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Sick in America, Aching for Africa

Posted by Administrator on February 15, 2012

Adam Nadel/Malaria Consortium

Adam Nadel/Malaria Consortium

CHICAGO — I came down with my first African disease in America. It happened after I traveled to Nigeria last April to witness my country elect a new government. I landed with notebooks and questions, but not antimalarial medication. I had been more prudent on dozens of prior stays, but, I thought, no matter: I had already been running around the continent for months with no mishaps. After three rounds of free and fair voting, I returned to my apartment in Nairobi, buoyant about democracy in Africa.

Two weeks later, during a visit to the United States for Mother’s Day, I found myself flat on a gurney, shuddering in a hallway in a bleached Chicago hospital. Fever, chills, muscle pain, dehydration: I knew I had malaria. The mosquito-borne parasite must have been brewing in my bloodstream for weeks.

Malaria is a nasty disease and a grave threat to life and to productivity, particularly in Africa. The parasite killed about 781,000 people in 2009, mostly south of the Sahara, and is properly called a scourge of the 108 countries where it’s endemic. But the disease can be prevented by taking the prophylaxis I forgot or simply by sleeping under a mosquito net.

Upon arriving at the Chicago hospital, I told every doctor in sight I had malaria. They needed a lot of convincing. Over the next two days, I underwent blood cultures to check for typhoid, a spinal tap to screen for meningitis, and lengthy interviews with the rarely roused tropical-disease specialist. Three bags of antibiotics hovered over two separate IVs in my right arm. Curious doctors hovered over them. Feverish and miserable, I found myself wishing I had fallen ill in Africa — anywhere where the disease is so prevalent as to be unmistakable. My nurse — a Nigerian, coincidentally — shook her head at the stream of orders and ointments coming into my room. “It’s just malaria,” she laughed with me.

Her laugh, along with the hospital’s final bill — almost $16,000, not fully covered by insurance — suggested that I may have been better off in a different cultural context. In Kenya, my home at the time, doctors treat malaria as a repeat player, not an exotic case study. A single prick of blood is enough to diagnose the illness; a spinal tap is out of the question. Thanks to subsidies from drug makers, the three-day sequence of pills used to treat the disease comes over-the-counter for less than one dollar.

The differential in cost and convenience is a result of both differing resources and differing attitudes toward risk. I’ve visited my share of hospitals and clinics across Africa, and I’ll venture to say that patients and doctors there are less cautious. Where official safety nets don’t exist, tolerance for illness and injury is high. Insurance policies are scarce. Resilience is assumed. Many hospitals are strictly pay as you go. It’s counterintuitive, but this “no frills” approach can improve outcomes and reduce waste. Absent expensive imaging equipment, doctors keep up their diagnostic instincts. Basic tasks are shifted to nurses or community health workers.

In the United States, by contrast, the most relevant thing about health care is that it does too little and costs too much: standing alone, the U.S. healthcare industry would be the fifth-largest economy in the world. Shannon Brownlee, a colleague at the New America Foundation who wrote a book about overtreatment in the United States, says that a Western sense of advancement is the result of “interventions in data management, consumer empowerment, and awareness, but not necessarily in retail care.” Doctors can outsource diagnosis to machines. Patients armed with Web research can insist on unnecessary procedures. The cost of such decisions is often mystifying to patients, and may ultimately break the bank.

I don’t wish to romanticize health systems in Africa. Africa’s advantage might not be so for a serious heart condition, or a car accident, or a mysteriously crying infant. Inadequate access to care is a real problem, especially outside of major cities. Still, if Americans have come to want it all, African patients tend to expect less, and the result may be greater efficiency.

Where’s the middle ground? Practitioners in rich and poor countries alike are looking for cheaper diagnostics and leaner models for delivering care: less of doing anything that’s possible, more of doing everything that’s reasonable. If there is a sweet spot, I’d wager that unfussy African health systems will get to it first.

