In 1987, Dr Richard Smith, then assistant editor of the BMJ, visited the Sultanate of Oman and wrote about the achievements and challenges of the Omani health service.1 I had worked in Oman myself from 1984–1986 and recognised much of what he described. Twelve months ago I returned after retirement from general practice in the UK, to take a post as a consultant in Family Medicine in Sultan Qaboos University in Muscat, the capital of Oman.
Since 1986 the country has been transformed, with an impressive infrastructure of roads, schools, internet, mobile phones, and a supply of electricity and clean water to every household. The health service has also developed a sophisticated network of health centres, polyclinics, and hospitals throughout the country. Health care is locally available and free to all Omanis and to expatriates working in the government sector. In addition, there are parallel health services for those employed by the armed forces, the police, the university, and the Diwan (Royal Court Affairs) and their families.
However, working here again I have become aware of a new and different challenge. Oman has a small and relatively young population yet the service is struggling with rapidly-increasing demand and long waits for referrals to secondary care. Across the world, government-funded health services are being forced to address this, but my impression is that overinvestigation, overdiagnosis, and overtreatment are at the root of the problem here and have become a significant health problem in their own right!
The causes are multiple and complex. There are those issues that now beset every modern health service: the influence of multinational corporations seeking to increase their profits by inflating the medical economy; newer/better imaging technologies that are so sensitive that they often demonstrate some minor ‘abnormality’, which then leads on to further investigations necessary only to reassure a now anxious patient; the all pervasive influence of the pharmaceutical industry;and the impact of private medicine.
Although private medical care is modest in Oman compared with the other Gulf countries, there are hundreds of small, private primary care clinics around the country as well as many large hospitals. Where doctors stand to benefit financially from doing tests and making diagnoses, it is very difficult to resist patient demand for unnecessary investigations and treatments. In an increasingly wealthy, consumerist society this is a particularly toxic mix.
In the early years when these new health services were being established in the Gulf countries, the doctors in primary care were often young, inexperienced Asian expatriates. Patients had an immature understanding of health and disease and had poorly-formed expectations of a modern health service. The doctors, anxious to avoid the disappointment or displeasure of their patients, fuelled their unrealistic expectations with inappropriate, investigations and treatments. It is much easier to arrange investigations or prescribe drugs to a patient than to explain to them (in a language in which you have limited fluency) why they are unnecessary. Although many nationals are now working as doctors, and health ministries have produced clinical guidelines and formularies, the practice has become the norm in primary and secondary care. Many doctors carry out blood/urine testing or imaging for almost every symptom a patient presents. Many patients with chronic symptoms or disease, frequently seek multiple opinions and repeated investigations from different health providers, both private and government. I wonder if it is the traditional Arabic culture that seeks to please or satisfy a guest, which makes it very difficult for doctors to refuse unrealistic and inappropriate patient requests.
The health problems in Oman in the 1970s and 1980s were those of all developing countries; poor sanitation, poor nutrition, and infectious diseases. Richard Smith described the government’s response to this and impressively these have been effectively overcome. Those problems have now been replaced by the ‘lifestyle’ diseases of western society: obesity, hypertension, coronary heart disease, and type 2 diabetes (now affecting 8.01% of Omani adults).2 Unfortunately, these non-communicable diseases (NCD) will never be overcome, however large the healthcare budget.
The move from treating sick people with diseases to treating well people with possible risk factors for future disease opens up a huge income stream for those seeking to profit from health care. The enthusiasm of the wealthy governments in the Gulf countries to improve the health of the people makes them vulnerable to NCD propaganda.
At the turn of the century, as a result of progressive government policies and strong leadership, Oman had the highest immunisation rates and the most efficient health service in the world.3 I wonder whether it will be able to recognise that maybe now it has too much medicine and take a leading role in the Middle East in confronting this new challenge of the 21st century?
- © British Journal of General Practice 2015