Was our healthcare system ever ready to deal with this pandemic?

"Wars may be fought with weapons, but they are won by men." -George S. Patton.

Yes, we are at war; always have been. For decades, countless men, women, and children have lost their precious lives while millions survived. Now that the country is facing its greatest adversary till date, we turn our head towards our trusted armada, the nation's healthcare system. Given the vicissitudes and adversity our healthcare faces on a daily basis, it is time to run a diagnosis on the healthcare system for a change and see what we can find.

Only three doctors for 10000 patients

"During my student years, Mymensingh Medical College Hospital had a bed capacity of 500. But the patients admitted in the hospital would be around 3500-4000", said Dr. Tushar Dev Baishnab, Medical Officer at Upazilla Health Complex, Gournadi, Barishal. "Moreover, we would have to treat 7500-8000 outdoor patients every day with an incredibly short-staffed situation."

The situation is as overwhelming as it sounds. If someone were to take a peek at any government hospital in our country, the most likely discovery would be finding more patients on the corridors than in wards or cabins. The World Health Organisation (WHO) has recommended a minimum of 1 doctor for every 1,000 population of a country. Whereas, according to the recent WHO statistics, Bangladesh has a shocking 3.05 physicians and 1.07 nurses for every 10,000 population.

"There have been instances where I have seen patients under other patients' beds for the shortage of space," added Dr. Avijith Bhattacharjee, Indoor Medical Officer at Sylhet Women's Medical College and Hospital. "We used to pull out the patients like pulling drawers from a cupboard, examine them, and put them back."

Needless to say, the patients are the ones bearing the brunt of this mismanagement and scarcity of resources. Due to the limited number of physicians and nurses, many patients have to wait for hours to get any medical attention upon admission while their conditions worsen.

"I went to a renowned private hospital located in Dhanmondi for emergency medical attention for my severe stomach ache," reminisced Nafisa Afreen, a freshman. "They admitted me in a ward and just left me on saline all night while I screamed in pain. It was only in the morning that someone finally came and ran some tests on me to find out that I had kidney stones which needed to be removed as soon as possible."

Another sufferer, Tamanna Wahid, stated that "When my father tested positive for Covid-19, I rushed to a public hospital in Dhaka with him only to see the peak of mismanagement taking place from top to bottom. I had to wait for hours for something as mandatory and basic as oxygen before deciding to move with him to a private hospital." 

"Although the hospital provided a better standard of services, I do not think it is accessible to everyone as it is costly. I had to pay a minimum daily bill of 1 lac taka during my father's stay there. I really hope that things have changed now. Or else, with the deadlier variant looming over our heads, I don't know how this fragile healthcare system will fare against the challenge that awaits us," she continued. 

"Unnecessary" tests

It is tough to find a patient in our country who has never complained about doctors ordering tests that seem irrelevant. In fact, most doctors are getting into people's bad books because of this allegation which is affecting patients' trust towards the doctors.

"Firstly, in the world of medicine, there is nothing called unnecessary tests." Dr. Rothi Das, Resident at BSMMU, shared her insight. "If I do not perform the required tests to rule out all other possibilities of the illness, I will not be able to detect a disease with dormant symptoms that may become fatal in the future."

"Even if I spend only 5 minutes per patient,I will be able to treat only over 50 patients in 5 hours. Given the patient inflow we deal with, this rate will not even scratch the gigantic surface," remarked Dr. Tushar.

There are about 7 primary routine tests that almost every hospital abroad conducts before reaching any conclusion. Even though these tests help the doctors detect the exact nature of the illness, the patients usually perceive it differently. Due to a prevailing communication gap between the patients and doctors, most patients suspect something fishy behind these seemingly "extra" tests. It is assumed, if the doctors had more time to debrief them, then the complaints would lessen. However, this is easier said than done.

