Economics

Today I found myself standing at the foot of a bed. The smell of rotting flesh, moist plants and dirt, old dressings, and the feel of a foot that is moving freely of its leg has forced my mind to seek refuge somewhere else. When overwhelmed by sensory stimuli, where does any reasonable brain turn? Economics, of course.

Twice today I found myself faced with difficult economic questions. It seems that here, when someone is between a rock and a hard place, it is much more obvious. Money really could make a lot of things easier.

First was a woman in the female ward. At 45 years old, she is a 'defaulter.' Previously on HIV meds, but has quit taking them. She has been sick for weeks before coming to the hospital. She came in looking like a skeleton, speaking nonsense, hallucinating, and refusing all oral medications. We treated her for a myriad of infections and she began to get better, until Friday. Her abdomen became tender, her fever worsened, she became more sleepy. Yesterday, she was stable. On my arrival to the hospital this morning, she is gasping, and non-responsive. Nobody knows which family members know about the HIV diagnosis.
I begin to hold meetings. So many draining meetings. It feels like divorce court, custody battle, criminal court, all mixed into one. First with the daughter, who knows the diagnosis. She recommends I talk to the patient's mother, so I gather them into my office for the second meeting. The mother guesses what's coming. Even though we are sitting across a desk from each other, while sitting, she turns her body away from me. She only glances over her shoulder to look at me when she thinks there's good news. Her frame visibly shrinks as I say HIV. She sheds a few tears. Secrets are common here. Crucial things are kept from the ones closest to you. Everything I say all day to this family comes as a shock.
After a few hours, the mother recommends I talk to the brother. The brother faces me squarely, stoically, calmly. I get the sense that he is the decision maker. We have a prayer. We make a decision. Nope. After a few hours the father shows up. We do it all again.
At every meeting, my message is the same. 'She has HIV. Her body cannot fight infections well. We have given her the strongest medicines. Any HIV medicines would kill her. We are out of options. She can stay here to die, or you can go home.' All the meetings have the same conclusion; she needs to go home. Transporting a live corpse is much easier, cheaper, and more legal than transporting a dead one. Strangely, this was not the most difficult part of this case.

The accountant, Junesa, comes to me asking about the case. I explain that there is nothing that can cure her and I'm just keeping her comfortable. "They haven't paid anything on their bill. It's 1.6 million Leones." ($160 USD) I tell him that I cannot answer his implicit question, 'Should we let them leave without paying anything? They won't come back to pay the bill on a dead woman.' What I do tell him was meant to be empowering, but probably felt like a ton of bricks.
"We are outside the realm of medicine here. This is about families, death, social customs, priorities. Things that I'm too new here to know anything about. On one hand, this woman probably should go home to die. On the other, it's the 6th and we can't pay everyone's salaries. I will support any decision you make."

How is he supposed to make this decision? His colleagues have been without pay for almost a week. With many hospital workers making about $3 a day, this 1.6 million would pay almost one and a half salaries for the month. On the other hand, this family is losing a 45 y/o woman. She is supposed to be making income for everyone. Now there are funeral costs. Are we going to financially cripple this family and deny this woman a death at home, over money?
Junesa is a good man. She made it home before she died, hours later. But there is still no way to pay salaries.



That was about 1pm. Now fast forward to 5:30 pm. It's Sunday. I'm trying to go home. I get word there's an emergency case in the male ward. I correctly assume that my plans for a 6pm lunch are going to be postponed.



A young, by US standards, approximately 47.5 year old man was in a RTA (road traffic accident) about 10 days ago. His leg was obviously broken with exposed bones about 8 cm above the ankle. They took him to the biggest hospital in the country where he received X rays and IV medications. He wasn't miraculously cured, so they left the hospital about 7 days ago to use "traditional medicine." This evening, he's in my hospital bed with a BP of 80/40, altered mental status for the last 2 hours, and no electricity or staff to run labs. I text Dr. Kabba, the surgeon, on his day off. He makes some calls and one of the theatre staff comes to the hospital to give me access to the dressing supplies.

The Traditional Medicine consists of twine, wrapped around thinly split bamboo that is holding into place some thin cloth. Under the gauze is 2 cm thick, black, moist, putrid plant and dirt material. It crumbles away into clumpy flakes that soon cover the lower part of the bed. Underneath is another thin cloth, and underneath that is rotting flesh. All of this is soaked in a pretty foul body fluid.
Like I said before, economics is sounding pretty good right now.

After cleaning the wound and applying some clean dressings, I pull the family aside. 'Tonight, I am going to try to stabilize him. If he survives the night, the only thing we can do to save his life is an operation to remove the leg. I don't know the exact cost. But if you are talking to your family, ask for money.'
"How much?"
'I don't know for sure. Dr. Kabba will make that decision in the morning. My guess is three to four million. If we don't do this operation, he will die.'

This leads me to my questions for the day:
- How does capitalism work, when the options are: "pay 3 million or die?"
- How do you place a monetary value on dying at home with family?
- Is providing a good death an ethical option, when you can't pay those who are currently living and feeding children?

Somebody may have the answers to these questions. But it's not me.
However, I do hope that by writing this before falling asleep, it will help me dream of dusty, boring economics books. That way, I can avoid dreams of other things I've smelled today.