Source: http://latitude.blogs.nytimes.com/2011/11/04/sick-in-america-aching-for-africa/

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12 Responses to “Sick in America, Aching for Africa”

  1. Malaria is a tropical disease and perhaps american doctors, may be not familiar with. I came from area called kijabe and doctors from america come regulary as volunteer team are helped by nurses who can tell where patient is suffering from by just explaining the symptoms even before blood samples are screened in laboratory . In kenya people who come from maralia prone areas don,t waste their time going to hospital they know when malaria is about to strike and take medicine others take herbal cures. The thing is medicare in america is quite expensive whereas I don,t think is the best in the world, recently a man who had kidney transplant was charged more than fifty thousands dollars , It okay since we can,t compare life with money this is so much money and not many people mighty be lucky to get such money. In india kidney transplant are done with less money may be quota fraction

    • Skinny said

      Njuguna,

      Healthcare in the US is not about curing the illness. It is about puting a bandade on it so that you keep coming back. That is they prescribe one drug and then another for take care of the side effects of the initial drug. Back home, you go in to the doctor (if you can afford it) or go the natural route. For things like malaria which may be common to you and me, it is as simple as taking quinine and resting. I just pray that as our hospitals at home get advanced, the health care practices do not become like the one in the US.

      • Jane said

        Thats not true at all.Why do people in Kenya die with diseases that are easily curable.Healthcare is expensive in America but remember they have to pay malpractice insurance.The reason they do all this tests is to make sure that they get the right diagnosis otherwise they will be sued.

      • wangari said

        healthcare in the usa is expensive but outstanding. in fact it is with sadness when i remember how i used to go to the hospital while i was back home in Kenya, one time i was so sick but had to wait all day to see a doctor, even then he never showed up and i had to go home sick. here in america people are living longer because they are getting quality care.

  2. ITHAVETHI. said

    I was down with malaria the first day I landed in America. After being rushed to the doctors office for treatment, and as confused as I was, they started doing some bloodwork, EKG and other tests even after insisted that It was malaria. Anyway, I was diagnized with flu. Without health insurance, and withou a job and nothing, they adamantly sent me a $750 medical bill. I was however able to receive FANCIDA from home a day later.
    Ten years later, I now understand why so many unnecessary tests are required even for a minor ailment: greed. Like our auto mechanics back home who can detect a problem from your car by listening to the sound of your car engine, our Kenyan doctors would ONLY conduct tests if they sense they is something more than you are complaining for.
    Simaanishi kuwa uchunguzi wa kitaalam wanaofanya ni bure bilashi. Nisemacho ni kwamba, huo ni uzembe wa kutopenda kutumia utaalam wao kugundua ni kipi kinachomuathiri mgonjwa. Utegemeaji wa mashini zikiwemo zile za XRAY ni sawa, lakini utaona kwa mara nyingi, zinazotumiwa kiholela holela kama kisingizzio tu cha kungoza ada kwenye malipo ya hospitali.
    Ni kweli kwamba magonjwa kama malaria ambayo ni nadra kuyapata hapa Marekani, huwatatiza sana madaktari na mwishowe huwa ni bahati na sibu ambayo yaweza kuhatarisha maisha ya mgonjwa.

    • Wanjiku (mama Njoki) said

      The last time i checked, healthcare involves science and there are no guess works in science. It is the only field where it is either 100% or its not or may be incorrect. Never gamble with your health life. Afya huwezi fananisha na gari bana. I’d rather they do a “million ” diagnostics to pinpoint what i am suffering from than being give quinine while i am constipating!lol…(typical of Kenyan physicians…