On the other hand, most patients do not have the financial support to get all of the tests done. In that case, the doctors take the necessary judgment calls. "I always ask my patients before suggesting tests if they can afford them. Even though I need to figure out their problems, it would be inhumane of me to rule out their financial condition," shared Dr. Zakia Banu, former OB-GYN at Rajshahi Medical College Hospital.

However, some doctors order extra tests for reasons unrelated to the health of the patients. Moreover, this unfair practice is more or less present all throughout the country. Sometimes even the doctors in question have their hands tied.

"I had an experience two years back in my previous chamber at Dhaka. The MD was disappointed because I was not giving enough tests to the patients, and it cost him more as he was allowing me to use his place," said a government hospital doctor wishing to stay anonymous.

Pictures beyond Dhaka

It is no secret that the medical conditions are much wrose beyond Dhaka. Starting from proper equipment, adequate staff members, and trained personnel, nearly everything is scarce.

"According to my current hospital organogram, there are supposed to be 10 consultants or doctors with postgraduate qualifications. In reality, only one doctor there fits that description," said a disheartened Dr. Tushar.

Since there are no incentives or resources present for the doctors and technicians to work outside Dhaka, a significantly low number of people actually turn up. 

There is also a prevalent issue of underdevelopment of infrastructure. For instance, Cumilla Medical College Hospital was established in 1992, but it just had an ICU in 2020. Instances like these indicate the morbidly slow progress of the healthcare system outside Dhaka. These certainly denote the urgency of implementing actions to ensure the matter of decentralisation promptly.

It is very convenient to point fingers and enumerate the reasons behind the sorry face of healthcare beyond the capital, but coming up with solutions is the key. Just because an Upazila hospital does not have the proper resources and doctors, patients with severe cases get sent to Dhaka, and a lot of the unfortunate souls do not last this long trip.

MBBS doctors: an allergy

A perpetual trend present in Bangladesh when it comes to consulting a physician is: the patient wants the professor and nothing but the professor. If any illness arises, most patients would rather rush towards costly chambers of professors or specialists rather than consulting with an MBBS doctor first. This irrational head-first visit to the professors or FCPS passed doctors and complete ignorance towards the junior level doctors are prevalent mostly among the people belonging to middle-class families and above.

"The baffling part is that most patients will always visit a specialist for almost any illness which is obviously more expensive than other alternatives and then those very patients will complain that the treatment is costly," said an exasperated Dr. Priyotosh Sutradhar, Emergency Medical Officer at TMMCH.

The western parts are often considered to be the epitome of perfectly synchronised administration. Even in those parts, it is not possible to straight up visit a specialist at random. For any checkup or consulting, there is a prevailing referral method. The patient has to visit the MBBS doctor at first, and then if required, with the referral of the previous physician, visit the Associate Professors and lastly, the Professor. But people in our country seem to have complete distrust towards MBBS doctors. There have been instances when patients seek validation from pharmacists regarding prescriptions from junior doctors.

"I have seen patients double-checking with pharmacists whether a junior doctor has given them the proper prescription or not. They honestly believe that a pharmacist has more knowledge than an MBBS graduate," said Dr. Zakia in disbelief. "Even my relatives act surprised after knowing that patients come to me even though I am an MBBS doctor. This level of distrust is unbelievable."

This act of distrust mainly originates from the notion as mentioned earlier that some unethical doctors do exploit their patients. As a result, most patients get even more sceptical about visiting an MBBS doctor with the premonition of getting the wrong treatment with a bigger bill. 

However, the dwellers in the rural areas do not have many complaints about visiting just an MBBS graduate doctor because they take whatever medical help comes their way. It is the urbanised society, where not visiting a specialist for any medical reason is considered rather odd.

Legal and regulatory framework- surely a maze if not a minefield 

The irregularities in our health sector at various stages have only been exacerbated by gaps in our laws as well as the ridiculously lenient enforcement of existing laws. If these laws are amended and strictly enforced, experts believe that the irregularities will be reduced to some extent. The regulatory framework is also riddled with flaws that can be easily fixed with minimal effort.

