You might have read ALIVE BUT NOT KICKING PART –1 in this
blog. I am recovering day by day but
the whole experience turned out to be much bigger than what I described in Part
1. I wrote the part 2 of the story more than a week ago in order to share the
experience with my colleagues here. Now I
am posting it here just to share some of
these learnings with you all, in the hope that it may prove beneficial to some
people at some point since the situation is very similar in most of South Asia.
22 April, 2010
Yesterday I was finally discharged from the third and
hopefully final hospital. They would liberate me from the plaster
packaging this evening and thereby restore limited mobility again. Until now I
had been completely immobilized and bedridden with a stiff packaging of plaster
of Paris to let the stitches heal and the skin graft settle.
In theses 12 days since the accident (See Alive but not
kicking Part-1 below), I have seen, learnt and been through a lot. In
fact these experiences almost pale the actual accident which caused the injury
and the hospitalization. From seeing Private hospitals reaping profits out of
peoples’ misery to what felt like a near death experience due to an allergic
reaction to an antibiotic injection to the realization that friends and
relatives are the biggest insurance in Asian cultures.
After the accident I spent 6 days in the Mission Hospital in
this lovely Hill town of Tansen (around 300 Kms from Ktm) thinking that
it was a small affair and I would be walking out to my work in the next few days.
However due to all the dirt that had gone into the wounds it was only after a
week of cleaning that the doctors said they were ready to do the stitching of
the knee, but they said the skin grafting to patch the burns (of third degree)
around the ankle would have to wait for another week. So I thought another week
of waiting and then several more days for healing in Tansen would be too many
days away from my work and residence. So we decided to move to Kathmandu
for the graft as well as the stitches. Thus on Thursday the 15th I
was flown to Kathmandu.
Moving to Kathmandu was rather smooth as my Danish
colleague and friend Henny was kind enough to accompany me. I was put in an
ambulance that drove me from Tansen to the Bhairhwa airport in the plains near
Lumbini. After some wait at the airport a small Beachcraft of Buddha Air flew
us to Kathmandu by dusk. At the airport my friend Jakob (Henny’s husband) was
waiting. CIWEC had sent its ambulance to pick me up. From the
airport to the CIWEC clinic was an eventless ride in the ambulance. What
unveiled after this was rather disturbing. The physical wounds on the
roads near Tansen did not pain me nearly as much as the commerce of misery that
I saw in the health facilities in Kathmandu did. It was a very educative
experience also to learn about the business going on in the name of insurance
and medical care.
The ambulance brought me to the CIWEC Clinic (Travel Medicine
Centre), which is considered rather well known among diplomatic circles, International
NGOs and foreign tourists. It is also well known for the out of the world
prices it charges for its services. Although based in one of the poorest
countries in the world their prices are set as if they were located in New
York. All services are priced in dollars and a simple consultation costs
more than USD 50.
I had hoped that at least the services would be of
international standards, but when they admitted me as an in-patient and brought
me into the cabin the first question I clearly remember asking the nurse upon
seeing the bed sheet and the blanket was ‘Are you sure the bed is not used by
another patient?’. It was a tiny room and everything looked quickly and
temporarily set up. And I had this déjà vu feeling – a vague memory which grew
stronger by the day that I had been in this tiny nose of a room (a Ladakhi
expression) once before. I think this room also functions as a regular
doctor’s consultation room and I had met one Dr David regarding my dust allergy
problem as an outpatient. So I think it had been quickly turned into an
in-patients room when the need arose. Well nothing wrong with
re-cycling of rooms or small sized rooms but just that I learnt after few days
that the bill to the insurance company would be... hold your breath (I
don’t want any more medical emergencies here)... USD 500 per night (roughly
Nrs. 40,000). This disturbed me a lot about the how the health and
insurance system worked or didn’t.
Who pays for it in the end?
Most people would say “it’s the insurance company that pays
so let them charge what they want you don’t have to pay yourself, after all
we/our organisations have paid hefty amounts to the Insurance company”.
But to me it felt that this was a trap we consumers have allowed ourselves to
be caught in and the final victims were none other than ourselves. The
insurance companies would want certain profits after they have deducted their expenses
(on the likes of CIWEC). The higher their expenses the higher they would price
the premium for their policy so that they can still have the desired profit
margins. So it’s the poor consumer finally who is caught in his own web.
The only comparison I could find for the CIWEC cabin was the
Hyatt Regency Hotel, Perhaps the most expensive five star hotel in
Kathmandu. Their website says that even their ‘Club Deluxe King’ costs
‘only’ $ 195, that too before discounts and offers. Hyatt’s highest priced
Regency Suit King cost $ 450 before discounts.
