By Prashant Bhatt
?Our revolution has been quicker than the Egyptian and Tunisian ones? is an oft repeated remark I hear on the streets of Tripoli. Is it true? I examined this assertion from a medical perspective, highlighting some fundamental issues which every society has to face.
How do we care for our sick and old?
The war in Libya has led to an increase in a phenomenon which is very common here-Cross border travel for medical reasons.
?I belong to an era which is never going to return in Libya. My family was from the old monarchy.? My friend of many years, Ibrahim, who is taking care of his 90 year old mother in Cairo, told me over skype. A humanist, he was wondering if it was possible to come over to Tripoli to sort out some old property related issues. I advised him against it for the time being.
?Who are you going to petition?? was the first question.
The era of monarchy is long over. The era of military dictatorship came to a brutal end. We are still in transition. The words of John Locke, the enlightenment philosopher who was also a physician come to mind as we see the carving of a new society from the dead weight of history.
Natural Law and the Role of Government.
A right to responsible, popular revolution
The modern conception of natural law as meaning or implying natural rights was elaborated by European enlightenment thinkers, of whom John Locke, was arguably the most important natural law theorist. The belief in natural law and universal order, a growing confidence in human reason were argued in
detail by Locke.
Certain rights self evidently pertain to individuals as human beings (because these rights existed in ?the state of nature? before humankind entered civil society.; that chief among them are the rights to life, liberty (freedom from arbitrary rule), and property; that upon entering civil society, humankind surrendered to the state- pursuant to a ?social contract? ? only the right to enforce these natural rights and not the rights themselves; and that the state?s failure to secure these rights gives rise to a right to responsible, popular revolution.(1)
The fluid conditions and various reports of human rights groups are available to all. I examine some natural laws through the story of my friend Ibrahim taking care of his mother almost single handedly, but never despairing, never having an unkind word for the health care delivery and support systems in his home country.
While the responsible popular revolution has been affected, the Libyan road to ?natural laws? of which John Locke had written over three centuries ago has still to be realized.
Having said that, I move on to more specific medical related issues.
In this article I will focus on the issue of cross border medical travel and see the issues of medical healthcare delivery which come forward.
We want the payment today:
Attitudes of a private organiser
?We do not want the payment tomorrow. We give the service today, we want the payments today,? a senior surgeon and owner of a private clinic told about his approach. ?Most of the treatment can be done in Tripoli and people are misusing the current crises to go and take treatment for even cosmetic reasons. This is a disaster,? he fumed. There were issues of community support, cost to the country, choice of treatment, complications which we will address.
Defining Tertiary Healthcare
Tertiary health care is a key aspect in providing universal access to healthcare in the 21st century. Tertiary care developed in western healthcare systems after 1940s with large hospitals, technology oriented investigations and expensive treatment.
In the UK, it was the government?s intent to provide universal healthcare and the budgetary support for this came through the Beveridge plan that made it possible.
In western health care systems, tertiary care developed for diseases common to those regions, using tests and treatments that were affordable to them. Even so, this has resulted in escalating health expenditures in developed countries, consuming 8% to 10% of their health budgets, making it almost unaffordable to many.
In the Libyan context the sanction of certain treatments abroad at cost to government state machinery has led many altered dynamics in a society already in severe crises. (2)
Need for a Technical Group
It is important that the government institute a technical group to define the parameters of tertiary care. This will define the common public health conditions that require outpatient and hospital care, including emergency conditions.
Emergency conditions (for example head injuries, gunshot wounds, strokes, heart attacks) and chronic conditions (for example cancer treatment, palliative care and stroke rehabilitation) require provisioning of tertiary care at the community level.
Returning to the example of Ibrahim whose bedridden mother had complicated spine surgery but now mainly requires nursing care which is not easily possible in Libya, forcing him to leave his home country and stay in Egypt.
The spine surgery can easily be done in Libya in one of the private clinics as mentioned earlier-whose owner wants the payment today, not tomorrow.
There is need for a technical group to orient towards positioning of emergency services to the public as close to their place of residence. Data on the prevalence of diseases is not currently available.
In addition cost-effectiveness data on different tests, treatments and technology interventions will help in decision making.
