Sunday, July 11, 2010

Healthcare disparities around the world

Now that I've given you a little picture of the overall situation in Sri Lanka, let me tell you a little about the places that I've been working. These include a free government hospital, a private clinic, and a volunteer first-aid camp at the Poson festival, each of which has shown me a different side of medicine here. (Please gloss over any medical jargon as necessary.)

The general gist of health care here, as far as I can tell, is that there are free government hospitals in most of the big cities (there are at least two in Colombo), but that the government provides the absolute minimum of care. Then there are private hospitals that people can visit if they have insurance or if they pay out of pocket, which is obviously only available to people who are fairly well-off -- not even the doctors I worked with at the government hospital can afford to go to the private hospitals.

Almost everyone has extremely poor dentition (most have only a few remaining teeth, all of which are rotted) and most have various fungal infections on much of their bodies, especially their feet and nails. The conditions are so common that nobody even bothers to mention them, let alone treat them. The most common infectious conditions seen here are dengue fever, which is currently epidemic here, with over 15k cases and almost 200 deaths since January, leptospirosis, typhoid and other diarrheal illnesses, and other nonspecific viral fevers, including rheumatic fever. Surprisingly, diabetes, hypertension, kidney and heart failure, are also extremely common, despite the almost complete absence of obesity. So in the end, a large part of what is seen here is also seen at home, although usually we see it at much earlier stages, rather than at the end stages that almost everyone reaches here. Blood sugars, blood pressures, and everything else - the numbers I'm seeing here are so high I had previously thought they were incompatible with life.

My first two weeks were spent at Colombo South hospital, the second biggest teaching hospital in Colombo. Everyone tells me that the main Colombo hospital is so nice and has tons of facilities, but I haven't seen it for myself. Colombo South, on the other hand, is... shall we say... often better than nothing. When I pictured a government hospital, I suppose I imagined some kind of run down version of our own hospitals. I was assigned to work on a general medicine ward for men, and it was pretty representative of the rest of the hospital. Patients are admitted on a rotating schedule, with "casualty day" rotating between three wards. On casualty day, everyone who comes in who isn't a trauma or surgical case goes to your ward, no matter how full it gets. On post-casualty day you are desperately trying to deal with the giant crowd that showed up on casualty day, and on pre-casualty day you are desperately trying to empty as many beds as you can before the next casualty day - and so it goes in a never-ending three-day cycle.

Our ward consisted of 40 beds that were about the size of the dorm beds we get in college, all lined up with about 2-3 feet in between them in a big open room with no close-able doors or windows. As such, the place was full of flies, and there were stray dogs and cats running through occasionally. With an average of over 90 patients in the ward, most times the patients were two (or even three) to a bed, and only the sickest got their own beds. Usually the men would lie head-to-feet in order to have more room for themselves, and at night many would bed down on mats on the floor because they had to sit in chairs during the day. I was told initially that suspected TB patients were isolated outside, but I later saw two TB patients inside with everyone else, including one sharing a bed with a heart failure patient (who was about to also be a TB patient).

I never saw the sheets on the beds changed, nor hands washed, except sometimes when doctors were leaving for the day. I rarely saw gloves used, and on multiple occasions I watched doctors and medical students get blood all over their hands when they performed a procedure without gloves on. When I asked about it, I was told that HIV isn't very common here. When pressed further, they told me that people knew the risks, and if they didn't use gloves it was their own fault. Doctors coughed freely without turning away or covering their mouths. Almost everyone on the ward was on antibiotics, not surprisingly given that infection was likely carried from one patient to the next.

Patients with end stage kidney failure were dialysed only when on the verge of death, after which they were sent home until their symptoms overwhelmed them once again and they returned for another emergent dialysis, and this only if the doctor in charge was feeling sympathetic. Diabetics consistently came in completely uncontrolled despite having been given medication, and even after a day or two in the hospital, their glucose was still sky high. Doctors would give orders and these would only occasionally be carried out. Patients would be wheeled three at a time sitting on a metal stretcher if they needed to go for tests, as there weren't enough wheelchairs for them to each have their own. One time I was in the ward when a patient died, and the body was wrapped up in the bedsheet and then left in the ward for about 3 hours before being wheeled out. Incidentally, this is the only time I ever saw a bedsheet removed from a bed.

In the maternity ward I was shocked to learn that new mothers are allocated 4 hours alone in a bed after they give birth, after which they must share with another woman. Because two women and two babies can't comfortably fit in a bed, almost all the beds had two babies lying on them, with their poor mothers sitting in plastic chairs next to the bed. I had the good fortune to walk into the delivery room just as a woman was giving birth, and I was then appalled to watch a young doctor take the baby over to a table to listen to its chest, answer her cell phone and take a call in the middle of the exam, and then leave the baby wriggling on the table and walk away.

In Peds I was told that they separate the viral fevers from the diarrhea in different parts of the ward, and when I asked how they prevented infection, I was told "in pediatrics, even the medical students wash their hands," as though this was something to be proud of.

What was interesting was the air of defeatism that pervaded the place. Every time I would ask about something, I'd get the same answer that there is no money, and we are a poor country, and people get their care for free so they are happy with what they get. But I was amazed by the things that I saw that could easily be prevented by simple things like hand washing and cough covering. Little things that wouldn't cost much at all could save tons of money in the long run by shortening hospital stays and reducing the need for antibiotics, which are horribly over-prescribed as it is. Yet no one would listen, always telling me that this is just the way it is in a poor country.

So I think it's important to remember that it may seem like there is no way to fix the problems we are facing even in our own "first-world" situations, but sometimes if we look from another angle, the main thing that is really limiting us is our attitude. My big question now is how someone like me (and you) can change the attitude of such a monstrous machine as a health care system. In fact they do need money and they do need manpower, but most of all they need a paradigm shift. So I'm open to suggestions and would love to hear your thoughts.

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