August 29th, 2009 Posted in Uncategorized | 3 Comments »
I just finished my fourth week here in the DR, and every day I find myself so happy, fortunate and proud to be here.
Although I had previously lived abroad in a developing country, I am only just now fully understanding the desperate need for medical missions in developing nations. This whole experience reminds me over and over again how grateful I am to live in a country whose medical system, while definitely flawed in its own ways, demands regulation and standardization in the education of our physicians and of the delivery of health care in general.
I know when I go to a hospital in the US that I am going to recieve good medical care - whether I have insurance or not. I naturally assume that the physicians are well-trained and competent. I expect that if I need surgery, the surgeon will be well-educated and will have had years of residency and fellowship before practicing on his own.
Yes, we all have had experiences in the US where we disagreed with the physician. Yes, we have all had experiences where two physicians have given us two completely differing opinions or plans of care. But, in developing countries, the discrepancy between a “competent” and “incompetent” physician is a whole other phenomenon that we usually don’t need to worry about in the States.
When I first got here, I was told that incompetent surgeons are one of the many reasons for the overwhelming number of orthopedic deformities in the DR. This struck me as incomprehensible, and I couldn’t wrap my brain around how this could be true. How could a surgeon NOT know what he is doing and still have a license?
Later, when when it was explained to me how and why this does happen, another wave of disbelief and anger, but mostly, sadness washed over me. How could this be? Who protects the patients? Why does the government let this happen? Why doesn’t anyone try to change the system? And does the negligent surgeon or physician feel any remorse? Do they not remember that they are supposed to be compassionate healers? Did they not take the Hippocratic Oath? Have they forgotten that, above all else, these are human beings???
Upon further questioning, this is what I’ve learned over the last couple of weeks about how the medical educational system works here:
- There is not a formalized entrance test (like the MCAT) in order to get into medical school here.
- Students can begin medical school straight out of high school.
- The basic requirements to get into med school are to: 1) Have inside connections or 2) Be able to pay your way in.
- “Doctors” are not necessarily expected to demonstrate proficiency, skill, knowledge, or understanding of medicine or sugery upon completion of their training.
Obviously, this is not true for every Dominican physician, and I’m sure it can’t be true for every Dominican medical school. But, it does occur. And because it does, there is a great likelihood for the people of this country to recieve substandard - if not completely negligent - medical care. And there seems to be no legal repercussions for it either. Without the fear of consequences, patients have no protection from incompetent physicians.
At CURE Dominicana, I see patients on a daily basis who were initially treated (or more accurately, not treated) at another hospital by an unqualified surgeon. The patients then find out about CURE after the fact and come to our surgeons later for either initial treatment or for a correction of a first surgery.
For example, last Friday I met a patient named Yemen. Yemen comes from a small town, about 1 1/2 hours from Santo Domingo. He is 17-years old and the bread-winner for his family. In March of this year, Yemen got into an accident while working and was taken to the largest trauma hospital in the country. Yemen had a fractured jaw, broken ribs (?) and a shattered left hip. The physicians at the hospital addressed the fractured jaw and ribs, but did not even take an x-ray of his hip.
When Yemen continued to complain of hip pain, they x-rayed his hip and found it was badly fractured. But, they told him they could not operate since he would likely die on the OR table. So, instead, the doctors put a cast on Yemen’s CALF. Obviously, the cast did nothing for his fractured hip and later the doctors removed the cast and sent him home with a brace for the calf instead.
Luckily for Yemen, he was fortunate to meet Kristin, a missionary here, who had worked with a previous CURE patient, and directed Yemen and his family to CURE. Approximately five months after Yemen’s injury, he finally had surgery to reconstruct his hip.
Yemen is now approximately three weeks post-op and he came to physical therapy for the first time last Friday for gait training with crutches. He will be non-weight bearing on the left leg for at least three months.
On a side note, Yemen’s family may lose their home (which Kristin describes as a ”tin shack”) if they cannot pay a substantial amount of money towards Yemen’s medical bills by the end of the year. As previously mentioned, Yemen is the bread-winner in his household. I don’t know how his family intends to handle their financial situation, but I do know that Yemen’s mom is always smiling and always seems to be at peace, despite what is going on in her family’s life.
