Defining ‘necessary’ in the ‘necessary injection’

 

“I know what works for me and what doesn’t. This is not your body it is mine. I am living and suffering the back pain every minute. So just give me the injection when I ask you for it. I don’t need your lecture. It is the injection that I need.”  - Mr. A

 

“Sir, I am suffering badly with the foot ulcer. The pain is unbearable. Most days I am unable to sleep because of the pain. I spend the entire day sitting and staring at the roof, crying silently and suffering in pain. Please….please…please give me the injection.” – Mr. S

 

The past week has been rough. We travelled into interior villages in our project area to interact with people. The heat was oppressive. I missed the intellectual companion with whom I used to travel these same villages to interact with people. The experience of sharing surprised looks when the community says things which are totally unexpected, the long discussions during the travel to and from the village talking about the “why?”, “how?” of what was discussed in the community and the back and forth debates about our respective interpretations used to be so rich and used to contribute to significant meaning making. The intellectual companionship outlived its purpose, and we each moved on in different directions. I missed those interactions very badly this time, the first time I am engaging in intensive community work without this companion. 

 

Coming back to the clinic, we have been struggling with ensuring rational treatments in the clinic since the past few months. We used to be very stringent about avoiding unnecessary injections and intravenous fluids. Somewhere down the line we got lenient and started giving them on demand. In fact, there is a popular practice in our clinic where a physician orders 5 weekly injections of vitamins for patients with body aches and pains. We had a vision building meeting for the clinical services some time in February 2026 and at that time we revisited the original vision of ensuring rational treatments and it was a harsh wake up call for us. We realized that we had drastically deviated from the rational treatment policies that our clinic was originally so clear about. We have started strictly enforcing rational treatments and avoiding unnecessary injections and intravenous fluids in the clinic. Since the time we started this, life has become difficult. 

 

Going back to the first two statements in this essay, the first one was by Mr. A. Mr. A is a farmer in one of the nearby villages. He has several coconut trees, and his main source of income is sale of the coconuts. He also has a few cows which give milk. He has been our patient for many years. He does not have diabetes or hypertension and is a relatively fit man, in his mid 60s. He rides his bicycle wherever he goes and that is one of the main reasons for his physical fitness. He comes to the clinic because of severe low back pain, which has been bothering him for many years now. An MRI scan done a few years ago showed lumbar disc disease and he was advised physiotherapy. He believes that the interferential therapy, referred to locally as ‘giving current’ or electricity, is harmful and will remove the vital energy from his body. So, he manages with some hot water fomentation and pain killer medicines. He comes demanding injections frequently. When he demanded an injection this time, I explained to him about the harmful effects of frequent painkiller injections. I also explained to him that tablets will do the same job as effectively. Mr. A has a quick fuse and so he got annoyed with my lecture and said, “I know what works for me and what doesn’t. This is not your body it is mine. I am living and suffering the back pain every minute. So just give me the injection when I ask you for it. I don’t need your lecture. It is the injection that I need.” I persisted on my stand. By now, his anger and his tone also irked me, and I did not give in. We had a long argument and then he got up and stormed off in anger. 

 

Mr. S is a soft spoken and quiet man in his early 60s. He developed a small ulcer over the cleft between the last two toes on his right foot. It started as a simple fungal infection. But very rapidly it worsened and deepened into an infected wound. The little toe lost its blood supply and started rotting. So I had referred him to the tertiary care hospital for amputation of the toe. The amputation was done, but the infection did not subside. It spread wide and far, and it ended up in more surgery removing a large part of the infected flesh on the right foot. Mr. S has both diabetes and hypertension. Usually, people with diabetes lose sensations over the feet and so while all these foot problems are happening, they don’t have much pain. But Mr. S had all his sensations intact, and pain was a major problem. We were giving him high doses of pain killers. Despite this he was suffering sleepless nights crying in pain. So, he keeps requesting for pain killer injections. When he literally implored for a painkiller shot the other day, I tried to rationalize with him and told him that tablets will do the same job. But Mr. S started crying and begging for the injection. He said, “Sir, I am suffering badly with the foot ulcer. The pain is unbearable. Most days I am unable to sleep because of the pain. I spend the entire day sitting and staring at the roof, crying silently and suffering in pain. Please….please…please give me the injection.” I did not persist on my stand and yielded. We gave him the injection; he was satisfied and left. 

 

I have been quite disturbed by the contrasting stand I took with Mr. A and Mr. S. The underlying issue was rational injection use. But I did not implement it equally in these two men. My decision to persist on my stand of ‘no unnecessary injections’ with Mr. A was reinforced by his argumentative approach which hurt my ego. On the other hand, my flexible approach to Mr. S was because he was emotionally vulnerable. While the stand of ‘no unnecessary injections’ is good, the biggest challenge is in answering the question – “what is a necessary injection?” The World Health Organization has a clear definition of when an injection is deemed necessary. When a person has a stomach or intestine problem when they are unable to take the medicine orally, or when orally taken medicines are not absorbed properly, then injections are used. Sometimes the drug has a property that it get destroyed in the stomach or intestine due to the acidic or alkaline environment in these areas. In such cases, the drug cannot be taken orally. Sometimes the situation may be an emergency. For example, a person’s heart may be struggling to beat. In such situations we do not have time. If a drug is taken orally, it takes time to reach the blood circulation and go to the heart. We may not have the luxury of time and so injections may be helpful. Sometimes patients may forget about the dose of tablets, not taking the medicine may harm the patient. In such situations depot injections are preferred. Other than these conditions, injections are said to be unnecessary. 

 

These WHO criteria do not consider the fact that the mechanism of action of medicines is not purely biomedical. A tablet or an injection is never just a pharmacological substance. It is a ‘symbol’ of healing. The very act of taking a tablet or an injection induces the secretion of feel-good hormones in the body such as endorphins and endogenous opioids in the brain. This gives an instant feeling of wellbeing. This is the reason that many times sore throat starts feeling better within a couple of hours of taking the antibiotics, while the actual action against the bacterium takes much longer to start. The process of taking a tablet or an injection itself marks a ritual of care and the ritual has a deep psychological therapeutic effect. Several studies have shown that people who spend more money out of pocket on tablets feel better sooner than those who spend less or get free pills. People who are prescribed a greater number of pills feel better sooner than those who are prescribed lesser number of pills. The other important aspect of the treatment effect is the relational mechanism of the treatment alliance and support. Treatment happens within the relationship between the doctor and the patient. It is not uncommon to hear many patients say, “I start feeling better the moment I see the doctor and come out of the clinic”. Therefore, the treatment effect is a combination of the biomedical effect of the drug + the therapeutic symbolism + the relational mechanism. It is impossible to separate these three components. So, when the WHO is making a judgment on ‘necessity’ of an injection, the criteria that are largely biomedical cannot be useful. 

 

After treating Mr. A and Mr. S differently I am now asking myself the following questions

1.        If I should practice shared decision making where the patient is an equal partner in the decision-making process, shouldn’t I be giving consideration to their lived experiences of what works for them – injection or tablets? 

2.        How should I judge rationality of any medical procedure? – is it purely biomedical rationality, or is it rationality within the combined context of biomedical, symbolic and relational matters?

I hope I can figure these things out for myself and have a better policy for our clinic soon.