Getting Insured, a Project

The first patient I interacted with at the municipal hospital opened my eyes to problem of health insurance that is prevalent throughout Ghana. 

When I met her, Erica, an 8 month old who had arrived at the hospital unconscious and seizing from severe malaria, was a healthy, laughing infant who had been discharged for over a week. However, because Erica did not have health insurance, and her mother did not have the money to pay the 250 cedi hospital bill, Erica remained in the hospital for 3 weeks after she was discharged. During that time, she once again contracted malaria, a tragically common occurrence due to the large volume of both malaria patients and mosquitoes in the children’s ward.

Unfortunately, Erica’s story is a familiar one. Many children in Ghana, particularly in the rural villages, do not have health insurance. Terrified by daunting medical bills, parents are less willing to seek professional medical care for their children when they fall ill. Instead, they nurse their children with herbal remedies, which although successful at alleviating certain symptoms, have not proven to be an effective means of treatment. These children are then rushed to the nearest hospital when, as Erica did, they fall dangerously ill. Delaying professional care not only exponentially raises the cost of treatment, it also increases mortality.

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The bill from one of the hospital patients. I snapped the photo before the cost per item was written down, but you can get the idea of how expensive it would be

Lack of health insurance should not be such a devastating problem in Ghana. Unlike the US, the Ghanaian government is the sole health insurance provider. Through the National Health Insurance Scheme (NHIS), it only costs 4 cedi, the equivalent of $2 US, to insure a child for one year.

During the time I have spent at the municipal hospital, at community clinics and at rural outreaches, I have continually felt helpless to make a concrete change. I cannot do emergency surgery to save a woman bleeding to death from a ruptured ectopic pregnancy, I cannot convince the hospital staff to isolate a woman suffering from TB so that she does not infect the HIV patients with whom she shares a room.

Providing health insurance to children in need is something that I am able to do. With the help of my friends and family, I plan on providing health insurance to the 300 uninsured children in Hodzo Ga, a rural agricultural village near where I am staying in the Volta region.

This Friday, August 10, accompanied by a community nurse and an NHIS official, I will be going to Hodzo Ga to register children for health insurance. I am in the process of creating a fundraising website to provide a straightforward, transparent way for those interested to donate to the campaign. As soon as the site is done, I will post it here. In the meantime, I want to get the word out and encourage others to do the same. 

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Malaria, unless proven otherwise

At all the wards I’ve been to at the hospital, malaria is by far the most common illness. In the outpatient department (OPD), where I’ve been spending most of my time shadowing Dr. Jonathon, everyone with fever and/or chills is immediately diagnosed with malaria.

In response to my questioning the frequency of malaria diagnosis, Dr. Jonathon responded, “Fever is malaria, until proven otherwise”.

He continued by explaining that during the rainy season, malaria is so common that any complaint of fever or chills is immediately diagnosed and treated as the disease. Often times, patients just have a case of simple malaria, which is characterized by fever, chills, weakness and frequently a lack of appetite and vomiting. Simple malaria is easily treated with a three day course of pills, usually Artemether/Lumafantrine or Artesunate.

I was surprised to discover how straightforward it is to treat malaria. From all the hype about malaria prophylaxis in the US, I was expecting treatment to be a grueling and drawn out process. Instead, malaria is so common, and its treatment so basic, that most people get malaria several times a year and recover by day two of their pill course.

However, if untreated, simple malaria can quickly become severe, and many complications can arise. A common cause of death in children under six, severe malaria is a general term that describes a variety of symptoms. On an assignment from Dr. Jonathon, I researched the different clinical and lab manifestations of severe malaria and discovered that there are about 20. Most common in the municipal hospital, and apparently throughout Ghana, are severe anemia (characterized by hemoglobin <5), cerebral malaria (where the patient’s brain swells and he/she often experiences seizures and loss of consciousness) and prostration (where the patient is too weak to stand or sit up).

In order to avoid an increased incidence of severe malaria, Dr. Jonathon usually prescribes malaria medication to anyone who has any of the illness’ classic symptoms as well as to anyone with a cold (since they are more susceptible to the disease) without a blood film test confirming the presence of the malaria parasite, p. falcipirum.  A very knowledgeable, patient and intelligent man, Dr. Jonathon explained to me that while drug resistance can develop by overprescribing medication, lab technicians often do not conduct an adequate blood film test, consequently incorrectly concluding the absence of the parasite. Therefore, he believes it is better to prescribe the medication, as side effects are minimal.

