My posting from yesterday for non-vernacular readers

हेल्थपोस्ट नेपाल

My hearty salutations to all my friends and colleagues in the NEPAL MEDICAL ASSOCIATION!

I have been a member of this Association since 1973 AD. As a relatively elderly colleague and in that capacity I have thought it necessary to put forth some of my thoughts before you at this juncture of crisis that has struck upon us, the community of physicians and surgeons in Country.

Qualified healers cannot be and are not the slaves of the society or community they serve; nor can they be of the State! We all are travellers together, each sect of the society contributing to and also gaining from other sects. With each and every member of the society that we live in there develops a closely knit bond of relationship. That is the nature of our chosen profession in life. I have absolutely no doubt that we all committed ourselves to this profession with the single resolve of serving the society, each one according to and with our acquired skills and knowledge. This profession is our religion, a way of life and also our livelihood, all at the same time. For this very reason, all the world over, the community of physicians is allowed a relatively comfortable and decent standard of living as an honour to the professional service rendered by it.

Skill and knowledge vary among the healers. It is only natural for a fresh graduate from medical school who has joined the service to have lesser skills than his or her senior peers. The uniqueness of this profession lies in the need for perseverance and doggedness with which this fresh graduate has to apply himself or herself throughout the lifetime in refining acquired skills with evolving new knowledge and also in making every attempt to acquire new ones. It has been an ageless and unwritten tradition in this profession that a skilled healer constantly transfers his or her special skills to his or her professional blood brothers and sisters. While stating this, I cannot but remember with great reverence all those professional teachers always ready to hold my hands and guide me in my professional advancement. On this count alone the intensity of the bondage seen and felt between professional blood brothers and sisters in this profession remains unmatched by any other profession to this day. If it were not so we would stand to lose all the skills and knowledge the world has been able to acquire in this field so far. I salute this unwritten but a very benevolent law in medical discipline.

The most severe ills that this Association suffered was when it turned into a sister organisation of one or the other political party after the 1990 People’s Movement. This has been most unfortunate and will remain so until we as a united body change our mindset.

We, the community of qualified healers in Country, do also harbour some untoward human weaknesses. In desiring coveted positions in the career ladder or in the greed for more material gains in life we often readied ourselves to align with one or other political faction in country and lent a partisan character to the profession itself. That kind of behaviour among us became the root cause of mal-alignment of the backbone of this Association. But I am optimistic in that there is time enough yet for all of us to turn into metaphysical ortho surgeons to try and fix the backbone of the organisation back to its normal self.

The most severe ills that this Association suffered was when it turned into a sister organisation of one or the other political party after the 1990 People’s Movement. This has been most unfortunate and will remain so until we as a united body change our mindset.

With that forethought I tried to convince and plead strongly after the political change in 1990 AD with the then strong political pillars in Medicine, Dr Shashanka Koirala from Nepali Congress and Drs Mathura Shrestha and Banshidhar Malla from the UML to refrain from politicising the Association only to receive wry smiles and unspoken dismissal from all of them. When my final plea with the Late Prime Minister G P KOIRALA to allow the NMA to remain a politically nonaligned professional organisation met with failure in 1992 I decided to keep myself aloof from the affairs of the Association and refrained from casting my vote in any of its elections. The last time I cast my vote in NMA election was before 1990.

I am convinced and fully that the real reason for the sheer disrespect shown towards the medical community by the State by bringing such draconian laws to tame the profession and the quiet but tacit assent exhibited by the larger mass of the general public in the past few weeks is nothing but the digression by the NMA from its stated role and responsibility to engage constantly in lifting up the national standard of professional service and of the professionals in country to building up partisan political interests and strengths in the organisation.

The Way Out: None in the medical profession should forget that applying oneself in the profession with diligence and perseverance has far reaching benefits; the most important one, that of respect. Perseverance should not be limited to caring for patients but should also extend to honest attempts towards constant and daily improvement and refining of the mode of care. Research and acquiring new knowledge has always been a significant part of this profession. Sincere documentation of all observations and data is of paramount importance in this regard. In this very context malafide intention, negligence of duty and responsibility, and wayward behaviour and attitude to the profession must be defined. All of us, with no exception, must submit ourselves to this litmus test and be defined. All of these actions deserve punitive returns. Intention to harm a patient has to be a criminal act of highest order.

