22nd April,
Yesterday I was finally discharged from the third and hopefully final hospital. They would liberate me from the plaster packaging this evening and thereby restore limited mobility again. Until now I had been completely immobilized and bedridden with a stiff packaging of plaster of Paris to let the stitches heal and the skin graft settle.
In theses 12 days since the accident on Saturday the 10thApril, I have seen, learnt and gone through a lot. In fact these experiences almost pale the actual accident which caused the injury and the hospitalization. From Private hospitals reaping profits out of peoples’ misery to what felt like a near death experience of an allergic reaction to an antibiotic injection, to the realization that friends and relatives are the biggest insurance in Asian cultures. I would like to share some of these learnings and experiences with you all in the hope that it may prove beneficial to some people at some point.
After the accident I spent 6 days in the Mission Hospital in the lovely hill town of Tansen(around 300 km from Ktm) thinking that it was a small affair and I would be walking out to my work in Kapilbastu the next day. However due to all the dirt that had gone into the wounds it was only after a week of cleaning that the doctors said they were ready to do the stitching of the knee, but the skin grafting to patch the third degree burn around the ankle they said would have to wait for another week. I thought that another week of waiting and then several more days for healing in Tansen would be too many days away from my work and dwelling, so we decided to move to Kathmandu. Thus on Thursday the 15th I was flown to Kathmandu.
Moving to Kathmandu was smooth as my colleague and friend Henny was kind enough to accompany me. I was put in an ambulance that drove me from Tansen to the Bhairhwa airport in the plains near Lumbini. After some wait at the airport a small Beachcraft of Buddha Air brought us to Kathmandu by dusk. At the airport my dear friend Jakob (Henny’s husband) was waiting. CIWEC had sent its ambulance to pick me up. From the airport to the CIWEC clinic was an eventless ride in the ambulance. What unveiled after this was rather disturbing. My physical wounds did not pain me nearly as much as the commerce of misery that I saw in the health facilities in Kathmandu did (must be similar in cities like Delhi also). It was a very educative experience also to learn about the business going on in the name of insurance and medical care.
The ambulance brought me to the CIWEC Clinic (Travel Medicine Centre), which is rather popular among diplomatic circles, INGOs and foreign tourists. It is in Lazimpat near the British Embassy. It is also well known for the exorbitant prices it charges for its services. Although located in one of the poorest countries in the world, their prices are set as if they were located in New York. All services are priced in dollars and a simple consultation costs more than USD 50. I had hoped that the services would be of international standards, but when I saw my room I had to ask the nurse ‘Are you sure the bed and blanket have not been used by another patient?’ It was a tiny room and everything looked hastily and temporarily set up. And I had this déjà vu feeling – a vague memory which grew stronger by the day that I had been in this tiny room once before. I think this room also functions as a regular doctor’s consultation room and I had met one Dr David there previously as an outpatient. So I think it had been hastily turned into an inpatient’s room when the need arose. Well, there’s nothing wrong with re-cycling rooms or small rooms but it’s just that I learnt after few days that the bill to the insurance company would be... hold your breath (I don’t want any more medical emergencies here)... USD 500 per night (roughly Nrs. 40,000). This disturbed me a lot about the how the health and insurance system worked or didn’t.
Who pays for it in the end?
Most people would say “It’s the insurance company that pays so let them charge what they want. You don’t have to pay yourself, after all we or our organisations have paid hefty amounts to the insurance company”. But to me this felt like a trap we consumers have allowed ourselves to be caught in, and the final victims are none other than ourselves. The insurance companies want some profit after they have deducted their expenses (on the likes of CIWEC). The higher their expenses, the higher they must price their policy. So it’s the poor consumer finally who is caught in his own web.
The only comparison I could find for the CIWEC cabin was the Hyatt Regency Hotel, perhaps the most expensive five star hotel in Kathmandu. Their website says that even their ‘Club Deluxe King’ costs ‘only’ $ 195, that too before discounts and offers. Hyatt’s highest priced Regency Suite King cost $ 450 before discounts.