Yesterday I called CIWEC to check some facts for this
write-up, I asked them about the status of their organization. A European
sounding lady immediately said ‘We are a private facility with no support from
any government. I could not believe my ears, imagine Nepal’s government
subsidizing half their $ 500 per night bills. Then she passed me to the
Administrator Ms Shashi and I was even more surprised to hear her say,
‘We are a private clinic established in the eighties after a Canadian
irrigation project called CIWEC. We are using CIWEC as a brand name but I don’t
know the full form, it is something like Canadian Irrigation project’. It
was rather confusing to see that the stationery they use has two other names –
Travel Medicine Centre and Menlha Nursing Home for the same facility.
When I asked about the owners of the clinic the administrator said she did not
know the names of the owners except that one of the business partners was an
American.
She also clarified that the cabin for in-patients cost $ 300
and the remaining $ 200 was for a morning and evening visit by the
doctor. That reminded me that it also included a shared nurse who had to
puncture me twice before getting the right place to insert an IV syringe
head. She also said the reason why they were so expensive was because
they had imported medicines and equipment... and doctors I guess. However I had
seen nothing in the room that was imported or expensive, nor had I ever got any
medicine that was not Indian or Nepali during my earlier visits to this clinic,
even when the bill was never less than $ 50.
Why CIWEC?
Like other INGOS we used to avail of their services for its
staff and since the insurance Company pays and perhaps the clinic is good at
making such payments logistically simple, people did not notice the prices so
much. So it was also in the best interest of my health that the former MS Nepal
Country Director Sten Andreasen had requested CIWEC if they could handle my
treatment in Kathmandu, and they had happily agreed. So that’s how on
Thursday night I was brought into the CIWEC clinic and examined. Interestingly
it was the same Dr. David who was on duty that evening who I had seen during an
earlier consultation. He had called in a surgeon from the Government’s
(Teaching) Hospital to look at my case and do the operation. My
first feeling was of shock that even with an expensive international insurance
I was being handed over to a surgeon from the Government’s Teaching Hospital
where doctors are paid a paltry 300 USD per month. But I consoled myself
saying that there is no reason not to trust a government facility, that it may
have the best doctors with long experience. And surely Dr. Jayan
the plastic surgeon I was handed over to, turned out to be a very
pleasant and kind surgeon. Though half of me was rebelling against the idea of
this Luxury clinic taking the doctors away from the much more needy government
hospital (in most countries this would be called moonlighting and not even be
allowed, if CIWEC follows western prices why not the work ethics). It
seemed to me that the plan was to get the government surgeon do the surgery in
CIWEC clinic. However since they did not have a real Operation Theatre and
anesthesia facilities the two doctors agreed to use the Operation Theatre
facility in another private hospital called Medicare National Hospital. They
said that I could be kept there for a day after the operation and then brought
back to CIWEC for recovery. As you will read later I always felt that
this decision was taken not in the best interest of the patient. I said
to Dr David that I did not feel comfortable with this piecemeal approach to my
treatment where no one would take responsibility in case of a problem. He agreed
but said ‘Well I know it is bit disjointed but you don’t want to be sent to the
Teaching Hospital do you! There they keep you waiting for 3 months, you
wouldn’t like that would you?’ This felt like a scare tactic because anybody
would know that if an insurance company can afford CIWEC’s $ 500 room then it
can also afford the best real hospitals in Kathmandu. It still remains a
mystery why CIWEC accepted my case when they did not have the capacity.
At the Gates of Medicare Hospital
So anyway the examination and the deal was done on how I
would be handed over to the Teaching Hospital Surgeon for the operation and he
would in turn hand me over to the Medicare Hospital for immediate care
and then I might be brought back to CIWEC for recovery. I reminded Dr. David
again and again that the local cheaper hospitals require someone to be with the
patient all the time and I as a foreigner here had no one and hence
requested if CIWEC could arrange for such help so that it could be billed
to the Insurance Company. His answer to that was “Umm let’s see, why
don’t you call us when you get there and if they don’t have such help then
we’ll see what we can arrange”. Of course CIWEC should have known about the
Hospital they were transferring their patient to, still I had to remind
this American doctor that it would be too late to wait till I get there
(especially with this instrument called telephone invented for a century
now). He said ‘that was a good idea’ and seemingly left to call the other
Hospital. But then when I arrived at the Medicare Hospital what happened
was exactly what I feared. There I learnt the hard way that the Hospital
wouldn’t even let me in without a friend or relative accompanying. So
they left me in the ambulance on the road for no less than half an hour.
