Contrasts

Contrasts

We have now been here for nearly 2 months now and we feel like we are settling into both our roles in the hospital and our lives in general here in Rwanda. Whilst they’re obvious differences that stand out each day relating to lack of resources or power outages, the areas that have stood out most to me relate to healthcare access and patient expectations.

In the UK you will often see patients presenting very early on in any illness or in fact without any discernible illness. The challenge this poses as a doctor is that it can be very difficult to make useful diagnoses, as the evolution of any disease is helpful in identifying it. This situation is the consequence of two things.

Firstly, the ease of access we have to healthcare in the UK. Whilst at times it can seem frustrating that your GP is booked up for the next couple of weeks, if you are determined to speak to/see a doctor that day or in the next 48hrs, it will almost universally be made available to you. In the same instance there are 24hr A&E departments or minor injury units that only require you to attend them. On top of all of this, if you feel unable to leave your home independently, GPs may visit you at home or ultimately an ambulance can be called, free of charge, to provide care at your place of need and often transport you on to a place of definitive care. All of this adds up to make quite amazing access to healthcare (this is without mentioning the huge variety of different services such as district nurses or peripheral hospital clinics).

Secondly, the expectations we have regarding our health. As individuals we expect to be able to lead a life free of infectious disease, able to participate in all the activities of life that we enjoy and for chronic diseases (such as diabetes or heart disease) to have minimal impact on our lives. We expect to be able to see with both eyes, hear with both ears and be sound of mind, as well as body. Resultantly, when there is deviation from this, we seek ‘fixing’ or reassurance through our healthcare system. As a consequence of the fantastic access we have this expectation is generally met. As consumers of healthcare we even have our rights written into law through the NHS constitution.

And all of this is right. That we expect to live productive lives, that our enjoyment is for the best part not constrained by ill-health and that when we are sick we are brought back to good health. All of this facilitated through access to healthcare at all stages of life and all times of day. We may have services stretched by volume, such as social care or A&E departments, and a whole service under the burden of financial constraint, but access remains universal and our high level of expectation is met.

Kibogora and Rwanda as a whole stand in stark contrast. Accessing healthcare is somewhat complicated. The structure of the healthcare system is different. There is no primary care (GP surgeries), rather local health centres serving the surrounding local population. These in practice are very basic hospitals – treating all complaints with a very small variety of medicines (some antibiotics, anti-malarials, analgesia and diazepam) and a place where women are encouraged to go to deliver their babies. They only provide management for acute problems and do not manage chronic disease. The health centres are staffed by nurses, most of whom will have had education to university level (though you can major in nursing at secondary school!)

These health centres are the point of access to district hospitals. In general you cannot attend a district hospital unless you have a transfer letter from a local health centre. This is effective in filtering out many of the cases that do not need hospital level care, but also causes delay in hospital attendance for those that are in need of it. To access an outpatient consultation for a chronic health complaint, such as hypertension or asthma, again a transfer letter is required from a local health centre.

Access is also limited by finance. Rwanda does not currently have universal healthcare access. The system works through a variety of insurance schemes (depending on who you work for), but the most common is called Mutuelle. For those that have it, on hospital attendance, the patient pays 10% of their final hospital bill, regardless of its final cost. For example, the basic cost of an outpatient appointment is 800 Rwandan Francs, meaning that a patient pays 80 francs = 8p! (However, add to this a fully itemised bill – for every blood test, every dressing and every xray). Whilst this is great value on the surface, for an individual to be insured a whole family has to be covered. This costs about 4000RFr per person, per year = £4. The average rural family may have anywhere between 4-12 children. Suddenly the cost of any one individual being insured is more like 40,000RFr (£40). This means that for the poorest, largest families, who have the greatest disease burden, health insurance can be unaffordable.

So with the protracted route to hospital care through local health centres and the potential prohibitive cost to many, patients don’t attend for ‘trivial’ problems. However, what is trivial is cultural. We might consider that twinge in our little toe that only occurs when we try and hop down the stairs trivial. However, trivial in Rwanda seems to be that which does not stop you from doing your days jobs. Now, as God blessed us with 2 eyes and 4 limbs, losing the function of one may well not stop you from cultivating. Therefore, the loss of sight in one eye, or useful function of one limb may seem only trivial. Or that cough productive of blood on only a few days of the week. It doesn’t really stop you from driving your motorbike taxi. Therefore, patients present much later in the disease process, with increased chance of severe disease, complication or even mortality.

Linked closely with this idea of triviality is that of expectation, and this is the area in which I have been most struck on the contrast with home. It is sometimes the case that Medicine doesn’t have the answer to people’s problems, whether they be financial, social or spiritual. And some problems are truly trivial, for which patience and time are the best healers. Working in the A&E here at Kibogora I have experienced startlingly low expectations and a fatalism that has shocked me. This was most personified in a young man, with HIV who attended the A&E with headaches and some chest pain that he had been suffering with for a couple of weeks. After some minutes of talking with him and taking his history, it became apparent that he at no point was making eye contact and that his gaze was fixed on seemingly nothing. Through my translator I found out that this young man had suddenly lost the vision in both his eyes about 4 days previous. When I asked why he hadn’t mentioned this he stated that he didn’t realise it as important and assumed that nothing could be done. I was astounded by his lack of expectation. When considering what I would have done in his position, all I could think was that I would go speeding to the nearest hospital, praying that someone could return my vision. I would have done this if it was just one eye.

This young man is not an isolated case. I have seen young and old with osteomyelitis (infection within the bone) and unable to walk for weeks who come because the pain has become unbearable, rather than because of thoughts that the problem with their leg could be healed. Now lack of expectation is not born of nothing, it’s formed from experience. This country remains a long way behind the UK in its economic development and with a formalised, government led health system still in its infancy. For many of these patients, they will know people who have lost sight or the function of limbs and life has continued, with these events seen as the inevitable trials of life. It still remains that for some these low expectations are appropriate – treatment for their problems not being available in Rwanda. The challenge is in preventing these low expectations from encompassing all of a person’s problems or worse, throughout their community.

The consequence on a daily basis for me is that I see lots of interesting pathology. I see problems that would have presented days, weeks, months or even years earlier in the UK. There are few patients in whom I am left wondering what the underlying problem may be (though making an accurate diagnosis is still not always easy). I frequently ask ‘why did you only come today and not before?’ and am met with a variety of answers, generally covered by what is written above.

Sadly, this little rant is purely observation. I don’t have the solutions to making healthcare affordable to the entire population of Rwanda or the answers for changing expectations. I am glad to work at Kibogora, where no patient is turned away due to lack of finance, using funds through its charitable support to fund the care of these patients. The hospital strives to serve its patient’s needs, hopefully raising expectations through quality care, and providing support – be it practical, emotional, psychological or spiritual – to those for whom a solution to their problem is still not available.

All this serves to help remind me how good we have it at home.