Where's the billing department?

On a recent trip to The Indus Hospital in Karachi, I was once again amazed by the extraordinary achievement of a few ordinary people. This is a free hospital completely supported by donations. No one who is seen and treated at this hospital is charged. If a patient wishes to donate a sum of money, it is accepted but they are not informed what their treatment might have cost in a different institution, and there is absolutely no expectation of a donation.

You might think this is a small, neighborhood operation, but you would be wrong. The hospital staff treats upwards of 300,000 outpatients per year and has admissions of about 11,000. And free doesn’t mean low tech, either. Indus offers invasive cardiology, endoscopy, lithotripsy, hemodialysis and all radiology services except MRI, and that will be in service before the end of this year.

Impressed? Well, there is another really amazing fact. Indus is 100 percent paperless! All records and reports—all business—are electronic. Of course, since they have no billing department—can you imagine?—a large need for paper is eliminated right from the start. When one visits a hospital ward at Indus, the robotic medication cart moving down the hall with monitor and keyboard on top should be a quick tipoff. All medications are ordered, tracked and recorded electronically. Every patient service is handled the same way.

How did this amazing institution come to be? A group of like-minded medical and business people decided it was needed and would be so—and now it is. The goal was free but excellent treatment for the poor, and Indus provides both.

I visited Indus because I will be screening our local staff for tuberculosis this fall. We do this on a four-year cycle, because TB is endemic in Pakistan, and it is important to screen for possible infection and to ensure that people are properly treated. The government of Pakistan has a TB treatment program, and the expert resources in the Karachi area belong to The Indus Hospital. My objective was to arrange a referral path, in case our screening indicated any employee needed further testing and, possibly, treatment.

After my tour of the main hospital, I was taken to the TB screening and treatment facility, which is in a separate space from the hospital proper. I really hate to overuse the term “amazed” but, once again, I was. This purpose-built building is ingeniously designed to accomplish infection control.

Karachi’s climate alternates between hot and hotter and there is, on average, 7 inches of rainfall per year. That is only 4.5 inches more than Death Valley’s annual average, so this climate is hot and dry. The TB treatment pavilion uses an open-air concept in which shade coverings that resemble boat sails are positioned horizontally to the ground. Every six feet, a bidirectional fan moves air toward the ground, air that is subsequently circulated up and out through the sails. Because the tubercule bacilli are lighter than air, any that might be exhaled from an infected patient are swept up and out with this efficient ventilation system, thus dispersing the bacilli and rendering them ineffective. In Karachi’s hot, dry climate, this ingeniously designed system is very cost effective. As an added safety factor, patients, staff and visitors all wear surgical masks to further reduce the chance of exposure.

In addition to this hospital-based TB facility, where patients are diagnosed, counseled, tested and treated, there is an extensive community support program. TB patients are given monthly food items for nutritional support, a monthly travel allowance to treatment centers, daily home visits by treatment supporters to monitor drug compliance—they utilize Directly Observed Treatment, or DOT—and to provide ongoing psychological and social support during the term of treatment. It is all without cost to the patient.

Here in Karachi, a city of 20 million in a country with an unstable economy and an average annual wage of approximately $450 per year, ordinary people have come together to do an extraordinary thing. Wow!

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

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.