Yesterday I called CIWEC to check some facts for this write-up, and asked them about the status of their organization. A European-sounding lady immediately said ‘We are a private facility with no support from any government.” Well, of course: Imagine Nepal’s government subsidizing their $ 500 per night bills! The administrator Ms Shashi told me, ‘We are a private clinic established in the eighties after a Canadian irrigation project called CIWEC. We are using CIWEC as a brand name but I don’t know the full form, it is something like Canadian Irrigation project’. It was rather confusing to see that their stationery has two other names for the same facility – Travel Medicine Centre and Menlha Nursing Home. When I asked about the owners of the clinic, the administrator said she did not know the names of the owners except that one of the business partners is American.
She also clarified that the cabin for in-patients cost $ 300 and the remaining $ 200 was for a morning and evening visit by a doctor. She also said the reason they were so expensive was because they had imported medicines and equipment... and doctors, I guess. However I had seen nothing in the room that was imported or expensive, nor had I ever got any medicine that was not Indian or Nepali during my earlier visits to this clinic, even when the bill was never less than $ 50.
Why CIWEC
Many international organisations avail of CIWEC’s services for their staff, and since the insurance company pays, and perhaps the clinic is good at making such payments logistically simple, people did not notice the prices so much. So it was also in my best interests that the former MS Nepal Country Director Sten Andreasen had requested CIWEC if they could handle my treatment in Kathmandu, and they had happily agreed. So that’s how on Thursday night I was brought into the CIWEC clinic and examined. Interestingly it was the same Dr. David who was on duty that evening who I had seen during an earlier consultation. He had called in a surgeon from the Government’s (Teaching) Hospital to look at my case and do the operation. My first feeling was of shock that even with an expensive international insurance I was being handed over to a surgeon from the Government’s Teaching Hospital where doctors are paid a paltry 300 USD per month. But I consoled myself saying that there is no reason not to trust a government facility, that it may in fact have the best doctors with long experience. And surely Dr. Jayan, the plastic surgeon I was handed over to, turned out to be a very pleasant and kind surgeon. Though half of me was rebelling against the idea of this luxury clinic taking the doctors away from the much needier government hospital (in many countries this would be called moonlighting and not even be allowed). It seemed to me that the plan was to get the government surgeon do the surgery in CIWEC clinic. However since they did not have a real operation theatre or anaesthesia facilities, the two doctors agreed to use the operation theatre in another private hospital called Medicare National Hospital. They said that I could be kept there for a day after the operation and then brought back to CIWEC for recovery. As you will read later I always felt that this decision was taken not in the best interest of the patient. I told Dr David that I did not feel comfortable with this piecemeal approach to my treatment where no one would take responsibility in case of a problem. He agreed but said ‘Well, I know it is a bit disjointed, but you don’t want to be sent to the Teaching Hospital, do you? There they keep you waiting for three months: you wouldn’t like that, would you?’ This felt like just a scare tactic because if an insurance company can afford CIWEC’s $ 500 room then surely it can also afford the best real hospitals in Kathmandu. It still remains a mystery why CIWEC accepted my case when they did not have the capacity.
At the Gates of Medicare Hospital
So anyway the examination and the deal was done on how I would be handed over to the Teaching Hospital Surgeon for the operation and he would in turn hand me over to the Medicare Hospital for immediate care and then I would be brought back to CIWEC for recovery. I reminded Dr. David again and again that the local cheaper hospitals require someone to be with the patient all the time and as a foreigner here I had no one and hence requested CIWEC to arrange for such help so it could be billed to theinsurance company. His answer to that was “Umm let’s see, why don’t you call us when you get there, and if they don’t have such help then we’ll see what we can arrange”. Of course CIWEC should have known about the hospital they were transferring their patient to, still I had to remind this American doctor that it would be too late to wait till I get there (especially with this instrument called telephone invented for a century now). He said that was a good idea and seemingly left to call the other hospital. But then when I arrived at Medicare Hospital it was exactly what I feared. The Hospital wouldn’t even let me in without a friend or relative accompanying. So they left me in the ambulance on the road for no less than half an hour. The ambulance driver was on constant phone with his CIWEC bosses but nothing seemed to move. I had my own reserve of solutions for these problems but I wanted to see the system for any individual in my condition. So finally I set off my own emergency mechanism and called my friend to help me again. For the next few days I had talked to this young Tharu student friend who used to help me in my house in Bardiya two years ago.Luckily he was in Kathmandu and unemployed so he happily agreed to come and help me as a relative in the hospital. She magically got there within 15 minutes and I was admitted into the ward. At this point I also called other expat advisors in my organisation to find out what the procedures was in such cases, as I was equally interested in being a guinea pig to check how the system worked.
