Power, Money and Medicine in Dakar

Michael is on call all the time.  His phone is always by his side.  So, when it rings during dinner, we're used to disturbances.  This time was different.

"Nagey is bleeding," Patrice, our guard, told Michael.  Nagey was 7-1/2 months pregnant.

"This is serious," Michael said, "Go to an emergency room."

Thirty minutes later, the phone rang again.  "We went to the emergency room  They told us to go to the hospital.  We're at the hospital.  They say she needs surgery, but they don't have a room." 

"Patrice, this is very serious.  You can't keep looking for a room," Michael admonished, "Go to Clinique de la Madeline." 

(These conversations are all in French, by the way.)

Michael is prohibited from treating anyone outside of Peace Corps, and he certainly doesn't have privileges at local hospitals.  Nor is he an ob-gyn.  But he can give advice.  And unlike other bosses that could have been called in the evening, he is knowledgeable about the Senegalese health care system. 

An hour later, we were sitting in the Madeline, a private clinic, outside a closed door with Patrice, assuring the clinic that we'd handle the bills (a major issue -- no money, no treatment).  We waited and waited at the blue door.   We couldn't hear anything, and no one came out.  Finally, we learned that Nagey had been moved upstairs.  We waited again.  No one was treating her.  We were at a great private clinic, but they were waiting for Nagey's obstetrician to arrive.  Patrice didn't have the phone number for the doctor, so Michael asked the nurse for the doctor's phone number.  The nurse wouldn't give it to him but insisted that she'd make the call on her own.

For this second pregnancy, Nagey was going to an obstetrician they were paying for.  We'd offered to pay for Dr. Ba, whom she'd seen for the first pregnancy, a gynecologist Michael knows and trusts, but they'd wanted to be responsible, which was admirable.   Come to find out, the doctor she was seeing is an 82-year-old stroke victim, now in a wheel chair, who takes some cases now and then.  When he can't handle the problem, he refers the patient to his son, who isn't even an ob-gyn.

So, they had to wait for this doctor to come.  We waited longer and were told that the doctor was on the way.  There was nothing more we could do, so we left.

That night, they took Nagey to surgery with her doctor's son who looked at her condition and said he couldn't do the surgery, so more waiting and eventually the clinic doctor was called in.  He did a C-section and took a baby girl.  She was alive.  Patrice got to see her.  She looked like his first child Mohamed Mikel. 

Thirty minutes later she was dead.

This was night one. 

No one told Nagey that her daughter had died.  The next day, she was asking about her baby, but she didn't seem strong enough to get the news.  That day, we learned that the baby wasn't really considered a person by the Senegalese, simply a medical condition.  In the Muslim religion, a baby isn't given a name until a week after its birth.  Many babies die.  So, rather than plan a funeral ritual, Patrice had to get a birth certificate, file it with the mayor's office and bury his baby daughter.

Sadness soaked our household.

In order for Nagey's treatment to continue, money had to change hands.  I went to the hospital that morning to make the first payment.  A deposit is required, and fortunately, they accept credit cards, because for us, getting big sums of cash is a problem here; out ATM limit dictates these situation.  So, we paid the sum, awaiting the bill for the surgery.  We assumed a few days more of recovery, and she'd be home.

The next night, Dr. Ba called Michael to say that she was at the clinic and Nagey was getting worse and being moved to the ICU.  Her kidneys didn't seem to be functioning.  We might want to move her to Hopital Principal, the public hospital -- if we didn't,  we'd have a bill of $10,000 very quickly.

We had an ethical debate about the right thing to do.  Was it moral for us to consider the cost of the care?  Could we "afford" a $10,000 bill?  Did we want to pay that kind of sum?  Was it immoral  to have these kinds of debates when a life was at stake?

There were benefits to the public hospital, the primary being a supply of blood, which doesn't exist at the private clinics.  (Nagey had gotten 3 units of blood at Madeline, but it wasn't always available.)  And there was the dialysis machine.  The public hospital is where Michael takes seriously sick Peace Corps volunteers.  It isn't as nice in appearance as the private clinic, but it has the proper equipment.  Maybe, all of this was a rationalization, but we became comfortable with the idea of taking her to Hopital Principal. 

