26 April 2010

Truly remarkable people

In my previous posting, I reported on the desperate lack of medical care some countries face. I would like to offer some balance by recognizing some inspiring people I’ve encountered in these dismal medical circumstances.

I consider myself extremely fortunate to have been assigned to Kabul in 2003-04. The capital of Afghanistan was safer then, and I was able to network with NATO medical providers—all military—as well as some Afghan medical personnel. Since then, the security situation in Kabul has deteriorated and my successors have been confined to the embassy compound. As a result, they’ve missed excellent opportunities to meet some truly remarkable people.

Dr. Farid was educated in England during the Soviet war in Afghanistan. A man of good sense would have stayed in England and forged a comfortable life for himself. Why come back to a country that was embroiled in war, had a failed medical system and offered nothing but hard work, disappointment, frustration and poor financial return on his education?

But Farid is a rare man, and return he did. He stayed through the end of the war and remained when the Taliban came. He stayed because his people needed medical care and most doctors were not staying. He had a ramshackle clinic in Kabul that would make most Americans flee just at the sight of it. But inside the clinic were other Afghan doctors he had recruited who believed as he did. These doctors had gone abroad for solid educations, but had returned to Afghanistan to do the best they could to help the helpless.

Farid was a happy man, but he fully realized the sacrifices he had made. When I asked him if any of his six children would follow him into medicine, he shook his head and said they all recognized what a hard life it had been and wanted something better for themselves and their families.

Some months ago, I spoke to an American contractor working in Kabul. He knew Farid and told me he is still hanging on, still striving to make a difference in the medical care of his community. Against all odds, he continues to hope and aspire.

Dr. Faquir Amin was an epidemiologist who never let war or evil steer him off course, either. His life’s work was fighting leishmaniasis and tuberculosis of the skin, two conditions that are endemic in Afghanistan. He particularly worried about the disfigurement of young girls, because it can make them unmarriageable. If one is illiterate, one needs a supporter, and girls must look good to get offers of marriage.

Amin’s clinic was the best of what could then be found in Afghanistan. He was fortunate to have foreign researchers who came to study these diseases, and they gave him the supplies he needed to run a good clinic. He even had solar panels on the roof to provide clean electricity for the lab computers and equipment, at a time when the only electricity available was through generators.

The U.S. Army offered him a financial grant to assist his work. Their first offer was to give him cash to purchase whatever his clinic needed. He declined the offer. No, he said, money was a responsibility and sometimes could be a temptation. He would rather tell the colonel what he needed and let her donate the items. I was standing there when he said it. She and I were amazed. Are there really people who refuse cash? Amin did.

Watching Amin was watching a man who loved people and wanted only to alleviate their suffering. His clinic treated anyone who came, free of charge. His most ardent desire was to eradicate leishmaniasis, a wholly unreasonable wish since, to do so, would require the complete elimination of the disease’s host, the sand flea. The immensity of this task was no deterrent to Amin. If he still practices, I know he continues to work toward this end, and those nasty little sand fleas better watch out.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

15 April 2010

The perfect health care system? I haven’t found it.

Even though I am an expat living in Europe, I am bombarded daily with news of the U.S. health care reform debate that seems to have our country polarized. I have seen so many other health care systems around the world that my viewpoint is probably a bit skewed from what it would be if I still practiced in America.

If there is a perfect system, I haven’t found it. My experiences vary from Guinea and Afghanistan, where there was basically no real health care available, to Mexico, where the range was from excellent to terrible, to the Czech Republic, where the care is on a par with what I would expect in the United States. I am referring to the standard of care, not the process of financing it. How health care is financed—fee for service, socialized, self-pay, etc.—is a wholly different matter, although it is a fact that if someone isn’t paying for health care in a country, it isn’t going to exist.

In Conakry, Guinea, there is one government-run hospital. The hospital is surrounded by a high wall with an iron gate. A patient who comes to the hospital must first pay an entrance fee of a few francs. No francs, no entrance—regardless of the seriousness of the illness or injury. Once inside, the patient will be seen by a physician and, perhaps, be assigned to a bed. The bed will have no sheets, no mattress. If the patient needs these things, the family must bring them. Likewise, if the patient requires any medication or supplies, including surgical supplies, the family must go to a local pharmacy and purchase them and bring them back to the hospital. The hospital carries no medications and no supplies. Not even a Band-Aid.

