Another take on Health Economics

Warning – I’ve packed it in after a long day and am drinking sherry while I write this, so expect a degree of rambling.

The frequent discussions on CCM-L and Med-Events on health economics are a constant source of interest to me.  Bear in mind that the majority of those that argue throughout the discourse are ‘comfortably’ parked in the USA, Western Europe, etc, while I have a very different developing world perspective.  I’m sure colleagues in countries such as Brazil and India will identify when I say that we have a dichotomous economic environment; First World excess and ‘hot-and-cold running nurses’ are available to those with the personal assets to purchase such care, while the rest make do with state-supplied bare-bones service.  The split between public and private healthcare may seem odd to many, but  to us it is a way of life.  Fortunately, I can say that there are equally brilliant and egregious doctors in both systems; I trained under physicians and surgeons in the government system who are quite simply world-class, whose names you would recognise from the keynote speakers at international conferences, and I have encountered their opposites in private hospitals and remote subsistence clinics alike.  Thus, I am not as concerned as some commentators on the ‘risks’ of having a split in healthcare services between private/public, insured/uninsured, consumer/medicare, or whatever description you wish to give it – it exists already in my country, and it does function.

My regular job has always been in the public service, with the government paying my salary.  Before coming down to Antarctica (where, incidentally, I am still paid by the state) one of my jobs was working in a ‘Community Health Centre’ in Khayelitsha, Cape Town.  Khayelitsha is a township/ghetto/informal settlement (pick your politically correct label) of about 1.5 million souls, on the fringes of Cape Town (just beyond the airport, should you know where that is).  It’s poor – the older established areas have the most basic houses imaginable with tin roofs and running water as a fairly recent luxury.  The poorest areas have only shacks – many more cardboard than tin.  One particular area has the wonderful distinction that 100% of the residents acknowledged in a survey that they or a member of their immediate family support themselves through crime.  I was robbed at gunpoint by an 11-year-old boy there a few years ago, so I believe the statistic.  (I remember thinking that I was impressed that his tiny arm could support a 9mm pistol so steadily, and chalking it down to adrenaline, as he was probably more scared that I was.)

At Khayelitsha CHC the working environment was vastly different from a normal city hospital.  Essentially, we provided primary health care to the local people, 99% of whom could never afford a trip to a GP.  A ‘Midwife Obstetrics Unit’ on the premises delivered all antenatal and labour care, completely staffed and run by nurses – occasionally we’d get called to assist with a particularly difficult delivery or neonatal resuscitation, but usually they got down to the business of delivering 20-30 babies a day without any input from the doctors.  Also nurse-run within the facility was a child-health clinic and mother-to-child-transmission HIV prevention program.  The former used the IMCI (Integrated Management of Childhood Illness) system to assess, manage and refer sick babies and children; the latter provides enrolled HIV-positive mothers with breast-milk substitute to prevent transmission of the virus to their HIV-negative babies.  Also on the property, housed in pre-fabricated constructions, were an HIV/TB clinic run by Medicins sans Fronteirs (Doctors Without Borders), and a rape centre with an impressive conviction rate for perpetrators – a magnitude of 10 higher than the national average.  Finally, a pharmaceutical service gave out repeats of prescriptions to masses of patients.  All of these services contributed to an impressive number of patients seen every day – about 1200 adults, children and infants received care of some sort, although between the nine doctors only we actually crossed paths with only about 450.  These were split between the ‘family medicine’ (aka GP) consultations, the chronic condition club du jour and the emergency unit.

Arriving, as I did, from my already high-intensity internship, I nearly fell over backward when told that as a newbie I would be expected to complete 40 consultations a day in the general clinic, to pick up to 60 per diem after a month’s adjustment. I was assigned to the ‘Hypertension Club’, and for 6 months spent two days a week seeing patients with chronic high blood pressure. We allowed 80 patients a day per doctor, but when understaffed I often saw more than 120. In times of desperation we would set a blood pressure value, blindly re-prescribe the medications for those who were under this cut-off, and only see the ‘problem’ cases. To many doctors this must sound like gross malpractice, but it was the only viable alternative â?? without a prescription, the patients would not get any medication. To make life even more fun, it should be remembered that most patients were communicating with me either in their second/third language (English), or in my third (Xhosa). Although we theoretically each had a nurse as interpreter, this was seldom actually the case, as the facility was always understaffed and we rather diverted nurses to the Kids clinic or emergency unit than have them repeat the same questions ad nauseam. My Xhosa flourished.

We had a simple system to control numbers of patients. The controlling factor was always the number of doctors available. One was always needed to man the ER, although two were usually needed. Two or three were needed for the Chronic Club of the day (Epilepsy on Monday could be handled by two, Hypertension on Tuesdays and Wednesdays needed at least three, Diabetes on Thursdays needed 3 but usually two could cope at gunpoint, and Wounds on Friday was a breeze once the got team up to steam). We also ‘lost’ a doctor three times a week to cover the local old-age homes and hospice, and the two senior specialists would have a referral clinic on a regular basis. One doctor was an intern on a family medicine rotation and had to work under supervision. Whoever was left was assigned to the general clinic.

