Monday, 5 August 2013

The socioeconomics of health (or the lack of it)

View from the front of the hospital
My nose is running (leaking?) like a tap. Probably an after-effect of almost 25 hours of work yesterday; got woken up at 4.30am to attend to an increasingly tachycardic pre-eclamptic primigravida lady post vacuum-assisted vaginal delivery. She turned out to have postpartum haemorrhage (with an acute drop in haemoglobin level from 113 to 53 in less than 12 hours) requiring manual evacuation of clots under sedation. And didn't get to bed until 5.30am the NEXT morning. "You have got to be kidding me" was my apt reply when informed by the nurse on duty at 10.30pm that the heavily pregnant mother of one of our long-stay patients (a malnourished pre-school boy) had gone into labour. I've been awake for much longer before but haven't needed to be "switched on" (seeing patients and having to navigate the intricacies of their management) nearly that entire time.

Anyway, that brings me to another of our long-stay patients, also incidentally a malnourished boy who's just under 3 years old. He's been with us for 2.5 weeks (which is very very long by the standards of a mid-level rural African hospital where the average turnaround time is just a couple of days). Poor kid's severely wasted and we've been trying to get his weight up to little avail despite successfully treating his malaria and diarrhoea (secondary to ascariasis, which I previously didn't know existed). We think it's most likely attributable to his HIV-positive status. We've been trying for over two weeks now to get him to the local public hospital's antiretroviral treatment centre (the only clinic in town with UN-funded HIV meds), which has to be one of the most trying endeavours I've ever embarked on.

First time, his mum 'forgot' the referral letter we had given her. Second time, she said that the centre had told her that there were no meds available. Third time, we sent our own VCT counsellor (voluntary counselling and testing for HIV prevention) to go along WITH her to firstly, act as an advocate on the patient's behalf and secondly, because we were suspicious that the mother had never actually reached the centre. You see, due to the stigma associated with the disease, most patients are (understandably) very reluctant to be seen anywhere near that centre. It doesn't help that it's located prominently right smack in the centre of the hospital compound with the sign "ART Centre" (antiretroviral treatment) written in large letters; not very subtle, indeed. Anyway, they were sent back to us the third time without any mention of further management for the kid's HIV, whether his CD4 count or viral load were tested and when and how ART should be commenced, etc etc. Just some desultory notes (which were basically copied from our own notes) about his intercurrent infections and starting cotrimoxazole (which we've already done). Gah! Felt like screaming at them.

And against all this was the backdrop of the mum's insistence on being discharged home in spite of the kid weighing less than on admission (hovering betwen 6.4kg and 6.8kg from 7.3kg for a 2 years and 7 month old boy on a maximal therapeutic feeding regime)! So so frustrating. Upon further questioning, the socioeconomic factors behind that bizarre request were elucidated. Firstly, she was concerned over how to pay for the boy's admission as she, being his full-time carer, was obviously out of work (just as a fyi, we never force our patients to pay and there have been many a patient who has defaulted). Secondly, she was worried about her husband and what he was up to; he had been MIA the whole time, which is pretty unusual as I've seen most African dads showing up every now and then to check on their family. Thirdly (and this I found most strange) she wanted to go buy soap and her boy's favourite food items since he didn't like what we offered (and I don't blame him - it consists mainly of beans and rice BUT it's probably more than what he would have gotten at home; when I suggested that she could leave the boy on the ward during the daytime to get the food, she actually confessed that she didn't have the money for the purchases so I thought this a moot point and just another excuse to leave).

Anyway, tomorrow's our fourth attempt at trying to procure these ridiculously elusive drugs. God willing, we will be able to start him on the meds he needs and that would prove to be the solution (since we've already exhausted all other options). The harrowing likelihood (and what's most depressing) is that the boy is going to return to his baseline state and possibly die in the next few weeks or months as soon as he goes home unless his social situation dramatically improves.

Why fight so hard for what seems to be doomed for defeat?
James 2:14-18 What does it profit, my brethren, if someone says he has faith but does not have works? Can faith save him? If a brother or sister is naked and destitute of daily food, and one of you says to them, "Depart in peace, be warmed and filled," but you do not give them the things which are needed for the body, what does it profit? Thus also faith by itself, if it does not have works, is dead. But someone will say, "You have faith, and I have works." Show me your faith without your works, and I will show you my faith by my works.

As the Apostle James so poignantly puts it. This passage has been one of my life's driving forces over the past few years. A Christian who does not lift a finger to help his or her brethren is no Christian. When would the church wake up and realise that there is so much need outside her doors? That God put us on this earth not just to eat, drink and be merry, but to use what we have been given for the greater good and for the glory of His name?

11-Aug-2013 Update:
Bah! The public hospital straight out refused to give him the meds without his attending a supposedly obligatory three-session education course which takes place only once a week, i.e. we've to wait a further three weeks to start him on ARV meds! This is despite our giving the hospital's medical director a call, who promised to give us what aid he could but then backtracked and gave in to the clinical officer (not even a doctor for crying out loud!), who persists in being obstinate over a stupid protocol! Dear God, give us patience...

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