Money Matters I

Certainly the differences and similarities between American medicine and African medicine are many. One of the most striking differences is the way that medical care is paid for. In residency, we rarely discussed medical costs with patients and money rarely directly influenced our daily choices (that we were aware of). We just did what we thought was best for the patient usually having very little concept of how expensive the treatment was.

Then I moved to Africa to work in a mission hospital in one of poorest countries in the world. Not only is there no universal healthcare but there is almost no health insurance. For any planned operation, I would tell the patient how much the operation cost and they had to bring the money before we would schedule their operation. Often they would have to go back to their village and family to borrow the money. Sometimes they never came back because they couldn't afford to.

However, patients who were admitted in the hospital were not refused care even if they could not pay (this was not usually true in surrounding hospitals). All of their expenses were added to their bill, which they were expected to pay at the end of their hospital stay. If they didn't, they had to pay when they returned or else they would not be allowed to see the doctor.

I didn't know how different this was different than the way that many African hospitals function until we were in Burundi. How is it different? Almost everything is pay-as-you-go.  Patients have to buy supplies for each dressing, purchase every bottle of IV fluid before it is infused, and pay for labs before they are drawn. This really makes you think before ordering anything.

I learned the system the hard way with one particular patient. When I first met him he had been in the hospital for several weeks with burn wounds on his legs. He was waiting to find the money to pay for his skin graft operation. Until he found the money, we were doing dressing changes every day. The wounds looked pale. He looked pale...and so very thin. I asked if he was eating. He said he didn't have much of an appetite (and I don't think he had anyone to bring him food). Food had to be brought in by family members, it was not provided by the hospital (which is true for every hospital I have worked in in Africa).

I filled out a lab slip to have his blood level checked. The next day the lab was not done because he had not paid for it. I decided to write a prescription for iron anyway, since I was sure he was anemic. I brought him some avocados that had fallen from the tree in our front yard. A couple days later I asked him if he was taking his iron. It was then I learned that he never got the iron because he couldn't pay for that either. He was languishing before my eyes but I could do nothing because he had no money.

I decided to do something that I had never done before...I took his prescription to the pharmacy and paid for his medication myself. I know that my paying for his medication is not a long-term solution for the poverty and lack of health care in Burundi. But, I was only going to be there for three weeks and I really wanted to help this man. He smiled and took the medicine gratefully.

Two days later the long-term surgeon returned and I learned that, in special circumstances, the doctor can write a note on a lab slip so that, even if the patient cannot pay, that lab will be done. So, he re-ordered the blood level to be done without the patient paying first.

The next morning I learned that the patient had been transfused for a very low blood level but then, later that evening, he had unexpectedly died. They weren't sure what he had died from but it seemed his body just stopped functioning. I was stunned and troubled. Was it his low blood level? Severe malnutrition? A complication of the transfusion? I guess we'll never know. What I do know is that I am left wondering...would he still be alive if he had had the money to pay?