The general walk-in clinic is a special thing. The community knows how things work: the early bird gets the worm. Long before I rolled through the security gate a little after 0700 â?? in fact, as early as 0400 â?? the patients would begin queueing at the door. At 0630 the door would open, and the clerks would seat prospective patients in rank and file in long rows of benches in a large hall. The first 100 in line would be allowed through a second door, to sit in the first anteroom. One by one they would be given their folder, and then assessed by a team of nurses. The nurses checked the reason for presenting to the clinic, and then performed a range of tests based on a protocol the doctors had created, measuring blood pressures, haemoglobin, blood glucose, body mass, etc. These were then noted in the folder before the patient was admitted to a second waiting room. From here, eventually, a doctor would appear, mispronounce their name (well, you try pronounce Tamcanqa Ngequelexe with the correct clicks!) and guide them in batches of 10 or 20 to another bench in another hall, from where they would eventually be seen. Often I sat at my desk in my small consulting room at four o’clock in the afternoon seeing patients who left home at the same hour in the morning. The rule was simple: the first 100 in line get brought in, no matter what; thereafter we allow 40 per ‘green’ doctor and 60 per experienced doctor. Usually this left one or two hundred at a loose end. For these we would assign the last available doc to ‘triage’ â?? basically he or she would see each for a minute or two and give the most appropriate management. Many got a pre-printed note entitling to be first in line the next day, others got a 30-second prescription, while sickest were sent to the ER.

Many who arrived at the clinic, of course, were there more to avoid work for some reason than to have a serious condition addressed. I fondly remember the dark humour I experienced one morning. We were in the midst of a public service strike. Of the 30-40 nurses employed by the CHC, only 3 had come to work, the rest either picketing and throwing stones and petrol-bombs at the gate or hiding at home in fear of retribution. Three of my colleagues and I had said that we would continue to provide emergency services at the clinic (despite threats), and under guard from the military we kept the emergency unit, mother-to-child-transmission clinic and child health services running running for several weeks until the crisis was resolved. Even with the strike and picket in full force, at least 300 patients were waiting in the hall every morning. On the third day I was assigned to triage the masses. Confronted by the sea of faces, I asked that everyone who was there only for a sick-note to get off work to raise their hand. A forest of palms replied. I had a clerk writing ‘Mr/Mrs/Ms X presented today to Khayelitsha CHC’ over and over on a sheet of sick-notes ad infinitum while I blindly signed them… so sue me. Those who really needed medical help that day received it, and I learnt something about human nature.

My favourite activity, of course, was working in the emergency unit. I’ve always loved emergency medicine, and Khayelitsha was no disappointment. I can probably boast that we saw enough trauma in the average night to rival a ‘First World’ ER’s monthly load. Indeed, if I didn’t have the chance to lay scalpel on flesh (albeit for a simple chest tube) it was a quiet day. A couple of gunshot wounds rolled through each week (mostly on weekends), probably because guns were too expensive for Joe Criminal on the street. Penetrating trauma was de rigueur amongst the locals, but we managed critical care patients with myocardial infarction, congestive heart failure, diabetic and other endocrine emergencies, severe pneumonias, complications of HIV/AIDS, flagrant pandemic tuberculosis, childhood illnesses of every type and so on, on a day-to-day basis. The emergency unit had the most basic equipment: a resus trolly, no ventilator, access to x-rays only during normal working hours and Friday/Saturday nights to midnight, no blood, no CT, no thromolysis, no specialist, no surgeon. Yet we managed polytraumas for hours until the overtaxed ambulance system could take them away to more advanced care; we tied and we clamped and we cut and we tamponaded with Foley catheters until the blood stopped flowing from gaping wounds; we compressed chests and bagged by hand until transport or angels arrived to take our patients. I put in endotracheal tubes and chest tubes on the floor when we ran out of beds and used Coke bottles for underwater drains when we ran out of equipment… and despite all this ‘madness’, patients survived, families thanked us, and the world kept on turning. It’s bush medicine in the urban jungle; war in peace, but when it’s something or nothing, something is everything.

I have a little score-sheet in my head; I call it the ‘Immunisation Index’. Basically, whenever I’m considering an investigation or intervention for a patient, a still small voice in my conscience asks â??How many babies could you immunise for the same cost?â? It’s a reminder of the ethics of egalitarian care – am I remembering the care of many when considering the care of one? The irony of my current position does not escape me â?? here I sit, providing care to a very select few at great (relative) cost to the multitude. It’s hard when I consider that the sum total of all the care that I have provided in more than a year cannot equal that of one night in Khayelitsha’s ER, yet I recognise the need. Still, when I compare to the (relative) excess of the average First World health ‘consumer’ (what a horrid concept) I am aghast. Somewhere there lies a happy medium, but neither caregiver nor recipient will recognise that point as equilibrium, for the only true balance will come when the doctor’s perceived beneficence is matched by the patient’s perceived malfeasance. Mourn the day, my brother and sisters in Hippocrates, Aesculapius and Panacea, when we acted in the best interest of the patient and they believed it so. Remember, however, you privileged few, that you have yet to hit the bottom of the healthcare barrel.

One Response to “Another take on Health Economics”

  1. inc.ryan Says:

    i live in cape town and yet in a matter of minutes, when i myself just slowed down my pace of speed, i realised that i have missed the most intrigate details of life in the harsh side, where value to time is no longer a measure able to be taken by dinamics. i can feel the tears dry in my neck, yet it is not controlled. WOW! would be an understatement. a complete sense of life where one tastes the way in which life moves, even when you can no longer see it. when u hit that side of no luxuries, you find spaces where life get real meaning. c.u.s

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