The Fate Of Patients In Resource Poor Settings

“I won’t be here next month.” Ten years ago I walked into my very first patient’s room as part of my medical school physical diagnosis course. I was momentarily confused- but thankfully I did not naively blurt out “why?” I noticed her pale skin and her bald head and felt like I had intruded because she was sitting upright in the hospital bed with her legs crossed and hands in her lap, almost as though she was meditating. She continued — “sometimes I go to the mall and I sit there eating and watch other people and think: I won’t be here next month… but they still will.” I’ve thought about her often during the past decade- not only because that brief encounter with her taught me a lot, and not because I have had many patients with cancer since then… On my flight from New York to Kathmandu it occurred to me that I am now the age that she was when she died a few months later… 32.

Illness is a burden we must all someday face. My young American patient had access to a tertiary care hospital with the latest diagnostics, treatments and the expert knowledge of sub specialists, and yet she still died. In stark contrast to this- many sick people throughout the world do not even have the illusion of adequate access to healthcare, and subsequently no hope. There are of course exceptions; and while I was in Haiti I learned that Project Medishare is organizing chemotherapy for patients with cancer (as has Partners in Health an organization that believes health is a human right). Based on current WHO statistics, residents of Sierra Leone have the shortest life expectancy at birth – and at around 47 years, this is a shocking four decades less than Monaco (supposedly the country on top of the list). Of course figures do not capture the lives cut short of people trapped in the midst of dozens of serious armed conflicts worldwide. Essentially, people endure a tremendous amount of suffering due to the misfortune of the place of their birth. In rural Nepal where I now work, the primary culprit of misery is how far away people live from the care they need. A close runner up is whether or not adequate resources are on hand once they finally arrive…

Those of us lucky enough to live in places where we do not face moment-to-moment struggles for survival sometimes forget that people cannot just will themselves into better conditions. This is as much the case for homeless people in New York City as it is for poor people worldwide. Contrary to beliefs that simply ‘working hard’ will lead eventually to a better life, most people are trapped so deep in vicious poverty that climbing out is infinitely more impossible than the rags-to-riches stories that we are all fed by Hollywood. In desperate situations the prerequisites for change simply do not exist, nor are their options to just start over by escaping to another reality. Although global health statistics may widely show things are improving for the worlds’ most vulnerable (in terms of metrics like under-5 mortality), they fail to capture individual stories of tragedy. In the drowning propaganda of social media these stories rarely ever reach us, unless of course a minimum threshold of death and destruction is met to make it interesting (think 300 000 dead during the 2010 earthquake in Haiti).

Anyone that has worked in resource poor settings realizes quickly that a fundamental problem is the absolute lack of lifesaving technologies – some of which have existed for more than half a century (for instance the mechanical ventilator or ‘breathing machine’ for patients with respiratory failure). Another major factor is the limited skill set of local providers (we face the same deficit of specialists in undeserved parts of the United States). All of this leads to astonishingly high levels of horrific endings for people that have little joy to begin with. As a physician, it is never any less jarring to face a family member when their loved dies, or to hear statements escape lips such as ‘she lived a long life’ referencing 40-year olds.

Recently, I walked into the ER and saw a Nepali health assistant working on a 11-year old boy who had fallen fifteen feet (out of a tree apparently). By the time I saw him. his pupils were dilated and barely reactive to light, and his breathing was getting worse. The tremendous coordinated response we enjoy in the U.S. is not the norm in most parts of the world- from the ambulance actually showing up, the ER providers waiting, and the trauma team of surgeons on call. Were the boy not in rural Nepal he may have had access to a stat CT-scan allowing 3D visualization of his skull and brain. In reality, it took the family half a day to travel to the hospital. After this, the patient received a thorough neurological exam by our team (a group of generalists) and xrays of his C-spine and shattered left leg. What followed was debate among our team as to whether there was any ‘point’ in sending him for the grueling 12 hour jeep ride to the next hospital where there was a CT scanner (yet no Neurosurgeon to do anything about whatever catastrophe resulted inside his head). Given his clinical condition, he wouldn’t have survived the journey anyway.

Things will not change by themselves. We must have greater aspirations in healthcare delivery in impossible places, and strive to augment vaccinations, antibiotics and preventative measures such as mosquito nets with a focus on modern marvels that can safe life and limb. The knee jerk response to investing in healthcare in undeserved areas is often ‘we can’t afford to pay for it,’ or in other words to label it unrealistic. Yet consider the world we live in now where ‘poor people’ who barely have access to safe water or a toilet may in fact carry cell phones. This dichotomy has shaped aspirations of companies like Internet.org (Facebook) that think it more important to bring free internet to the bottom billion than free healthcare. They would be wise in worrying less about creating customers, and doing more to keep existing ones alive. Every young person that dies due to lack of access to healthcare sends a powerful message to our fellow human beings- that some lives really do matter less than others.