  3. Dr. Otieno A.A said

    For all those who care to read. I have worked in the kenyan health system. Every doctor in the world is trained on how to arrive at a diagnosis. It is a process that only those who are trained can understand. A doctor is trained that taking a good history from a patient provides him/her with about 90% accuracy on diagnosis. The remaining 10% comes from physical examination and tests. What i am trying to say is that a good doctor should know what is wrong with you just by talking to you. The examination and tests are just to confirm what he already suspects. Doctors do learn epidemiology and therefore have knowledge about distribution of disease states! As a doctor you put more emphasis on what you encounter on a daily basis. It is for that reason that most of you feel that the doctors in kenya can diagnose malaria better than the ones in the US. But look at it this way, the doctors in the US will be able to pick up signs and symptoms of a myocardial infarction much quicker than the counterpart in kenya; reason being that they do see alot more cases of myocardial infarction than the ones in kenya. The other difference is also the fact that in the developed world like the US we do have alot of sub-specialization. For example, you will meet a doctor specialized in Infectious Diseases but with more bias to either TB, HIV or malaria; whereas in Kenya, doctor with specialization in Internal Medicine (this is broad) is the one you are likely to meet at your local district or provincial hospital; if you wanna see the ones with sub-specialization then you have to travel to KNH or Moi hosp. Of note is also that we were trained that malaria is endemic in certain regions of kenya – Nyanza, Western and Coast. It would be therefore follow that it might take a little bit of more time for a doctor who has only practiced in Central province all his life to come up with a diagnosis of malaria or sickle cell disease; these conditions are rare in those regions!! Also note that the treatment approach in the US is very different from the one in Kenya. Yes they do alot of tests in the US; they are not unnecessary as some of you may think. Most diseases present with the same signs and symptoms, and therefore the only way to eliminate others is by performing these tests. Like i said earlier, taking a good history from a patient helps you come up with a list of possible diagnosis also known as differential diagnosis in the medical world. You have to eliminate each one of them till you narrow it down to 1 or 2 conditions. And this brings me to another treatment approach in the US. In the US, they try narrow treatment to a specific disease, whereas in kenya we kind of try to hit all the suspect diseases due to lack of equipment for tests. If one has bacterial infection of the throat in the US, your doctor may perform culture/sensitivity tests and then give you an antibiotic specific to the organism causing infection; the same scenario in kenya, your doctor will try to use a broad-spectrum antibiotic that would cover or hit all the organisms that could cause throat infection. The problem with the kenyan approach is that then we start getting cases of bacterial resistance. Latter is worsened by the fact that patients can just walk into a pharmacy/chemist and purchase antimalarials and antibiotics without prescriptions. One other example that i would like to give in conclusion is: Malaria Vs Flu. How would you know that it is a case of malaria for sure? Based on history of presentation, both of these conditions present with the same signs and symptoms – fever, chills, rigors, headache, nausea and vomiting. History alone tells us that the differentiating factor here is a cough. In flu, there is a cough. However, i would only know the definitive answer by performing a blood test for malaria. Also note that Typhoid fever presents the same as the above two, therefore i would also perform a widal test (for typhoid) and stool culture/sensitivity (to rule out typhoid fever). So many people in Kenya died of typhoid fever (intestinal perforation) just becuase the clinician was busy treating malaria and did not do any tests to rule out typhoid fever on his first encounter with the patient. Alot others were lucky and ended up for surgery a few days following unresponsive treatment for malaria; this is surgery/laparatomy that could have been avoided if tests were done early enough. In the US, protocols are followed to the letter/book; how many people in kenya care whether a patient is on recommended therapy post-MI (after a heart-attack)? How many people care whether a Diabetic patient is on an ACE-Inhibitor for kidney protection? There is really alot that we could talk about, but there is just not enough time in here. Much more later. Forgive me if this was too long, but i do feel that we need to have better healthcare in kenya – Linda-afya as the docs in kenya call it. They started well, and all we need to do is to ask our folks to support them and put the politicians in check.

    • wangari said

      then if you know all that you ought to do better!

      • Jane said

        I agree with you 100%.Its important to get the the right diagnosis.

