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.

Unpacking history

Today is moving-in day for me. I arrived in Prague in October but my HHE (household effects) were just delivered. I had a much smaller shipment that arrived from Islamabad in October, so I’ve been perfectly content living with what I have, and I have dreaded this day for several months now. I need to give you the background on the problem.

Allow me to introduce you to one of the oddities of Foreign Service life. We move—a lot! Our standard tours are one to three years, depending on the difficulty of the location. While our housing is provided, and almost always furnished, personal items, household goods, kitchenware, books, etc. move with us. Some posts are in areas where standard goods are difficult, if not downright impossible, to buy. If we are moving to one of those “hardship” posts, we are also granted a consumables allowance, which is an additional weight to use for products we will need while we are at that post and are not likely to find locally.

In 2001, I transferred to Conakry, Guinea in West Africa. Conakry is one of those “hardship” posts where a consumables allowance is essential. Guinea is a country incredibly rich in resources with a long-standing corrupt government that has kept the people in abject poverty. Fortunately, people don’t usually starve there because food grows abundantly, but the people are starved for everything else. As a result, goods and services are largely unavailable.

I was supposed to be in Conakry until 2004 and I brought with me ample goods to see me through. I’ve learned that I do quite well on local food, so most of my consumables are things such as paper products and cleaning supplies. One can really tell a lot about a person’s preferences from seeing what is chosen for consumables. Let your imagination be your guide: disposable diapers, wine and beer, ethnic foods, various canned goods, etc. For me, it is American paper products. They can’t be beat! If you have ever used non-American toilet paper, you know what I mean.

Unexpectedly, I was offered a move to Kabul, Afghanistan for the spring of 2003, more than a year before I was supposed to leave Guinea. I jumped at the opportunity and began the preparation of moving. But there was a catch. Housing in Kabul consisted of a 17-foot by 8-foot metal shipping container, and I was only allowed to ship 500 pounds of goods and bring two suitcases. So everything I had in Guinea that was non-perishable was put into storage for me by the Department of State.

My plan was to do the one-year tour in Kabul and then go to another regular post, but again I was offered my dream job—worldwide rover. My things stayed in storage for the second and third year while I worked temporarily in nine different locations, filling in staffing gaps. In fact, the things I had shipped to Kabul were now in storage, too, as I was down to two suitcases—period!

As providence would have it, for my next posting I chose Islamabad, again one of those limited-household-effects posts, and all I was able to move was the stored goods from Kabul. I stayed in that one-year post for three years! This brings me to today. This morning the belongings that have been stored since 2003 were delivered to my apartment.

I have been opening boxes all day, discarding things I wondered why I packed at all, trying to find a place in my limited storage space for other things I know I don’t need. I’m even getting nostalgic over a few items. When I opened a box filled with dinnerware my son gave me years ago, I choked up. And when I came across a couple of items that had belonged to my daughter, I sat down for a good cry. Perhaps nearly seven years of not having my real life with me was too long. I need reminders of my history to reassure me and help me remember who I really am and where I came from, not just things that chronicle where I’ve been.

Some of the boxes have been real surprises with contents I actually don’t remember at all. Several times today I have said, to no one present, “Where did this come from?” Fortunately, I like most of what I’ve found.

And then I came upon the consumables. I won’t bore you with the details, but I will tell you this. For the rest of my life, I will never again have to buy paper towels.

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