Friends & Relatives an Insurance System
At first the system of requiring a relative as an entry pass for admission into hospital looked bizarre, but later I realized that that is how the whole system in the hospital is organized. In Nepal, unlike in the west, the social structure is such that there must always be an immediate relative helping with all immediate needs when a person is ill. This hospital uses this asset to cut down on staff and lower their prices. This seems to partly explain why in many South Asian countries many people do not bother to have health insurance. They may not have commercial insurance but they do have a social insurance network in the form of relatives and friends, into which they have invested over the years with similar support. So one reason why Medicare was so much cheaper, was it depended on this social network, so I could not understand why CIWEC sent me here when they knew I did not have relatives in Kathmandu but I did have international commercial insurance.
A Budget Hospital
Medicare was a budget hospital in more ways than one. I got a private cabin but things did not look very clean. Smriti Shrestha who heads HR at ActionAid Nepal and is a local from Kathmandu said that the room looked much dirtier than other private hospitals she had been to. She very much wanted me to move to another hospital for recovery after the operation as she feared that I could catch infections in such an environment.
There was an attached bathroom but it had neither a towel nor soap. While towels were not in the budget it took 24 hours for half a soap (literally split half) to arrive. The nurses looked stressed and did their things very mechanically; a smile or a greeting in the morning even from my side seemed to disturb them. This changed a bit towards the end of my stay as I kept being playful and cracking jokes at my own expense. I learnt to remember my medicine timings as the nurses tended to forget. Once they forgot to remove the IV glucose drip line after the bottle had emptied, I noticed then that blood had started mounting up. When I called the sister to see what was happening and why, they argued back that I could have closed the flow myself. I was speechless, I had thought that as a valid certified patient now was my chance to get some attention.
The system is such that the attending friend or relative has a very active role to play in every event and that explains why they did not accept me without a relative. Though the sisters officially called them ‘the visitor’, the visitor had to run down to the shops below to get every piece of medicine a doctor or nurse needed. This was true even during an operation. That Friday evening when the operation was being conducted on my knee and ankle, the visitors were required to wait outside the theatre to go buy each item needed in the operation. Smriti, Henny and Jakob who kindly played the role of the visitor during my operation told me that sitting outside they could tell how the operation was progressing from what the doctors were ordering. First gloves, then grafting blades and so on and in the end, dressing ointment, bandages, etc.This system was perhaps designed to minimize the handling (and pilferage) of medical supplies by the hospital and to minimize costs for the patient, but it is not free from risk as things are not planned in advance. At the end of the operation the surgeon needed plaster of Paris but the stores nearby did not have it, so they had to wait for some time with the patient lying on the operation table till it came from a nearby hospital. Like a good patient (this hospital taught me the true meaning of this word) I was patiently listening to all this from the table.
After the operation we tried to move to another hospital with better facilities and support. In this process Jakob called CIWEC on my behalf to take their opinion. They suggested that I could be brought back to CIWEC clinic. It was at this point that we first asked and found out that it would cost $ 500 per night. I saw Jakob asking twice to make sure it was not bad phone lines that made him hear absurd amounts. Then we asked Medicare what their charges were and found out that it was only $20 per night. It was then that I decided I would rather stay at Medicare for the whole 6 days than be a party to what felt like a scam. And if my insurance is considerate then I would like them to share at least half the savings they will make due to my sacrifice with a not-for-profit hospital like the Mission Hospital in Tansen for the treatment of patients without ‘visitors’. Over 11 days the difference between $ 500 per night and $ 20 per night comes to no less than $ 5,000 (means one local nurse employed for three years).
This seemed like the end!
