The case study by Bevin Vijayan (1) draws attention to a well-recognised public health problem – trauma and the lack of formal trauma care services in India (2). This is the reality in India for trauma and for many other health problems. Despite decades of dutifully repeating the platitudes of “availability” and “accessibility”, the problem is not merely a case of a service being “present” or “absent”. A layered milieu of multiple elements related to peoples, systems and cultures determines the services people actually receive. It is here that we see the non-formal healthcare provider, often called a Rural Medical Practitioner (RMP), make an entrance.
Do the practices of these RMPs amount to biomedicine? Bio-medically speaking, one would approach the incident referred to in the case study with several concerns. Why did the person fall in the first place? Is it due to an underlying endocrine or metabolic disorder, or perhaps a stroke? What are the possible issues the person has in addition to the scalp laceration – other injuries or fractures? What complications are likely – eg intra-cranial bleeds? Conceivably, aseptic wound repair, infection prevention and control, pain relief, correction of underlying issues and vigilance for complications might have done the person a whole lot of good and he might have been alive today. However, the person ended up getting unsafe injections and sutures which could transmit dreaded diseases like tetanus, Human Immunodeficiency Virus, Hepatitis B or C. The patient and family were led into a sense of reassurance that was possibly false. Money that may have contributed to better care got spent elsewhere. The advice to shave the wound area after the suturing clinches the case for the travesty that took place. As with many biomedical interventions, the jury is still out on whether shaving is really beneficial or not, but it remains a common practice among surgeons in India (3) . However, shaving happens before suturing as that is expected to decrease post-operative infection, ease suturing and application of dressings. So, does the “form over function” type of service the man received amount to biomedicine, even in an informal or non-formal sphere? Probably not.
Who can be held accountable for this transgression ─ the patient or family for not seeking proper care? The non-formal provider / quack? Imagine a river separating a village and a school where children are forced to depend on a substandard country boat to get across. The boat often being overcrowded may capsize and lives may be lost. Who is to be held responsible? The children for overcrowding, or the boatman for offering unsafe transport? Or someone else for the lack of a bridge or a safe ferry? In such situations as that involving the metaphorical boatman or the non-formal care provider, there are probably no heroes to summon or villains to malign. On that account, one should recognise that the formal system that claims proprietorship over biomedical knowledge cannot be absolved of all blame for quackery – the peculiarities of the former partly create the spaces and circumstances for the latter.
Within this frame of reference, the ethical principles that can help guide resolution here are:The RMP service may impart satisfaction to the receiver and may be sufficient for wound healing in uncomplicated situations. Potential benefits from the formal system include pain relief, infection control and correction of underlying conditions and complications, and eventually, survival.
The possibilities of harm with the RMP’s service, listed earlier, often outweigh the benefits. The formal system has its share of ills too – financial hardships, stigmatising behaviours and medical errors. Providers and systems representing the formal system often put profits over people, either due to a culture of venality or to concerns over the economic sustainability of the system in its current form. The end result is often patients and families being trapped in debt. Some of the potential harms may be almost completely compensated for by the benefits of the intervention. But meanings are not the same for everyone. Some forms of harm ─ like those related to physically invasive investigations ─ may be perceived by health professionals as trivial in relation to the potential benefits. However, these may be perceived as important harm by patients and families.
The biomedical lens almost axiomatically lends a paternalistic perspective to the issue, as seen in the first half of this commentary. Patients are thus helpless individuals and if they end up placing their trust in the wrong persons, the consequences may be very unfortunate. The power the paradigm holds implies that paternalism also shapes regulations, policies and programmes (4).
Autonomy is the power of self-determination of the patient and family to make a choice. But does it supplant a paternalistic decision to refer the patient to care which might have saved the patient’s life? While patient autonomy increasingly figures in medical discourses, particularly in the West, with calls to at least have a judicious balance of paternalism and autonomy, health systems in India are notoriously paternalistic and patients are passive recipients of care (5).
The acceptability of the practitioner in the tanda suggests that he upholds their dignity. The tribes may have experienced stigmatising behaviours from formal providers, thus influencing their healthcare choices.
Money is exchanged for services received – the people are part of the process and this makes the acceptance of service from the RMP more tangible. Treatments in the formal systems are not often patient-centred and shared decision making based on the patient’s experiences and expectations is quite rare.
Such situations can be particularly challenging for researchers with a biomedical training, familiar with the Hippocratic injunction “Whatever houses I may visit, I will come for the benefit of the sick” (6). One will need to decide between fidelity to the Oath and fidelity to the protocol. Approaches like ethnography compound the dilemma, as active intervention in such a situation may drastically modify how the community perceives the researcher and thus influence the research process itself. By choosing to be silent, will the silence of the researcher be interpreted as endorsement of the care provided? Will the researcher end up having to impose moral sanctions on himself/ herself if harm occurs subsequently? The ethical requirement of confidentiality and the lack of a clear fiduciary relationship with therapeutic intent between the researcher and the persons involved in this event may absolve the observer from taking remedial action or reporting this event to institutions like State Medical Councils or professional bodies. However, in the event of the researcher being called upon to testify as a witness, he/she may have to be more explicit when legally released from such confidentiality requirements (7).
Such dilemmas are likely to be common in public health research, but the accounts may vary based on the researcher’s personal values, training and past experiences. Researchers may, therefore, opt for maintaining a diary of such ethical dilemmas they come across in the field and reflect on the choices and possible consequences of their actions. Further, they should initiate discussion with peers and mentors to facilitate better engagement with such issues. If nothing else, they must recognise that while it may be difficult to endorse such practices, the patient and his family members are probably not diminished in front of the non-formal providers the way they might be when they access a formal provider.