The Ambulance driver was on constant phone with his CIWEC bosses but nothing
seemed to move. I had my own reserve of solutions for these problems but
I wanted to check out the system for any individual in my condition. So finally
I set off my own emergency mechanism and called Henny my friend to help
me again with immediate problem, as for a help for the next few days I had
talked to this young Tharu student friend who used to help me in my house in
Bardiya two years ago. Luckily he was in Kathmandu and unemployed so he
happily agreed to come and help me as a relative in the hospital. Henny
magically reached within 15 minutes and I was admitted into the ward. At
this point I also called other expat advisors in the organisation to ask them
to find out what the procedures was in such cases, as I was equally interested
in being a Guinea pig to check how the system worked.
Friends & Relatives an Insurance System
At first the system of requiring a relative as an entry pass
for admission into hospital looked bizarre to say the least, but later I
realized that that was how the whole system in the hospital was
organized. In Nepal unlike in the west the social structure is such that
there would always be an immediate relative helping with all immediate needs
when a person is ill. This hospital uses this as an asset and in return it
enables them to cut down on staff and lower their prices. This seems to partly
explain why in many Asian countries so many people do not bother to have health
insurance. They may not have a commercial insurance but they do have a
social insurance network in the form of relatives and friends, into which they
would have invested over the years with similar support. So I could see
one reason why Medicare was so much cheaper, it was designed around this Asian
society, but I could not understand why CIWEC sent me here when they knew I did
not have relatives in Kathmandu but I did have a international commercial
insurance.
A Budget Hospital
But Medicare was a budget hospital in more ways than one. I
got a private cabin but things did not look very clean. Smriti Shrestha
who heads HR at ActionAid Nepal and is a local from Kathmandu had come to visit
and help me that evening, she said that the room looked much dirtier than other
private hospitals she had been to. She very much wanted me to move to another hospital
for recovery after the operation as she feared that I could catch infections in
such an environment.
There was an attached bathroom but it had neither a towel
nor soap. While towels were not in the budget it took 24 hours for half a soap
(literally split half) to arrive. The nurses looked stressed and did their
things very mechanically; a smile or a greeting in the morning even from my
side seemed to disturb their chain of thoughts. This changed a bit towards the
end of my stay as I kept being playful and cracking jokes at my own
expense. I learnt to remember my medicine timings as the nurses tended to
forget. Once they forgot even to remove the IV glucose drip line after
the bottle had emptied, I noticed then that blood had started mounting up. When
I called the sister to see what was happening and why, they argued back saying
that I could have also closed the flow myself. I was left speechless, I had
thought that as a valid certified patient now was my chance to get some
attention.
The system was such that the attending friend or relative
had a very active role to play in every event and that explained why they did
not accept me without a relative. Though the sisters officially called
them ‘the visitor’, the visitor had to run down to the shops below to get every
piece of medicine a doctor or nurse needed. This was true even during an
operation. That Friday evening when the operation was being conducted on my
knee and ankle, the visitors were required to wait outside the theatre to go
buy each item needed in the operation. Smriti, Henny and Jakob who kindly
played the role of the visitor during my operation told me that sitting outside
they could tell how the operation was progressing from what the doctors were
ordering. First gloves, then grafting blades and so on and in the end dressing
ointment, bandage etc. This system was perhaps designed to minimize the
handling (and pilferage) of medical supplies by the hospital and to minimize
costs for the patient but it was not free from risks if things were not well
planned in advance. At the end of the operation the surgeon needed plaster of
Paris to wrap my ankle in a fixed position but the stores nearby did not have
it, so they had to wait for some time with the patient lying on the operation
table till it came from a nearby hospital. Like a good patient (this hospital
taught the true meaning of this word) I was patiently listening to all this
from the table as only the lower half of my body was anesthetized.
After the operation we tried to move to another hospital
with better facilities and support. In this
process Jakob called CIWEC on my behalf to take their
opinion. They suggested that I could be brought back to CIWEC
clinic. It was at this point that we first asked and found out that it
would cost $ 500 per night. I saw Jakob asking twice to make sure it was
not bad phone lines that made him hear absurd amounts. Then we asked
Medicare what their charges were and found out that it was only $20 per
night. It was then that I decided I would rather stay at Medicare for the
whole 6 days than be a party to what felt like a scam. And if my
insurance is considerate then I would like them to share at least half
the savings they will make due to my sacrifice with a not-for-profit hospital
like the Mission Hospital in Tansen for the treatment of patients without
‘visitors’. Over 11 days the difference between $ 500 per night and $ 20 per
night comes to no less than $ 5,000 (means one local nurse employed for three
years).
This seemed like the end!
