Borders

When I first heard the news, it was just one more piece to add to the pile that was adding up to a bad day. It wasn't until I sat down about an hour later that I realized just how hopeless things had just gotten, what the implications of this new development were going to be.

They say that one of the perks of being in medicine is that you and your job are relatively immune to the ebbs and tides of the world economy. Turns out, patients aren't. With the recent worldwide economic meltdown, hospital endowments have taken a big hit, and the one that we depend on for advanced imaging, chemotherapy, complicated cardiac surgery, and other methods of medical management far beyond what we can muster at our public hospital in Lesotho had found itself in a financial crisis. A memo had been circulated to staff, and in hushed tones, a doctor on the other line, the one who I would consider my go to person for times when I'm in over my head, a woman who I am convinced has her spot in heaven well secured, whispered to me the situation. No, they wouldn't be able to do a CT for the child with presumed TB meningitis. No, they couldn't see the child with obstructive jaundice with a liver the size of a basketball. No, evaluation of the child with chronic lung disease was just out of the question.

I've never met the woman before, but her thick Afrikaans accent betrays a mountain of compassion, the sound of an older woman who's life and commitment to children are inseparable. She uttered profuse apologies on behalf of people who had made decisions she would never have agreed with. She knew this spelled a grim fate for dozens of those admitted to our wards.

I spent all of last week on the phone with physicians of various pediatric subspecialities. I asked them how they would manage patients that were in my charge. Each offered recommendations, and each offered regret that those recommendations were the best they had to offer. Not a single one agreed with what was unfolding, each one's hands tied just as mine.

I'm starting to understand what it might feel like to live in a Mexican border town. When your lot in life is decided by a line that separates you from one of the wealthiest countries in the world. When your child doesn't stand a chance because he doesn't have access to simple measures that can make all the difference.

I can't tell you how angry I am that I have almost half a dozen children in my charge who are dying from meningitis. They're infected by bacteria that we have vaccines to in the states: H. Influenza and Strep. Pneumonia. By the age of two, every child in the states is mandated to have a series of shots that provide protection against these insidious bugs. Here in Lesotho and in the developing world, it turns out these particular vaccines are too expensive. So instead I sit there and watch as brains literally melt away. And now with the loss of our referral center in South Africa, there's even less recourse for these children. When they get so sick that they're necks arch back, they lose control of their motor function, their ability to swallow, I have nowhere to send them. So instead I read. I call up other docs. I cross my fingers and pray. It's made me a better doctor. It's put my back up against a wall, forcing me to fight my way out. But it takes its toll when one after another slips between your grip. And they keep coming, sick ones to replace the the sick, the dying coming to replace the dead.

This weekend, while I was rounding on the wards, I bumped into a young mother who was crying in the family room. She was barely 18 and her child had been admitted for an acute case of gastro: diarrhea and dehydration, one of top three killers of children in the developing world. Her child had shown promise shortly after admission and within days had recovered his original weight, his diarrhea resolving just a couple days afterwards. But she had no money to pay her hospital bill and no one that she could contact for the needed funds. So she sat on the hospital wards for an entire week waiting for a solution.

The past week I had been scrambling to cover the wards on my own, and when her child recovered, I let the medical officers follow him, thereby allowing me to focus on the sicker kids. It was mentioned to me on more than one occasion that she was waiting for money to come through, and then she would be discharged. When I stopped by on Friday to check on her and her child, she mentioned he had a cough that had just recently developed. When I finally made it to the bedside of her child this past Sunday, I noticed it was empty. Bracing myself for the inevitable, remembering the sight of her crying in the empty room just hours before, I turned to the english speaking mother next to me and asked what happened.

Her child had passed away that morning from sudden respiratory distress. Without warning her child started gasping for air and just hours later, his lungs gave out. I thought back to the cough, to any possible sign that would have signaled this fate. Nothing came to mind.

The english speaking mother of the child in the next bed added that she still remained here because she still didnt have to funds to pay the hospital or for transportation home. Realizing that I had failed her in what felt like every conceivable way, I opened my wallet and pulled out a 20Maluti bill, the equivalent of two dollars. As I reached to hand it to her, I realized with horror what I was doing. I was trying to assuage my guilt and buy her forgiveness with two US dollars. And even though I made it a point to admit fault to this mother and make it clear that this in no way was supposed absolve us of our error, I think we both knew that I was trying to make myself feel a little better, maybe a little less helpless.

I walked back to the nurses station, grabbed the chart with the tell tale R.I.P. at the top, and flipped through to the final note. I amended it to say that the child had expired suddenly, likely of complications of TB. In doing so, I bought the mother an exemption, a listing of one of four diagnoses for which a patient's hospital bill is waived. I lied through my teeth to get that exemption, I cheated the hospital and the health care system out of a bit of cash, a health care system that is barely surviving.

There are speculations that the hospital in Bloemfontein pulled its support because the country of Lesotho had been delinquent in payment of its bills. As part of an agreement to have our patients seen in South African hospitals, the Lesotho government pays a nominal fee as a measure of good faith for each patient, thereby helping to offset the costs in some small way. But this country has yet to pay off the one CT scanner it had installed in the public hospital, and now that it is broken, the manufacturer refuses to send anyone to repair it given that the original bill was never settled. There's debt piled upon debt, and with one health crisis after another, it's hard to see an end, or rather, where exactly to start. I don't blame the Bloemfontein hospital anymore than I blame our own hospitals and health care system for turning away sick patients whose only hope rests in our hands.

I admit I am naive. But it still shocks me that at the end of the day, health outcomes are still dictated by money. Whether it's here or in the states, your lot is ultimately decided by your paycheck. And whether we like it or not, in accepting this, we are putting a price on life. When we accept that care is governed by financial resources, we have compromised our commitment to our core values of "life, liberty, and the pursuit of happiness." You can't claim that all men are created equal if you let some die of disease where others are spared. Back home it's not so overt. The casualties aren't quite so high, so it's easier to overlook. But there's ample research to show that health outcomes are drastically different based on socioeconomic status. If nothing else, I'm thankful for the opportunity to know first hand how the rest of the world scrapes by, to feel what it's like to be on the other side of the fence, to watch a person lose to a disease because they lived two miles in on the wrong side of the border.