The arrogance of closed borders

These days, closed borders are on everyone’s minds. But the borders of the US are not the only ones that are closed and hotly debated. There are some closer to home that may affect the poor and the marginalised just as much, perhaps a lot more, than the US borders.

Last week, I had the pleasure of meeting a number of researchers who are concerned about the growing level of anti-microbial resistance in Pakistan. With the quality of medicines questionable, the widespread use of antibiotics without any definitive testing, and the availability of drugs without the need for a prescription all contribute significantly to the problem. I had known about all of these dimensions and have written about them multiple times in the past. But as I spent a wonderful afternoon at the Department of Microbiology and Molecular Genetics at Punjab University in Lahore, I became aware of another, and perhaps the most dangerous of all dimensions: arrogance!

Let me elaborate. The faculty colleagues and researchers at the department, who were trained in microbiology and had done extensive research in the field of anti-microbial resistance, were extremely frustrated not by the patients, or their families, or by the pharmacists, but by the doctors. The chair of the department told me that despite being an expert in the field, and having published in leading journals in the field on the issue of antimicrobial resistance, she is shunned by the doctors, who consider her an outsider, and unnecessarily interfering in their profession. Even in cases, when there was a clear reason for a particular antibiotic to be ineffective (or perhaps detrimental), clinicians at public hospitals were unwilling to listen to her. This was perhaps out of a habit, or perhaps out of arrogance. Bothered by the continued practice, she tried to persist in her arguments but eventually she was told by one of the hospitals to mind her own business and stop coming to the hospital altogether. Any notion of medical and clinically relevant research outside the hospital, according to colleagues at the department, is not only non-existent, it is viewed with extreme suspicion. The borders of advice, from basic science researchers to clinicians, are closed.

The doctors in their defence argue that they know the patients and the treatments best, and have the best interests of the patients at heart. They also argue that by allowing anyone to come over and tell them what to do would be dangerous and criminal. Both of these arguments are true — but so is the fact that our doctors are not up to date on basic science. They do not have the time to read medical and basic science literature extensively. There are also few opportunities for them to go to conferences and learn about the most recent developments in basic and applied sciences. Those working at public hospitals are burdened by politics, low pay and crumbling infrastructure. Under these circumstances, they have to be protective of outside interference.

So under these circumstances, where best practices are often derived from precedence and not recent discoveries, what is the way forward? Can we build some bridges of understanding when there is such a deficit of trust? The longer-term solution will come from an overhaul of the curriculum of medical students, who fail to appreciate the value of basic sciences. For example, the discussion of antimicrobial resistance in a single course in microbiology (taught at most national medical schools) is superficial, dated, and fails to provide local context. It also lacks recent literature on the problems facing the region. There is no doubt that the training of the future doctors is demanding, but it fails in creating a sense of inquiry or a desire to work with colleagues from basic sciences.

In the short term, the clinicians have to recognise that just as there are charlatans, there may also be colleagues out there, who may know a lot more about treatments that are no longer effective.

Protecting the borders of a discipline is a good idea, but so is letting good ideas come from outside the borders.

Published in The Express Tribune, February 7^th, 2017.

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