Effect of inequality on care for patients

HealthEffect of inequality on care for patients

By Dr. Attia Anwar

A few decades ago I was working as a resident in the gynecology department of a posh hospital in Lahore. The standard of care at that hospital was good and ethical. We used to run an infertility clinic once a week. It was a relatively easy day for us away from antenatal check-ups, Labour Room, and other hectic routines. So we used to give patients, who were dealing with infertility ample time to discuss their concerns and expectations. Women who came there were usually from higher socioeconomic backgrounds. They usually know what their options are.  They know about options that were not even readily available in Pakistan. So I usually had a very productive and satisfying talk with them. Which made me and my patients feel good. Although it was almost 25 years back from now. Internet was not widely available and it was sparingly used, but those women with no responsibility for children managed to read some books. So that was a very good experience for me and I decided that I would continue to talk to this type of patient, give them some time, and explore their concerns. As some of the women said we know there is not much that could be done, but we come here maybe there is something new or new research from which we can benefit. So that clinic has always been something for me to learn.


After two years I shifted to the peripheral area of Punjab and joined a new hospital. The hospital was providing its services for everyone and trying to do their best. There was no separate infertility clinic, but of course, women with this issue come to the usual clinics and we deal with them. After my training in that hospital and my promise, I used to give these women some more time and try to show empathy. A woman came to me. She was not educated. She complained about not having kids for so many years I prescribed her medicine which promotes the growth of eggs in the human ovary. This was the medicine that was commonly used in carefully considered cases to promote fertility at that time. There was a set of instructions and counseling involved along with that medicine. So I talked to the women in clear Punjabi language. I told her “I am giving you medicine which is going to make eggs in your ovary. You have to take that medicine in this time of cycle then you have to do certain other things”.

At the end of the consultation, I asked what did I tell you? She said that she had to make an omelet and take medicine with that omelet. I was astonished at where I went wrong, did I give too much information? Anyhow I tried again and told her this medicine has no relationship with hen’s egg. It is for your eggs without which you will not have a baby. Humans also have eggs. I convinced her and she went.

Although I worked on my communication skills I encountered these situations again and again. Women want some food advice along with their medicine. Usually, they ask whether I should take these medicines with milk. Unfortunately, milk hinders the absorption of many drugs. They should not be taken with milk.

I tried to search for reasons behind this social phenomenon. I found two things. One is our male-dominated social setup in some socioeconomic groups. Where if a woman wants to eat a nutritious diet she should have some reason for that. They sometimes need a doctor’s advice to drink milk and eat eggs and apples. This also implicates the mother-in-law and daughter-in-law dilemma in some cases. Here food is available and there are no economic problems. It is purely a social norm problem. That gives them a fixed mindset of not thinking much and focusing on their desires. Myths and false beliefs about different foods also contribute to this.

The second factor is poverty which means a real lack of resources. When you don’t have enough you cannot think about the future you cannot make long-term plans. Your main concern is your next meal. You only can think about the short term and that is the curse of poverty, as George Orwell said “It annihilates the future. All that remains is surviving here and now”. They want to have kids for them. Because it is ingrained in their mind they will grow up and earn for them. Even before growing up kids can be useful for them to earn and work. So they don’t take children as responsibility but rather as capital. Which increases generational poverty. What they all need to think straight is money. That is the solution to their all problems and that is not available to them. It has been proved by many studies that the poverty trap makes them do dumb things. And rich people wonder why they always make dumb choices. Everybody advises poor people which they are unable to understand because of poor thinking ability. It is clear that they do not need any advice but they only need money to think rationally and clearly.

Living in extreme inequality adds further fuel. Psychosocial sequences of living in unequal society are, that people spend more time worrying about how other people see them. Recently international Monetary Fund published a report that too much inequality inhibits economic growth. Income inequality makes all of us less happy with our lives even if we are well-off.

A recent report by the World Health Organization indicates that 17.5% of the adult population has infertility issues says roughly one in six adults experiences infertility. The prevalence of infertility in Pakistan is reported as 22% according to some reports. It produces psychosocial trauma for women. Our social norms equate it with failure on personnel emotional and social levels. Infertility is diagnosed when a couple is unable to conceive after 12 months of living together. The cost of infertility treatment is very high. And it is usually funded out of pocket. It makes it a major equity issue. It can be a medical poverty trap for those who are affected.

The author Dr. Attia Anwar is a consultant family physician with a postgraduate degree from the Royal College of GP UK. She is a strong advocate of health and well-being and wants patient participation in decision-making regarding health.

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