Ever since then I felt more relaxed and at ease with the
Medicare system and the stay felt more or less comfortable until the
midnight of 17th when a nurse came and injected my regular antibiotic
dose of Ceflaxone, suddenly my body had a strong allergic reaction to the
medicine. I felt an asthma like attack in my chest making breathing
difficult, my head felt a strange pressure inside, limbs had tingling
sensations and then there appeared a little bump on my arm. Oxygen saturation
dropped to 85% and I was put on piped oxygen. I was
definitely scared and thought those were perhaps my last moments as pumping
five ml of allergy causing stuff straight into my veins could wreak
instantaneous havoc in my system. I had also heard of death of a person I
knew due to such reaction. But most fortunately the reaction stabilised after a
point. The doctor also pumped in other anti-allergy medicines in me. Strangely
even in such an emergency the medicines had to be bought from the shop
downstairs by the ‘visitor’ when a few seconds could become the difference
between life and death. It was a mystery why my body reacted like that to
an injection that I had been taking for the last one week.
Alive and learning
Now that I am out of the Hospital I am trying to jot down
the experience. I had thought that the accident would give me a lot of time to
relax and reflect but as you have read above that was not the case. Each day
was full of events and the only thing I could reflect on was the disturbing
situation I was caught in.
But these 12 days have definitely been an educative
experience. I have seen the kindness of common people who took me to hospital
and took care of all my belongings although many say that this would not be
common in many countries; I was blessed to have friends like Jakob and Henny
who were no less than relatives and hence easily qualified for the status of
visitor. I have seen hospitals and health systems of different kinds, from
austere and efficient Mission Hospital Tansen, to brokers of healthcare like
CIWEK to private hospitals like Medicare designed around the local
realities.
Among doctors I have seen a mix of Nepali and western
doctors. At the Mission Hospital in Tansen I was mainly treated by two Western
doctors. Dr Tone, a Norwegian Doctor who looked competent but I did not
like how she would undo the bandage on my knee in such a painful way. I
would say that her way of opening the bandage stuck to the wound and body hair
was no less painful than the accident itself. I asked her if there wasn’t
an easier way and she said ‘no’. However the next morning Dr.
Douglas an American doctor came to examine me. He was a very kind and
cheerful person, as he started opening the bandage I told him how painful I
found this and told him I wish there was some medical innovation to avoid such
unnecessary pain. He said, ‘well the best innovation I know is to
soak the bandage in water for few minutes, and he asked the nurses to put
saline fluid on my bandage while he took the next 15 minutes to check other patients
and like magic what was such a horrible experience the previous day had
become so painless. That made me wonder why Dr. Tone had not
bothered to do the same. I could also not help questioning myself if she
would have done the same painful way with patients in Norway or was it ok to do
this in Nepal only.
Then in Kathmandu I was handled by Dr. David at CIWEC and Dr
Jayan of the Teaching Hospital. Although CIWEC says that their high charges are
partly because they employ western doctors I did not find anything different in
a positive way in Dr. David. He always seemed very unsure of everything and
close to clumsy in handling things. It was thanks to his organizing skills and
resistance to planning in advance that I was left on the road at Medicare gates
for more than half an hour. When he was opening my wound in the clinic
upon arrival from the airport I urged him to use saline fluid to wet the
bandage first. Unlike the Norwegian doctor he was kind enough to do that, but
without keeping a tray or sheet beneath to collect all the fluid. As a result I
was soon sitting on a wet bed with my bottom embarrassingly wet as the nurse
who cleaned up looked at me with bit of a suspicion, but luckily I think she
could see that the epicenter was around the knee.
The doctor I felt most comfortable with was my Nepali
plastic surgeon Dr. Jayan. Nepali doctors may be underpaid and overworked
but they seem competent and compassionate. Dr. Jayan took utmost care to avoid
pain and discomfort to his patient. I only hope that CIWEK pays him the
unlikely sum of $ 100 that I saw CIWEK had billed the Insurance company,
for a half hour consultation on the first day.
I am happy I could begin to understand how the Nepali health
system worked making use of the Nepali social assets thereby minimizing
transaction of cash and maximizing the transaction of kindness and
strengthening bonds of family and friendship. I could also understand the
inherent flaws in the western medical insurance system which first weakens the
family bonds and people’s spirit of interdependence and finally becomes a trap
of mounting costs with business sharks like CIWEC flourishing in the gap
between the consumer and the insurance company.
Finally I learnt once again that going out of way to help ( in this case with this motorcycle when I had a flight ticket) can bring sufferings to oneself, but I know I have not learnt a lesson, I don't want to. More important than that I learnt to celebrate this event, even if it turned
out to be bigger than it initially appeared. I feel very fortunate that
it was not much worse, when I know that hardly a day passes in Nepal without
several motorcyclists dying on the road. I am happy that I am alive even if I
am not kicking.
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