Recently, local physician Patty Ruze spent six weeks with the Boston-based organization Partners In Health on a volunteer medical mission to the center of the Ebola outbreak in Sierra Leone. This piece is part of a series of reflections Dr. Ruze has written regarding her experiences on assignment at the Port Loko Government Hospital and Maforki Ebola Treatment Unit. Last week, Dr. Ruze wrote about her life outside the treatment unit. This week, she reflects on the complicated economics of giving care.
Recently, local physician Patty Ruze spent six weeks with the Boston-based organization Partners In Health on a volunteer medical mission to the center of the Ebola outbreak in Sierra Leone. This piece is part of a series of reflections Dr. Ruze has written regarding her experiences on assignment at the Port Loko Government Hospital and Maforki Ebola Treatment Unit. Last week, Dr. Ruze wrote about her life outside the treatment unit. This week, she reflects on the complicated economics of giving care.
Dr. Ruze safely returned to Harvard on March 12 and is completing a three-week, voluntary self-surveillance period of quarantine. She has been told to avoid public gatherings, so you won’t see her at Town Meeting this week, but she is permitted to go shopping and walking and have visitors.
The following was written in February.
Today I am especially grateful for Dr. Ashley, one of my volunteer colleagues here in Sierra Leone. I not only appreciate her critical care expertise, I love her enthusiastic compassion for every one of her patients.
Making do
Take Mariatu, a 16-year-old woman who miscarried late in her first pregnancy. She came to our hospital a few days ago from the Ebola Treatment Unit (ETU), very short of breath and with a pulse in the 160s. Every sentence she spoke was punctuated by a gasp for air. Her brown eyes, full of fear, pleaded for help. In my previous job I would have called for immediate assistance with intubation and transfer to the ICU team. Here, my team scrambled to find a sheet for her bed and an IV catheter.
The lab said that her hemoglobin was low at 4.1 gm/dl. Dr. Ashley ordered two units of whole blood for Mariatu. It feels good in this hospital when we can provide care that is clinically appropriate and can really help patients. More often than not, as American clinicians here, we are frustrated by not having access to the diagnostics, medications, and equipment our patients need.
Here in Sierra Leone, we don’t bank blood at our hospital. Family members are asked to donate units. If they are unable or unwilling, the practice has been to purchase blood from community “sellers” for 90,000 leones (just under $20) per unit. My predecessor in this job had advised me to be prepared to take these funds from our petty-cash box and give the money to the lab technician for each transfusion. During my first several weeks, I had not been presented with a request for cash, so I hadn’t paid for three previously requested units for other patients. Now that we urgently needed at least two units of blood, the request was made for 270,000 leones plus the additional money for the next two units.
Complex financial transactions
Partners In Health currently provides all medical care, including medications and diagnostic testing, free of charge to inpatients at the government hospital. However, I am gradually discovering that nursing care, pharmacy, and laboratory services in our “free” government hospital involve multiple complex financial transactions.
We have attempted to handle financial affairs directly, with clear documentation and transparency. Although this approach seems like simple common sense, it has created a dramatic upheaval in the economics of the hospital.
Obtaining lab work previously involved direct payments to lab technicians, who purchased the reagents out of pocket, allowing them to supplement their unreliable government salaries. A private pharmaceutical system seems to run parallel to the limited and somewhat dysfunctional public supply of medications. Nursing care, and possibly physician care, also involves informal payments for services that we might consider routine, such as diagnosis and medication administration.
For Mariatu’s case, arrangements were made for 450,000 leones to be paid directly to the hospital to facilitate the blood transfusion for our patient and what we owed for the prior units. Unfortunately, this didn’t translate into cash for the blood sellers, nor repayment of the lab staff for the prior funds advanced for the other units of blood. When this issue was pushed up the chain of command to the hospital administrator, we learned sadly that selling blood is illegal in Sierra Leone.
Coincidentally, Dr. Ashley and I are both O negative blood types. This means that we are universal donors. Ashley, with her usual enthusiasm, immediately extended her right arm out to donate. We were informed that the hospital policy is that only “matched” blood types could donate, which meant since the patient was B positive, she could accept only B positive blood. An energetic, and minimally academic, discussion ensued.
Not a simple gift of the heart
The process of giving up two units of blood was easy and one of the more rewarding experiences I have had here in terms of directly helping a patient. Seeing my deep maroon blood fill that little plastic sac on the floor of our office reminded me that I am here creating better health for the people of Sierra Leone.
An irritating thought crept up in my sleep later that night. What about the next patient who needs blood? What kind of precedent had we set at the hospital?
The next day, the lab tech who had so kindly greeted me each day prior, told me that he was unable to run any tests for us at the lab, explaining that they had run out of all reagents for TB testing, hemoglobin, and VDRL. He further explained that he had advanced his own money for lab supplies and would not be doing any testing until he was reimbursed. I spoke with the lab director later outside our office. Although his English is not perfect, I think we understood each other.
While my gift of blood may have been the moral thing to do, it may not have been right. It certainly was not the simple gift, given from my heart, that I intended.
The next morning, Ashley and I were joyous to see our patient, Mariatu, sitting up in bed, smiling.
