Pediatric Blog
I received some policy documents from the hospital in Haiti where I will work. There were aspects of hospital policy that concern me.
When I worked for this hospital in 2010, the medical care provided, including medications, was free. According to the documents I received today, the hospital is "no longer able to provide care completely free of charge." Patients are "expected to pay" for initial assessments, lab tests, and medications.
The document also notes that the Chief Medical Officer and the executive directors "have a system in place" that allows them to determine "patient payment and exonerations." Sounds like a "means test," something that I do not agree with. Means tests are demeaning and are obstructions to access in health care.
This is disappointing news. Money should not be a factor in access to health care. When access to care has a price, then access is restricted, and care is not available for the poor. This is wrong.
How can anyone expect that a parent in Haiti can afford to pay anything? Haiti continues as the poorest country in our hemisphere and only about 20% of the population have a job. For workers in the garment factories, the pay is only 31 cents an hour ($2.50 a day!). In 2009, the Preval government voted a minimum pay law that would be implemented in steps and in October 2012 the minimum wage was scheduled to increase to 62 cents an hour ($5.00 per day). Even if the industries pay this, the amount is still below a subsistence level estimate of $12.50 a day for a mother and two children!
The hospital is surrounded by tent cities like this.
How could anyone who lives here afford to pay for hospital care?
Reading the document brought back a flurry of memories.
As a young intern at Sick Kids in Toronto I was asked to go on strike for higher wages. I refused and together with some (a minority) of the other young physicians in Toronto, we refused to leave our work for more money.
When I interviewed for my job as the Associate Professor and Head of Paediatric Nephrology in South Carolina, the most important question that I asked my future boss was if I would ever be obliged to deny care to someone if they could not pay. My boss reassured me that I would never be required to restrict care. I accepted the job. He was true to his word and I never had to deny access if a person could not pay. However, once working in South Carolina, I realized that my perspective was not the norm and that many of my colleagues routinely denied service if a family could not pay. I found this repulsive but held my tongue. I was the foreigner. However I made it a point of honor to purposefully seek out Medicaid families and to treat them in an identical fashion to the patients with money or private insurance. I was resented by some of my colleagues because I did not conform to their double standard. I have many stories to tell about how the double standard was practiced in South Carolina and about the depth of the hypocrisy I found there. I stayed in the state long enough to build up the largest Medicaid service in the State and was honoured with the 1998 Maternal and Child Heath Care Award by the Governor of the State of South Carolina for my service with poor mothers and children. This award remains high on my list of achievements.
When I worked in the United Arab Emirates as the Chief of Pediatrics at the Royal Hospital, I witnessed another system where money determined access. Again I was reassured that I would never need to deny care, and I was never required to, but once working there I learned that there were two hospitals in the city. One hospital was for the poor foreign work force (from Pakistan, Sri Lanka, Bangladesh, Indonesia) who provided cheap labor to the country and one hospital was exclusively for the Emirate citizens. I only had authority at the hospital for the Emirates. My hospital offered care similar to that offered in Canada (sort of), and the other hospital offered decidedly second class care. There was another top level of care available to the Royal Family. I have many stories to tell about the triple standard in the UAE. There was at least no hypocrisy in the Emirates. Citizens of the Emirates actually believe they deserve better than the rest of us.
After my first visit to Nicaragua to work in a rural clinic I learned that the clinic charged a modest fee for the patients to see me and another modest fee for medications that I prescribed. I insisted that there would be no charge for my personal care or for the medications that I brought with me and dispensed. The clinic agreed and with this understanding and I visited four times to help out.
I will need to find out the true meaning of the hospital policy such that families are "expected to pay." My principles are idealistic for some, but they are my principles, and they are important to me. I want my time, my experience, and the medications that I bring to be free for families in Haiti.