Another example of medical negligence comes in the form of a 13-year old boy named Neftaly. Neftaly broke his elbow and underwent surgery at another hospital - a surgery which left him with a non-healing fracture and the inability to use arm. After a second surgery at CURE, Neftaly has just finished his post-op physical therapy with us and now has full range of motion of his elbow, but continues to lack the strength that the average 13-year old should have. Additionally, he still has a bony deformity of his elbow which the surgeon at CURE was unable to fix - at least with the first surgery.
I don’t know what the plan is for Neftaly now. I don’t know if his family wants to address the deformity or if they surgeons are even able to address it, but at least he is now able to use his arm.
Not only have I learned some things about the medical educational systerm here, I have also learned more about the hospitals in the DR:
- The public hospitals are notorious for substandard care including lack of attention to patients’ needs, poor bedside manner, lack of available equipment necessary to diagnose and/or treat the patients and inadequate cleanliness of the facilities.
- There are private hospitals, which provide better overall care and outcomes, but they are very expensive and the average Dominican cannot afford them. These hospitals have ERs, but if you can’t pay when you come through the doors, they’ll send you away - emergency or not.
- Due to the above, many people choose not to go to the doctor or hospital at all. They hope (?) that the injury, wound, sickness, lump, infection, etc will go away or heal itself on its own.
Within my first week at the hospital at the in DR, I saw my first example of this sad situation. A patient arrived to Dr. Nelson’s clinic with a tumor that stretched from his hip to his distal thigh. The tumor was found to be a slow-growing malignant cancer. Several days later, Dr. Nelson had to perform a hemipelvectomy (amputation of the entire leg, hip and half of the pelvis) on the patient in order to remove all of the tumor - which according to the medical students who helped with the surgery weighed between 60-70 pounds!!!!!
Can you imagine any person in the States waiting that long before going to see a doctor? If an American noticed a lump on their thigh, it’s more than likely that, even if uninsured, they would be heading straight to either a doctor’s office or to a hospital ER.
The health care problems in the DR are so pronounced that one of the nation’s most successful male singers, Juan Luis Guerra, wrote a song about them which was released in 1999. For those who are unaware of the problems that exist in the DR, the song just merely seems to be humerous. But, really, the song is a sarcastic and sad commentary on the state of health care in the DR. A Dominican friend of mine that I met here introduced me to the song in the last week, and I can’t stop thinking about it. The lyrics are powerful and honest, but in a very simple way.
To end this blog, I’m posting the translated lyrics to Juan Luis Guerra’s “El Niagra en Bicicleta” which is a Dominicanism meaning ”to overcome many problems” and which literally translates to “The Niagra (Falls) on Bicycle”.
Lyrics:
I fainted one Sunday morning
When I least expected it.
I fell hard, like a soursop fruit, onto a sewer grate.
Is it my blood pressure? Or has my bilirubin level gone up?
I got a fever,
And started to turn white like a mothball.
They took me to a hospital “of the people” (supposedly).
In the emergency room, the receptionist was listening to the lottery numbers.
(“30,000 pesos!”)
“Someone take pity on me!”,
I shouted, losing consciousness,
And a nurse approached my ear and said
“Calm down, Bobby, calm down.” [A phrase used to talk to a dog]
She caressed me with her Ben Gay hands and asked me
“What happened, champ?”
And I told her, in intimate detail, what had happened to me.
“We need to check your blood pressure,
but the room is occupied.
And, my dear, in this hospital there’s no electricity for an EKG.”
I opened my eyes like the full moon,
and I grabbed my head,
Because it’s very hard
To cross Niagara Falls on a bicycle.
Don’t tell me that the doctors left.
Don’t tell me that they don’t have anesthesia.
Don’t tell me that someone drank the alcohol,
And that the thread for stitches
Has been sewn into a tablecloth.
Don’t tell me that the forceps are lost,
And the stethoscope is off partying,
That the x-ray machine has burnt out,
And the IV fluids have been used to sweeten the coffee.
I leaned on her shoulders like a lame man leans on his crutch
And I said to her “What should I do, princess?”
And on a prescription slip she wrote very sweetly
“I’m sorry, champ.”
She caressed me with her Ben Gay hands and went on her way,
And I heard her clearly when she said to another patient
“Calm down, Bobby, calm down.”
I dropped my eyes to half-mast and I grabbed my head,
Because it’s very hard
To cross Niagara Falls on a bicycle.