      • Dr. Otieno A.A said

        They would like to do better (me included), but again it boils down to poverty and politics in the kenyan situation. For starters, these essential medications are not available in the government institutions for the common mwanainchi. The doctor will give the common mwanainchi a prescription for lets say a case of post-MI who now needs to be on maintenance medications – Aspirin, metoprolol, lisinopril and artovastatin. Tell me for how long will this patient continue to buy these essential medications that he/she needs to prevent a future heart-attack or even stroke? The common kenyan cannot simply afford!! The kenyan health system is similar to the one in UK (National Health Service) where the government is supposed to provide care for the citizens by making the medications and equipment available at cheaper affordable rates or even better free!! If only the docs can succeed in getting everything they listed on their 12-point return to work formula following the recent strike, then all these can be done and achieved. The doctors in kenya have the best training/knowledge, but equipment and medications are lacking in government hospitals. May be i should rephrase my statement, “who cares….”. The doctor cares, but the government does not!! That diabetic who seriously needs his/her ACE-Inhibitor for renal protection cannot simply afford to buy it every month if not assisted by the kenyan government!! Remember, in the US patients can afford to buy these medications or have tests done simply because they carry insurances who pays for these services. And if they do not, then the federal government or the State where one resides provides medicare or medicaid to cover all these at no cost to the patient. A medicaid patient pays $0 to visit a doctor for consultation/treatment; they pay $0 for the tests and medications; and all these are available as soon as one is born, on day 1 of life; how sweet!! Medicaid also gives doctors bonuses so long as they can keep these patients healthy and not visit the Emergency Room!! Any doctor whose patients to not visit the ER for a given duration gets bonuses – coz ER services are expensive to the insurance. So that is an incentive to ensure that your patients enjoy the best health!! Keep them healthy, and keep medicaid smiling all the way!!!

  4. Dr. Otieno A.A said

    Oh, i forgot. Do you have a relative in kenya suffering from hypertension? Do they rely on the government hospitals for treatment? If the answer is yes, then i would like you to do a simple survey for me. Ask them what medication(s) they are using to control the blood pressure. Then check the same with another kenyan in a different location, then compare. Compare Nyanza, Central, Coast, Rift valley etc. Chances are that they are all on the same kind of medication. Back then it used to be Aldomet; now i do not know. My point is, different people respond differently to same medication. Studies show that certain races or groups of people may respond to a certain class of anti-hypertensives better than others. So what is the point of putting everyone in the country on the same med? Can’t the government expand the formulary in hospitals and keep at least 2 medications in each class of anti-hypertensives? Just for your information there are about 8 different classes of anti-hypertensives!!
    It is not news to you that everytime a politician is sick they run to foreign countries for treatment. A case in point – both ministers currently in charge of ministry of health have been going abroad for treatment. They do not have faith in the same system that they set up for kenyans. Why don’t they have faith? They would rather get treated in South Africa, UK or even US. Why can’t they provide everything that everyone in the country need so that they themselves can attend and be treated at KNH, Nyeri prov hosp or even New Nyanza prov hosp? A certain Dr Kizito from KEMRI recently wrote a good article in the standard newspaper about African leaders going for treatment abroad and not using their own country’s health system!! If you have a chance, google it and read it.

  5. Dr. Otieno A.A said

    Remember i talked about specialization and sub-specialization? Doctors in Kenya know something about everything. Whereas doctors in US/Europe know everything about something! Confusing, eh? Pay a visit to a dr in kenya; he/she will have an idea of what to do with you whether you malaria, heart-attack, a fracture or even stroke. Pay a visit to a dr in any one of these developed countries; let’s say he/she is your primary physician and you show up with a fracture, stroke or even burns -he/she will refer you to a specialist; they are afraid to touch what does not belong to them; may be for fear of law-suits! Ladies will agree with me on this – how many of you ever went to the outpatient/casualty and the dr or even the clinical officer on duty performed a vaginal exam on you? It was normal then. Now, in the US it is almost an exclusive area for the Obs/Gyn dr only; it will be unsual for a ER doc to perform that kind of exam. Even while at the ER they will always call in a Gyn dr as you wait. Big difference, eh!!

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