When healthcare isn’t free…

Of the pitiful amount of Arabic words I’ve learned to use over the last 6 months working in South Sudan, ‘mafi’ is the one that will stick with me for life. It basically means ‘nothing’ and out of the words for pain, diarrhea, vomiting, blood, sorry and ‘may I’, I’ve picked up, it is probably the most commonly used on the Emergency Medical Ward. At first it was a reassuring word: ‘mafi mushkala’ or ‘no problem’ would say a nurse when I asked how the patients were (until I learned that the nurses had no idea how the patients were). Then it became irritating: ‘mafi money’, when I asked for a blood test, or ‘mafi co-patient’ when I asked why someone hadn’t been washed or taken for xray. Recently this word has begun to haunt: ‘mafi antibiotics, mafi IV fluid, mafi bedsheets, and then yesterday, ‘mafi gloves’! I’ve come to realize, it is very difficult to save lives with mafi. Having grown up benefiting from and working in a health care system which is entirely free at the point of care, it is disconcerting to be working with the world’s poorest people and charging for almost every aspect of their care. This feels awful when a patient has relatives, who come from miles pooling the village’s resources to pay the inflated prices for drugs and equipment. When a patient comes on their own, with nothing, it’s worse than awful. A young emaciated girl was brought in unconscious by her brother this week. She had a long history of watery diarrhea, weight loss and fungal infections. She was someone I didn’t need to do an HIV test for to know her status, but when I did the cause of her demise was confirmed. I had just done a teaching session on ‘an approach to a patient in coma’, so started quizzing the young doctors on what they should do. She would need an IV line, a drip set, IV fluid, strong sugar solution, blood tests, a spinal tap, a chest xray, antibiotics, antifungals, anti-malarials, an NG tube and a urine catheter… all of this coming to the equivalent of £18 per day of treatment. The brother slunk away, never to be seen again. Five days later, we’d begged, borrowed and bought some of her drugs, but I realized that no one had touched her but us. Her death was as undignified as you can imagine. Doctors don’t save lives at Juba Teaching Hospital. They help a bit, but what is key to survival is having a wealthy, willing family by the side of your bed to buy and administer your care. Business is booming down the road however. Pharmacies and laboratories are springing up, hoping to benefit from the increasing existence of ‘mafi’ in the hospital. I popped in on the brand new ‘Advanced Laboratory’ that opened this week. Proudly they showed me their price list: liver function tests were on offer! – 200ssp (that’s about £25, and 50ssp cheaper than the one down the road). But although a bit of competition might help bring down the prices, they are still unaffordable to the people that need them most. While slowly slowly, South Sudan will improve its public diagnostic capabilities, its logistics systems and drug supply many patients will sadly lose out without the benefit of some cash in a family-members hand when they arrive to hospital. Meanwhile, I will endeavor never to take for granted the marvel of the NHS; there may not be mafi mushkala, but there is free healthcare, free IV lines, fluid, antibiotics and gloves, free complex imaging, procedures and therapeutics I can’t even remember exist any more, and health-workers who do their jobs 24/7.