What is remarkable, though, is that we were making these huge decisions for Nagey.  Not the family, but some employers of her husband, people from another country, another culture.  No one seemed to mind.

So, the next day, Michael called the private clinic as well as an ambulance service to arrange Nagey's transfer to the public hospital.  I had to pay the bill in full, or they wouldn't transfer her. 

Then, Michael began his delicate dance with the treating physicians at Hopital Principal.  Michael has learned how to ask to look at charts, to get doctor's thoughts about his patients.  When the patient is a Peace Corps volunteer, he has less of a problem getting the doctors to collaborate.  This was more difficult.  But he started going each day to check in on Nagey. 

She was sick.  It felt like an episode of  House.  She had an auto-immune reaction to the baby.  They could only give her supportive care, which included dialysis, transfusions, a respirator.  But there was no plasmaphoresis machine (which cleans blood). 

For a few days, she was touch and go.  They never did dialysis, nor did they give her any more transfusions.  It was as if all those treatments were precious and weren't going to be used unless absolutely necessary.  Days went by.  They put her on an oxygen mask.  And we worried that she might die. Michael asked the doctors details of the treatment.  Some cooperated.  Others resented his intrusions.  One sarcastically responded that she was getting "so much oxygen" because it is "good for the blood."

After four days in the ICU at Principal, she turned a corner and started to urinate.  It was time to get her out of intensive care.

But they didn't have a room for her in the obstetrics ward.  So, they wouldn't transfer her, which meant we had to continue paying for intensive care. 

How could we resent paying the extra money when she was alive?

A few more days, and she was ready to be discharged.  Again, they don't discharge you without cash in hand -- and for this, it had to be cash.  So, again we paid.

There is no way that Patrice or Nagey could have financed these large sums.  Had they been on their own, she would have gone to a public clinic -- not the private clinic or the premier hospital -- not gotten the transfusions and likely would have died.  We did learn that even though Nagey's employer didn't have health insurance, they reimburse their employees for health care (at the measly rate, it seems, of $20/month!).  But you only get the health care if you have the sums to pay at that moment, so a promise of reimbursement is not a promise of treatment.

A week after the first admission, Nagey went home.  She was still weak and wasn't eating. 

Michael started asking detailed questions and discovered that even though Nagey had been discharged with a prescription for antibiotics, Patrice had not filled it.  No one had told him the importance of it, and he didn't have money for this.  I'm sure he didn't want to ask us for more money. 

Michael, impatient by now, insisted that Patrice fill the prescription immediately.

Then, we demanded that Nagey see Dr. Ba for another analysis.  Dr. Ba said that Nagey was healing.  All was well.

At the time this was going on, the huge disparities in medical treatment were glaring us in the face -- and the power of money to make a difference.  Had we done nothing, she'd be dead.  Had Michael not known about the medical system, she'd be dead.  If she died, they'd call it God's will.  Maybe, they'd say it was God's will that Michael was there and that we could pay for the care.

This is not the first Senegalese staff life we've saved.  A few years ago, when our housekeeper Victorine was hospitalized, Michael asked why she was getting only half a dose of medicine for meningitis, and when he was told it was because the doctor didn't think she could afford to pay for the full dose, we assured her that we could.  And Victorine lived.

There was some famous economist who recently determined that 95% of wealth results from where you are born.  Because of our birthright, we are privileged.  Because of theirs, they are not.  And so, to those to whom much is given...yes, much is expected.

Comments

[Christina Frei]

Hi Amy, Michael, and Rachel,
What a story! I wonder how many of those 95% lucky ex-pats would have done the same?
I will miss your blog, and I wish you all the best with your move to Portland. I'm sure Dakar will miss you for a long time.

Christina

[Amy G. Smith]

What a thought-provoking account. Maybe I'll share this with my students to see what their thoughts are on these issues. I'm so glad Patrice's wife lived and I'm so sorry about the loss of their baby girl. It's all so tragic. Glad you could make one final difference before you left.
J can't wait to see you! I'm soooo jealous.
xo
Amy