The patient will be charged a daily rate to cover the “overhead” of the hospital. If he can’t pay each and every day, he will be removed from the hospital. The same is true for the physician’s fee. Physicians must be paid in advance or they will not render services, as they are not paid by the government. This is also true of private clinics and medical offices available throughout the city. Either pay up front or forfeit services. This was the system that was in place when I left Guinea in 2003. If it has changed, it has only been for the worse, as the country has spiraled downward into instability.

Afghanistan’s medical system was decimated by 25 years of war. While I was posted to Kabul, various NGOs, as well as the Ministry of Health, were trying to put together rudimentary care, at least in the capital. My most poignant memory is of one day in 2004 when I learned that 17 mothers or babies had died during childbirth at a maternity hospital in Kabul. These lives were lost because there were not enough personnel at the hospital to take care of the delivering mothers. There was no system of organization at that time and, for whatever reason, most medical personnel assigned to work that day didn’t come. There were no phone lines, and mobile phones were still a rarity, so staff couldn’t alert the hospital that they wouldn’t be there and the hospital couldn’t call in replacements. At that time, Afghanistan had the highest maternal/child mortality rate in the world, so, because of a poor communication system, those 17 lives added to the dismal statistics.

I left Afghanistan in 2004 and spent a couple of months in Sierra Leone, which ended a 10-year civil war in 2001. They, too, had been stripped of a medical system that was insufficient to begin with. In fact, the only hospital in Freetown, the capital, was vacant and shuttered. The government simply had no money for medical care. A few physicians had trickled back into the country after the war and opened offices, but they were only able to provide basic services. Medications and supplies had to be imported, and sources were not reliable. As in Guinea and Afghanistan, severe lack of medical care was a bitter fact of life. I do not know actual statistics, but I feel confident in saying there are many more people in the world who have little or no modern medical care available to them than there are those who do and, while I agree the American system needs tweaking, I’m still very grateful we have it.

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.

05 April 2010

Too much of a good thing

Unfortunately, the spring equinox did not bring warm weather to Prague, but we are having sunny days and there is no more snow, so I’m quite happy. It is windy and there are scattered showers. I’m not very fond of wet, windy and cold weather but, if the sun shines, it is tolerable, and I was so ready for sun.

Even if the weather is not cooperating, there are plenty of other signs that spring is in the air. Europeans are known for being great lovers of dogs, and the sidewalks have suddenly come alive with dog walkers. The downside is that not all dog owners are responsible, and I have to watch my feet as carefully now as I did when ice was on the sidewalks. It also makes me wonder where all these dogs were during the winter months?

The sidewalks have become treacherous for another reason, too. Preschool kids are out en masse on their wheeled toys, and most moms are less than attentive about where the kids are going or whom they are running over. I literally had to jump sideways this week when a tot whirled his vehicle around, right into my path. It was jump or fall right over him, and I was pretty sure hitting the cobblestones would do me a lot more damage than it would him. I hollered, “Prosim!” (please), which his mother totally ignored as she walked right past me and shooed him forward.

The local eateries have put cafĂ© tables out on the sidewalks, and the street and park benches are full of people soaking up the sun. A few crocuses are peeking their heads through the barren ground. The park behind my apartment has suddenly burst with activity as people enjoy the outdoors. This includes the young—and not so young—lovers, who seem to be on every street corner and doorway, and in the back of each tram. They are, as my dad would have said, “Makin’ whoopee!” I’m no prude but I ask you, Is it safe to make out on an escalator in a department store?

But the biggest change—one I’m fairly sure portends the first thing I won’t like about living in Prague—is the throngs of tourists. There were tourists when I arrived in October and there were lots of them over the Christmas holidays, but now. Oh my, are there tourists! They are everywhere, even on my street, which really isn’t a tourist area at all. On any given day, I wonder if Italy or Spain has closed their doors, because I’m reasonably sure all the Italians and the Spanish are in Prague.

Walking home after work has become a challenge, because the sidewalks are filled with strolling people who obviously have all the time in the world and believe they’ve rented the pavement for the day. The tourist areas of the old city are impossible to maneuver, as I discovered this past Friday when it took me 45 minutes to make a 20-minute walk to my dentist’s office. Local colleagues tell me
that every Praguer who is able to do so leaves Prague in August, because vacationing Germans flood the city. I’ve already started perusing the city map to plan which areas of the suburbs I’ll be discovering for the next six months, as I endeavor to stay clear of the maddening crowds.

Ah Prague, the better to know ye!

For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.