The example of National Institute of Clinical Excellence (NICE) in the UK is one such approach to the problem. NICE was set up in 1999 to reduce the variation in the availability and quality of treatments (2)
Go To Tunis Syndrome
Is it a social pressure and prestige issue to go to Tunis for treatment. As an Indian doctor who has stayed in Libya for almost a decade, I have come across many complex cases which get as complicated in Tunis as they would get in Tripoli.
When I was new here, I still remember a seriously spine injured patient whose brother said that he will take him to Tunis.
When I tried to reason with him that the general condition of the patient is not good, he said he wants to give his brother whatever little chance he has, as in this place, he has no chance.
This attitude of desperation and disbelief lead many gullible persons to be cheated in foreign lands.
Again, as in the case of Ibrahim?s mother, this spinal injured patient will not die because of the injury but due to the lack of nursing support.
What to look for in Cross Border Care
C Costs Low cost care need not necessarily be of less quality. There are several instances of low cost competent high-quality, comparatively low-cost, consumer-oriented treatment in countries like Egypt, Jordan, India, China. When factoring costs one should include the issue of families traveling with the sick persons.
C Choice Before one deci-des whether to arrange for a particular line of treatment, prospective patients must understand risks of treatment, anticipated benefits of treatment, alternatives to treatment and consequences of non-treatment.
C Complications A growing body of scholarship indicates that some patients suffer serious medical complications and require costly treatment as a result of traveling abroad and purchasing health service.
Current evidence suggests that poor outcomes are attributable to substandard surgical care, infections that in at least some circumstances are a result of inadequate infection control measures in surgical settings, deep vein thrombosis and pulmonary embolisms following long-distance travel shortly before or after surgery, and inadequate post-operative care following departure from the treating facility
C Continuity Follow-up appointments and post-operative treatment plans should be established before patients travel abroad for medical care. Organisation of pre-travel assessment, monitoring of patient care during stays at international health-care facilities, and post-operative care should be seen as crucial components of arranging cross-border health services.
Some of the risks associated with obtaining health care at international facilities could likely be reduced by better coordinating post-operative care following return of patients to their home communities.(3)
A sister in Tunis
?As the doctor in the leading government teaching hospital kept my sister waiting for over an hour and just disappeared after taking her for examination, we took my sister to Tunis? one friend told me this Friday.
?You should have been a bit persistent,? I tried to reason.? The initial response of most government departments, be it medical, consular-immigration, police, bank is to try and turn the person away so that they will not have to start the issue at all.?
But as the saying goes-it is difficult to see things from another person?s eyes if one has not walked in his shoes.
?Can a mentally ill person not have a gynecological problem? What put my sister off was the initial response of the gynecology doctor despite having a detailed radiology report. She did not go through the report and instead instructed my sister to be taken to the hospital for mental illness.?
That his sister has mental illness is a living reality of my friend, something which has affected his life, made it difficult for him to get married.
I wondered about the issues of Costs, Choices, Complications and Continuity of care as my friend stoically drove to the Friday prayers.
?I belong to an era which is never going to return in Libya.? As I recalled the words of my friend ? the humanist Ibrahim, I wondered when and if they will be able to say this about some basic services.
Notes and further reading:
1. The Britannica Guide to ?The Ideas that made the modern world?- Page 168
2. http://mfcindia.org/main/bgpapers/bgpapers2012/am/bgpap2012d.pdf
3. Leigh G. Turner :Quality in Health Care and Globalisation of Health Services: Accredita-tion and Regulatory Oversight of Medical Tourism Companies Posted: 02/06/2011; International Journal for Quality in Health Care. 2011;23(1):1-7. ? 2011 Oxford University Press
Keywords: Healthcare, Revol-ution, Medical Refugee
(Prashant Bhatt is Head of the Radiology department of Libyan British Medical Centre, (www.lbmc.med.ly). He has kept a regular journal since 1983. Writing using Oral history life-story guidelines he records history from below focusing on working lives of ordinary people. The following is a link to his blog (www.prashantbhatt.com). In this series of I will focus on the cultural issues of working people.)
Source: http://www.tripolipost.com/articledetail.asp?c=12&i=9146
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