Criminal court must look into such behavior in conjunction with the mental health experts to assess the psychological make up of the miscreant to make a just and sound verdict. My own take is that no sane physician ever harms a patient knowingly or deliberately. Harm comes to a patient from any of these factors: a) inadequate competence for the task at hand; b) negligence of duty and of one’s responsibility at a given time; c) wayward attitude to one’s profession; and d) the last but not the least, ( often the most) weaknesses and deficiency in the system of service delivery itself. Negligence of duty and responsibility, not uncommon, demands reprimands from the regulatory body, warning, suspension or disqualification according to the severity or the number of times such lapses are recorded. Watertight system of service delivery is of paramount importance in our field in order to minimise harming the patient. Institute of Medicine (IOM) in the US documented ten percent hospital mortality rate during 1990s from unintentional harm brought to the patient during the course of patient care. System correction over the past two decades has brought it down to around 2 to 4 percent.

To dwell in this context of healthcare, NMA should have taken the lead role in lifting up the standard of medical practice throughout the country by instituting appropriate mechanisms of surveillance and monitoring of care in different parts of the country, play a role in rectifying professional weaknesses in very many areas instead of getting broiled in the nation’s political partisanship. NMA should be in a position to challenge, coax, pressure and support the State in system improvements. That is the only way to earn the respect and love from healthcare user groups. Lackadaisical approach to healthcare by the State could then and should have been challenged and protested against by the Association with much vigour and enviable strength, with all the user groups behind us. Various disciplines in healthcare science should have been invited and given enough room in the organization for them to be able to assist the organization in its core duty of lifting the standards of healthcare and healthcare professionals in country.

Specialists in various disciplines should have been asked to plan and implement training workshops in different parts of the country to refine the learned skills among the local care providers and also to train them on new skills and knowledge. They would have been useful in supporting the weak providers by strengthening their skills and also in weeding out the ones judged definitely harmful for the community. NMA, unfortunately, did not concern itself in all these activities.

In a country where epidemics and outbreaks of infection are so common and frequent the community of physicians in country seemed not to consider it their concern but what did happen too frequently was some kind of superficial involvement, a knee jerk reaction, by some for patchwork only as a tag along to their political masters in their own locality or the ones visiting from the centre. Name and photo with the leaders across the media that is so plagued with sycophancy. Political gains for oneself and to one’s masters. Achievement? I have my doubts.

We, the medical community of Nepal, have never been above board in the way we have dealt with deadly outbreaks of diseases that tend to occur in different seasons and across various parts of the country. We have continued to live without compunction watching or listening with an inert mind the almost daily events of untimely deaths of children and young adults from these outbreaks. That is not the medical community that commands respect from the society. Here, though, I do have to assert that the main culprit is the State itself. Flagrant negligence in instituting a sound mechanism for disease surveillance and rapid response. State cannot shy away from this responsibility and, yes, it is not an inexpensive affair. Honest surveillance costs money; money for decent labs scattered over the length and breadth of the country for easy accessibility and also trained public health, laboratory and clinical personnel. Surveillance of epidemic infections without the support of a decent lab can easily be likened to gambling. It has been clear for sometime that gambling with the lives of innocent citizens has been one of the core rights of the Nepali State.

Billions of rupees spent in foreign lands for the treatment of end-stage kidney disease and a forceful sojourn to Tokyo with a large retinue of service providers and entertainers for a mere colonoscopy would have been sufficient to cover the cost of establishing a good disease surveillance programme supported by decent laboratories in almost half of the country. No, that does not happen in my country. By remaining a silent witness to such flagrant violation of citizen’s health right by the State, NMA has revealed its most unique and incomparable weakness as a professional body.

Leaning on these basic weaknesses of the medical community, the Nepali State has today grabbed the opportunity of undue gains from the community by passing a set of seemingly populist but extremely irrelevant, irresponsible, inhuman, senseless and illogical laws pertaining to medical practice.

To practice medicine under this new law I have to make myself stand in the dock of a criminal court first before I dare even touch the patient. The law insinuates that only if and when the patient gets back to normal and leaves for home happily will I be able to come out of that dock, or else…! Else has all the opportunity to win all the time. I’d rather be a patient than a physician. On turning into a patient i can go on winning, every time, and even after my death. Nowhere else in the entire world is there a law that compels the citizen to self incriminate. This is what we are being asked for before we decide to accept a patient for treatment. Therefore I beseech you, each and every member of this Association, with folded hands that we should now begin to engage in active self regulation, rectify our past mistakes and remove from us some of the degrading human weaknesses. At the same time, let us unite together to reject and tear up into fragments this inhuman act coming from the State that has shown blatantly its malevolent face towards the medical community. Reject it at whatever cost and with our heads held high!

Once again I salute you all and the profession at large with much reverence. Thank you.

Madhu Ghimire, MBBS (Del); MRCP (UK); FRCP (Edin)
Life Member
Nepal Medical Association

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