10 December 2019

The mother lounged on the thin, vinyl-covered mattress covering the wooden platform--a bed in the pediatrics ward. Her 4-year old lying beside her appeared fatigued and ambivalent. The nursing student presented the case, reading the chart slowly. Malaria--positive test in Kelo (the nearest hospital an hour or three away to the West by motorcycle taxi). Quinine had been ordered, but only one dose had been bought. A review of the carnet--the medical booklet that most patients faithfully bring with them to each visit--shows that they were diagnosed in Kelo, but that the mother requested transfer to Béré because of concern for the cost of care. She paid a motorcycle taxi to drive her all the way here from Kelo, in hopes that we would treat her for free. The medications that I had just prescribed for her child would cost less than that motorcycle ride, at least in our pharmacy--what are these people in Kelo charging to treat malaria??

We have developed a reputation. I don't know which of our previous missionaries caused this, but somewhere along the way, they gave this hospital its reputation. Well, really L'hopital Adventiste de Béré is known throughout our part of the country--within a couple of hundred kilometers--for several things. We're known for good surgical care thanks to James and more recently Danae and her dad, as well as visiting short-term volunteer surgeons. We're known for having Nasara doctors. Sometimes patients travel from far away and demand that the "foreigner" do their consult or their ultrasound because they traveled all the way here for that purpose. Among the hospitals nearby, we're known for having surgical obstetrics and for having ultrasound and x-ray. They often refer to us when the roads will support referral. Occasionally they also refer just hoping we have something more advanced than any hospital in the region--endoscopy or ophthalmology or other specialty services which we actually don't have yet either. But this one other thing I'm discovering that we're known for is the most vexing part of our regional reputation.
We're known for caring.

We have noticed that patients from Béré and nearby have a tendency to play games with us--games like hide-the-husband. The premise of this game is that if you bring your sick child in for care, you can try to get all of your care for free if you can convince the Nasaras that there's no one in the family that can afford to buy the life-saving medications. "Oh, no, my husband is in N'djamena. I'm alone. There's no one else in my family." Then we follow up in the evening after buying the medications for the patient and find the child's father at the bedside.

Practicing medicine here can feel like chicken. How much pressure do I put on this family? Who is more concerned about you dying--you or me? Who is going to hold out longer, waiting for the other to give in and pay for the treatment? The thing is, the local population has figured out that we really don't want their kids to die--that when we believe that IV quinine for malaria or a full course of IV antibiotics for meningitis will save the patient's life and the family has exhausted their funds somewhere along the way of diagnosis and treatment, we do step in to help them out and pay for the medications ourselves. The frustrating part is that sometimes the family has the money but doesn't want to spend it on this medication or on this child. We hear all sorts of tragic explanations.

"I don't want to buy the quinine. I bought it for my older child when he was 3, and he died. This one is just going to die, too."

"I have three wives. I have too many children to afford medical care for this one."

"We just came for the free blood transfusion. We don't want to stay at the hospital for malaria treatment."

Another reason--usually unspoken, but sometimes explained by the nurses who interpret for us and occasionally stated by the patient's family member--is that if our initial treatment doesn't fix everything in a day or two, the family wants to try the traditional healer. The traditional healer does not work for free, actually may cost more than treatment in the hospital. So they save their money for him rather than spending it on Nasara medicine.
Often the barrier to paying for medical is not a lack of resources, but a lack of faith in the treatment and a lack of willingness to invest in it.

On the other hand, sometimes a family spends all they have and then also tries to give the pharmacy whatever items they have that seem most valuable to them, to borrow against them until they can come up with the money. They occasionally offer a bag of peanuts, a new piece of fabric, and if they're wealthier but still spent all they brought with them, maybe a bicycle or even a motorcycle. It's easy to want to help these patient's financially, when they've tried everything but truly don't have anything.
Actually, most of the time I'd prefer if we functioned in such a way that the family could pay a few beans or peanuts or grapefruit or a chicken and get all the care they need. But we're supposed to employ all these local employees. If I try to accept payment in beans and peanuts and distribute that to our 40-50 hospital employees as a salary, the employees won't be here long. So we could staff a whole hospital with expat missionaries who can live on altruism and some sort of income somewhere else in the world, or we can employ and train local people, and function as a local institution that has to have some income to keep itself going.

So we try to sort out the true situation of each family, which barriers are real and which are a front to convince us to swerve first, and we try to eek out a living for this hospital from a population that is employed in herding and farming and hardly has any cash.

Today, I upheld our reputation for caring too much. I paid the equivalent of less than $1 USD for the next few doses of quinine. The next morning, the patient had all of the other medications I'd prescribed, too. After I paid for a few pills, the patient's grandfather came and bought the rest.
I guess I lost a game of chicken, and about $0.50. I'm not sure what impact I had overall on our reputation. But at least for the moment, I feel like everybody won.