very prevalent in our area of Nepal. According to the older textbooks we had, the treatment for typhoid fever was twenty days of chloramphenicol. However, because we had a limited supply of the drug we gave only ten days treatment instead of twenty. In 95% of cases the results were just as good as with the full treatment, and all the patients had been treated. If the full twenty days’ treatment had been given, then only half the patients could have been treated. We decided that it was much better for everyone to receive a ten day course of treatment, resulting in a 95% cure rate, than to treat only half of the patients with the full course and allow the other half to go untreated. Due to a lack of resources in the developing world we have to decide on what is the ‘minimum essential treatment’ which will effect a cure in most cases. We cut back on diagnostic tests. We keep patients in the hospital for less time than in Western countries. We use the cheapest drugs for the shortest possible time and the great majority of our patients do well and are satisfied. Unfortunately, some of our wealthier Nepalese patients are not happy with this. They demand X-rays and cosmetic surgery. If they can pay for it, we provide the extra treatment. Our mission hospital then makes a little money from of these wealthier patients, which goes to help cover the costs of treating the poorer patients.
It may seem unfair that we give less treatment to the poor than we do to the rich. However, we give the poor adequate treatment to cure their disease. The rich demand and pay for those treatments and services which I call the ‘frills’. (It’s interesting that the longer one works in the developing world, the wider one’s definition of ‘frill’ becomes.) In the developing world, maximum treatment only goes to those who can pay for it.
The second main problem that confronts doctors in the developing world is the lack of time. For example, consider a hospital with three doctors and an average of 300 patients daily. One of those three doctors is a surgeon who has to spend part of his day doing surgery. Another is called away by a complicated obstetric case. Then a child presents with meningitis and the third physician is unavailable. Meanwhile there are 300 patients waiting to be seen in the outpatient clinic. How should one handle this situation?
One solution would be to plod steadily on doing as much as one can, but doing it well. If people don’t get seen at the end of the day, it is too bad. The important thing is to work carefully and deliberately. In the past, many doctors on the mission field took the attitude that ‘you should do what you can do well, and forget the rest’. However, I believe that all, or almost all, of the patients can be seen and adequately treated by compromising on the following two points.
1. Sacrificing thoroughnessDoctors have to spend less time with each patient. This means that some things will be missed, but in my opinion it is better to see all the patients and misdiagnose 5% of them, than it is to see only 50% of the patients perfectly and let the other 50% go untreated. Furthermore, there are ways to keep the percentage of misdiagnoses to a minimum. The main trick is quickly to separate the serious illnesses from the less serious ones such as colds, aching joints, worms, fungus and so on. In most cases it is possible to do this in the first 30 seconds of seeing a patient by looking for criteria such as weight loss, anaemia, significant pain, shortness of breath, obvious pathology or deformity. If one of these signs is present, one should slow down and examine the patient more carefully. As one gets more experienced, one can see more and more patients and make fewer and fewer errors.
2. Using paramedicsThe second compromise is to train less qualified workers, who can treat patients with less serious illnesses and can detect and refer those that are likely to have a serious illness to the physician. Doctors do not like to think that less trained people can do just as good a job as themselves with a high percentage of patients. Admittedly some paramedics are not as good, but then there are some not-so-good doctors too! With adequate training and supervision, the great majority of paramedics are very competent.
Practising medicine in this way is actually very satisfying because very little unnecessary work is done; everything makes a difference. We successfully treat 98% of our patients. Furthermore, it is possible to show patients compassion even if they are seen for only two minutes.
This whole discussion can be boiled down to one principle. Choose a level of care that is appropriate to the country you are working in, but keep the standard of care high. In other words, decide what you are able to do, and then do it well. Once you have determined the level of care you can provide (according to the amount of money and time available) you can go all out and practise the best quality of medicine possible. In this way, many ethical dilemmas of medical practice in the developing world can be resolved.
One may wonder whether Christian health professionals have been able to influence the health care system for the better in the developing world. I can only answer for Nepal, where over the past 25 years mission and government programmes, together with the important help of international agencies like WHO, have resulted in a 50% increase in the average life expectancy and a 50% decrease in child mortality.
As far as Christian health workers are concerned, I think that the biggest contribution that has been made in the developing world is the example of compassionate health care that has been set. Not only do individual Christians do this by setting a personal example, but we have also emphasised compassion, caring, conscientiousness and honesty in our mission training programmes.
In Nepal, as a result of this, patients consistently bypass their own nearby government hospitals and walk one or two days to get to a mission hospital. It is not our goal to outshine or embarrass government health services, but to be a model for them to follow. The government is the first to criticise the weaknesses of their own system. This is true of many parts of the developing world. Christian health professionals have profoundly influenced health care practices in many countries. We don’t set policy, we set an example of compassionate and conscientious service.
Both Christian and non-Christian health professionals face shortages of time and money. However, whatever level of care we choose, whatever speed we are forced to work at, and whatever hard decisions we are required to make, our compassion and conscientiousness can and must show through in our every word and action. This, above all, is what will set us apart as Christian health workers. It is our compassion and conscientiousness which will continue to proclaim reconciliation and integrity through Christ, until he returns again.