Keywords: Unethical treatment, quacks, RMPs, reporting unethical treatment, access to healthcare

Background and context

The health workforce in India is unevenly distributed within and across regions, with qualified practitioners more concentrated in urban areas (1). In rural and poor areas where there are no doctors, unqualified medical practitioners are the first point of contact for healthcare needs (1). These unqualified medical practitioners, also called Rural Medical Practitioners (RMP), practise western medicine without any formal training. They may hold certificates from organisations that are not recognised by regulatory authorities (2). RMPs work under doctors as helpers, observe their work, and then set up clinics or practise in areas where there are no doctors (3). They are described as quacks by the IMA and the Supreme Court of India. The IMA has been fighting to eliminate these providers from the system (3, 4).

An ethnographic study was done among a nomadic tribe in a rural district to understand their access to healthcare. The tribe lives in settlements called tandas (5). The nearest public health facility from this particular tanda is around 9 km. Road connectivity to this public health facility is good, but there is no public transport to reach the facility from the tanda. People have to rely on private vehicles. A few RMPs and Bachelor of Ayurveda Medicine and Surgery doctors live in a settlement about 3 km from the tanda. They provide services in their clinic and also visit the tanda whenever called. They are available on call even in the middle of the night.

The case

The researcher, who is undertaking an ethnographic study, visits the tanda regularly to observe and interview the people regarding their access to health care. Consent has been obtained from the village head and the elected representative to carry out this work. During one such visit, the researcher observes an old man being treated by an RMP for a head injury sustained by a fall. The RMP does not belong to the tanda but provides emergency services here and was called by the relatives. The RMP informs the family that the wound needs suturing to control bleeding. The researcher notes that the RMP instructs one of the relatives to bring a bowl of hot water and some old newspapers. The RMP then takes out a pair of gloves, cotton and suturing materials from plastic boxes in a compartment of his bag. The boxes do not seem to have been maintained in aseptic conditions. The RMP uses the cotton to clean the wound, asking the relatives to hold the old man’s body and head in position. He sutures the wound without administering local anaesthetic or other pain medication. The researcher observes the old man writhing in pain throughout the procedure. After suturing, the RMP cuts the suture material off with a pair of scissors which he takes out from his bag.

After the procedure, the RMP instructs the relatives to clean the scissors, using the hot water provided, and asks them to dispose of the used cotton and gauze which was placed on the old newspaper. He then washes his hands and puts the scissors and suturing materials back in the plastic box.

The RMP takes a syringe from the bag, loads it with what seems to be some medicine, and injects it into the old man’s buttocks. He then removes the needle and flushes the syringe by loading it with the water from a container nearby. He then takes another vial from his bag, attaches the needle to it, loads the syringe with the medicine from the vial, and injects it into the other buttock. The syringe is put back into the bag. The RMP informs the family that he will visit them in the evening to inspect the wound. He gives them antibiotics and pain killers and instructs them on their use. He also instructs the family to get a barber and shave around the wound area.

The researcher, who is trained in modern medicine, finds the treatment inappropriate. If he intervenes in this situation, the family’s only alternative would be to take the old man to the hospital 9 km away. Reporting the RMP to the concerned authorities would deprive the tanda of the only source of health care available at their doorstep.

Ethical issues

1. What are the researcher’s ethical responsibilities? What are his possible courses of action, and why?
2. The researcher obtained consent from the village representatives to observe the residents of the tanda. Should the researcher have obtained consent from the RMP, who is not from the tanda, to observe his treatment of the old man?
3. The researcher on his next visit in the tanda learns that the old man had died on the fifth day after his fall. Considering the events that the researcher observed, how would the death of the old man reflect on the dilemmas already faced by the researcher?

Acknowledgements:

The author thanks Dr Vijayaprasad Gopichandran, Dr Amar Jesani, Dr Rakhi Ghoshal and Dr Ravi Prasad Verma for their comments during the Workshop on Public Health Case Studies held on March 26-27, 2018 at the Achutha Menon Centre for Health Science Studies, SCTIMST, Thiruvananthapuram.

Note

¹Ethnography is a research tool which describes and interprets the shared and learned patterns of behaviour, beliefs and languages of a group. The aim of ethnography is to provide rich insights and descriptions into the views, beliefs and actions of people through detailed observations and interviews. It involves observations of the group and interviews of participants.