Let me take an example of more common problem of fever and how economy decides the level of care. In a general out-patient care 80% of patients will be infections. Another fact that we have to remember is patients in low socio economic status earn about $4-6 a day, on which the whole family lives. The wage earner takes leave, the whole family suffers. In this situation let us say this wage earner gets a fever. He usually waits for a day or two to see if it subsides by itself or by medications taken form the local pharmacy (Which can be something simple from Acetaminophen to antibiotic to sinister steroids). When he comes to the doctor, he wants fast and economical relief. He does not have the luxury of taking rest for three days to observe whether it is viral or bacterial or the character of the fever. The more days he is unwell the more his family is suffering. He is willing to spend a little bit for a fast relief. In this situation, the doctor is in a dilemma – should he treat like in an ideal situation -give symptomatic relief and wait then start an antibiotic Versus start an antibiotic for the benefit of doubt and see that he is back to normal without the need to come back. While the later is less than ideal or maybe irrational also, many practioners do that only. As long as the antibiotic is cheap and the patient can complete the course, he is not going to propagate resistance. For resistance comes mainly because of discontinuing antibiotics before the course completion. The problem comes when practioners start using more and more expensive narrow spectrum antibiotic pushed to them by medical representatives. Then the patient is exposed to a costly medication with more chance of default and resistance. (Eg Doxycycline costs 12.5 cents a course compared to 10$ for Co-amoxi-clauv). The second problem comes when we do the same thing to people who can afford, for who the standard regime can be followed. This is very common, you go to a corporate hospital, the patient is spending a lot of money to see the consultant and of course he does not disappoint the patient but gives him the cutting edge, wallet cutting antibiotic for a common cold. Conscious judgment is necessary to try to see the social situation of the patient, his clinical condition before appropriate course cannot be taken. There is no single guideline for all patients.
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