On being approached for his thoughts on the legal and regulatory shortcomings of this sector, Dr. Md Parvez Sattar, a renowned international development consultant and assistant professor of law at the Independent University of Bangladesh, shared his input.

"Guaranteed by the Constitution of the country (Articles 15 and 18), public health and nutrition are the primary responsibilities of the State by securing the basic necessities of life including medical care. Ironically, there is very little if not no effort to update the existing regulatory framework inherited from our colonial legacies as well as introducing necessary law addressing the application of recent innovations in healthcare- clinical, technological and administrative". 

"Even the existing bunch of laws in the health sector is often constrained by its own Achilles heel. The legal framework also remains ambiguous in terms of distribution of responsibilities and coordination between concerned agencies- public and private," he concluded. 

However, the relevant authorities should closely monitor that these changes in the legal and regulatory framework are not used as a tool of oppression by enforcement agencies, as otherwise arbitrary use of authority will occur on a regular basis, setting new real-life examples of the adage "power corrupts, and absolute power corrupts absolutely." 

The intervention of the agents

Among the numerous issues present in the rural depths of our country, the practice of some doctors employing certain "agents" as their representatives is still in practice. In exchange for a commission, these people are used as a tool to lure patients into a trap that only breeds inexplicable trouble for them. 

Given that these agents typically target the less fortunate, more often than not, these patients fall for the "fat discount trap" without thinking about checking the background of the professional or hospital in question. Most of the time, the services provided to these patients are mediocre at best and grossly negligent at worst.

Mohammad Waiz, a shop manager, said in this regard that "I'll always remember the first time I had to come to Dhaka with my grandmother for her treatment. We were supposed to go to a doctor's chamber located at the Bashundhara Residential Area. But as soon as we hired a CNG to go to that place, and told him that we wanted to go to a doctor, he started telling us that the doctor had a bad reputation here and that he knew someone who was better and would treat her for a much more reasonable cost."

He continued, "We somehow fell for the trap and went with him to that doctor's place. After months, when my grandmother's condition wasn't improving with his treatment, we consulted with another professional who informed us that the treatment she was receiving was not the right one. It took us a lot of time, effort, and money to realise our mistake and I know for a fact that many of my relatives and friends have suffered the same fate at the hands of these agents."

Dr. Sanzida Islam, who is working at a renowned private medical college, accepting that this is a very common incident in our country, explained the situation with a befitting example. 

"Assume a patient is suffering from gastritis. The agent is unable to understand her problem and takes her to a gynecologist from whom he receives a referral fee. This not only results in financial loss for the patients, but it can also be a matter of life and death when the patient is suffering from complications caused by other serious diseases." 

"Another source of concern is that these agents mostly work for quack doctors, which opens the door for negligent treatment to be given and received. The situation has already spun out of control and immediate actions are needed to be taken immediately to save thousands of innocent lives, if not more," she added with a worried tone.

Conclusion

With over 166 million souls onboard while a monster named Covid-19 runs rampant and wreaks havoc, Bangladesh needs all hands-on deck. It is not the time to lament over the prevailing lack but to take matters into our own hands. Even though all the numbers are stacked against the physicians, patients continue to be treated with such efficiency that is unthinkable by most nations. Even with limited resources, diseases like TB, polio, cholera, etc. have been handled with dexterity.

"The average lifespan of Bangladeshis was about 65 years in 2000. Now it has jumped to 73 years. This just says what access to better resources can do," said an optimistic Dr. Tushar.

However, the past achievements do not justify the problems that are prevailing now. More doctors are needed, more beds need to be in hospitals, areas beyond Dhaka cannot be a haven for poor medical service. The healthcare system is in shambles; our beloved country is bleeding, and the authorities must act as platelets.

Shubhashish Chakraborty Turjoy is a sophomore at IBA-DU. 

Arafat Reza is a journalist.

Disclaimer: The views and opinions expressed in this article are those of the authors and do not necessarily reflect the opinions and views of The Business Standard.