Dr. Jonathon has been a tremendous wealth of information, both about clinical medicine and about Ghana’s health care system. He not only patiently answers my incessant questions, but also quizzes me on topics he has previously explained or has asked me to research. Standing in for a doctor on leave, Dr. Jonathon had his last day at the hospital yesterday. I’m very sad to see him leave.

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Dr. Jonathon admitting a patient to the Children’s Ward from OPD

Genuinely interested in helping his patients and practicing good medicine, Dr. Jonathon is one of the few medical professionals I have met here who is not yet jaded by the health care system. Despite being restricted by administrative barriers and certain cultural practices, he does his best to advocate for his patients.

Two instances stand out the most in mind. The first occurred a couple of weeks ago with a girl who had hydrocephaly, an enlarged cranium due to an excess of water. Although the girl was at the hospital for a variety of other symptoms that turned out to be malaria, gastroentiritis and an upper respiratory tract infection, Dr. Jonathon was very concerned that nothing had been done about her hydrocephaly when she was younger. He prescribed her a variety of medication for her other complaints, and upon noticing she did not have health insurance and was struggling to make ends meet, gave her money for the prescriptions. He then instructed her to come back in a week, after she had recovered, so he could sign her up for health insurance. It was so touching to see this act of empathy in a hospital environment where many of the staff treats patients brusquely.

The second has been an ongoing battle with hospital administration. While doing rounds in the female ward a few days ago, Dr. Jonathon discovered that a woman with tuberculosis was in the same room as two HIV patients. As they are severely immunocompromised, the HIV patients had a high risk of contracting TB from their highly infectious roommate. However, the TB patient was no longer producing sputum, so although her chest x-ray displayed a very large granuloma, the diagnosis could be confirmed by a sputum test.

Dr. Jonathon has been arguing with the female ward nurses, the head nurse and the administrative staff to have the woman put into an isolated room, to no avail. Despite being told by other doctors that his battle was futile, he is still determined to get the TB patient isolated. The last time he was in the ward, he declared he would wheel her out himself if it came down to it.

Getting Informed

7/6/12

Today has been very informative and interesting so far. I went to the pediatrics ward at the municipal hospital again. Some of the same kids from yesterday were there, and I was able to see how they had progressed from the day before. There were 4 patients in the ward: Perfect, a 9 year old girl who has sickle cell disease, a girl with a leg wound, a girl with malaria, a boy with really severe malaria and possibly typhoid, and the premature newbie with malnutrition. There were also several other kids who had been discharged but were still in the hospital because they did not have money to pay.

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Playing “Inky Binky Bonky” with one of the patients who had a leg wound

Although it’s extremely interesting to witness the symptoms of these different diseases first hand and to see how they are treated in the hospital, it’s still really hard to get used to the lack of resources there.

The majority of the staff are student nurses who are doing their 5 week practical at the municipal hospital. I talked to one of them, Joy (age 20), a lot and learned about her life as a nursing student. There was one male nurse, Djzohm, who has been working in the ward for awhile and was extremely knowledgable about all the different diseases. Exhibiting much patience, he explained the different symptoms of malaria and sickle cell disease to me and Alicia.

Here is what I’ve learned so far:

Malaria: Characterized by high fevers and vomiting. If very severe can go to the brain, causing cerebral malaria. The nine year old boy with severe malaria (i think his name was Abukar) had a consistently really high fever that did not respond to malaria medication. After 2 weeks of a high temperature and malaria medications, the doctor prescribed him with cipro and another antibiotic, thinking that the fever was caused by a bacterial infection such as typhoid. We watched the nurse, Dzijom, give him the antibiotics intraveneously, which was really interesting. The boy was so sweet and so strong. Even when he was shaking from the fever and obviously in pain he never cried.

Sickle cell disease: Characterized by joint pain because the blood cells get stuck in the joints and then cause severe pain. Fatigue. The only way to treat it is to get a bone marrow transplant because the bone marrow is creating defective sickle shaped red blood cells. It’s very expensive and not feasible so they just manage the crises situations by giving medication to relieve the pain and by thinning the blood with IV fluids.

I really enjoy going to the hospital and getting informed. It’s made me realize that I do really want to become a doctor. Hopefully I can get over my squeamishness of blood and needles!