Ever since then I felt more relaxed and at ease with the Medicare system and the stay felt more or less comfortable until the midnight of 17th when a nurse came and injected my regular antibiotic dose of Ceflaxon, suddenly my body had a strong allergic reaction to the medicine. I felt an asthma like attack in my chest making breathing difficult, my head felt a strange pressure inside, limbs had tingling sensations and then there appeared a little bump on my arm. Oxygen saturation dropped to 85% and I was put on piped oxygen. I was definitely scared and thought those were perhaps my last moments as pumping five ml of allergy causing stuff straight into my veins could wreak instantaneous havoc in my system. I had also heard of death of a person I knew due to such reaction. But most fortunately the reaction stabilised after a point. The doctor also pumped in other anti-allergy medicines in me. Strangely even in such an emergency the medicines had to be bought from the shop downstairs by the ‘visitor’ when a few seconds could be the difference between life and death. It was a mystery why my body reacted like that to an injection that I had been taking for the last one week.
Alive and learning
Now that I am out of the Hospital I am trying to jot down the experience. I had thought that the accident would give me a lot of time to relax and reflect but as you have read above that was not the case. Each day was full of events and the only thing I could reflect on was the disturbing situation I was caught in.
But these 12 days have definitely been an educative experience. I have seen the kindness of common people who took me to hospital although many say that it would not be common in many countries; I was blessed to have friends like Jakob and Henny who were no less than relatives and hence easily qualified for the status of visitor. I have seen hospitals and health systems of different kinds, from austere and efficient Mission Hospital Tansen, to brokers of healthcare like CIWEK to private hospitals like Medicare designed around the local conditions.
Among doctors I have seen a mix of Nepali and western doctors. At the Mission Hospital in Tansen I was mainly treated by two Western doctors. Dr Tone, a Norwegian Doctor who looked competent but I did not like how she would undo the bandage on my knee in such a painful way.I would say that her way of opening the bandage stuck to the wound and body hair was no less painful than the accident itself. I asked her if there wasn’t an easier way and she said ‘no’.However the next morning Dr. Douglas an American doctor came to examine me. He was a very kind and cheerful person, as he started opening the bandage I told him how painful I found this and told him I wish there was some medical innovation to avoid such unnecessary pain. He said, ‘well the best innovation I know is to soak the bandage in water for few minutes, and he asked the nurses to put saline fluid on my bandage while he took the next 15 minutes to check other patients and like magic what was such a horrible experience the previous day had become so painless. That made me wonder why Dr. Tone had not bothered to do the same. I could also not help questioning myself if she would have done the same painful way with patients in Norway or was it ok to do this in Nepal only.
Then in Kathmandu I was handled by Dr. David at CIWEC and Dr Jayan of the Teaching Hospital. Although CIWEC says that their high charges are partly because they employ western doctors I did not find anything different in a positive way in Dr. David. He always seemed very unsure of everything and close to clumsy in handling things. It was thanks to his organizing skills and resistance to planning in advance that I was left on the road at Medicare gates for more than half an hour. When he was opening my wound in the clinic upon arrival from the airport I urged him to use saline fluid to wet the bandage first. Unlike the Norwegian doctor he was kind enough to do that, but without keeping a tray or sheet beneath to collect all the fluid. As a result I was soon sitting on a wet bed with my bottom embarrassingly wet as the nurse who cleaned up looked at me with bit of a suspicion, but luckily I think she could see that the epicentre was around the knee.
The doctor I felt most comfortable with was my Nepali plastic surgeon Dr. Jayan. Nepali doctors may be underpaid and overworked but they seem competent and compassionate. Dr. Jayan took utmost care to avoid pain and discomfort to his patient. I only hope that CIWEK pays him the unlikely sum of $ 100 that I saw CIWEK had billed the Insurance company, for a half hour consultation on the first day.
I could understand how the Nepali health system worked making use of the Nepali social assets thereby minimizing transaction of cash and maximizing the transaction of kindness and strengthening bonds of family and friendship. I could also understand the inherent flaws in the western medical insurance system which first weakens the family bonds and people’s spirit of interdependence and finally becomes a trap of mounting costs with business sharks like CIWEC flourishing in the gap between the consumer and the insurance company.
Finally I learnt to celebrate my accident even if it turned out to be bigger than it initially appeared. I really felt very fortunate that it was not much worse, when I know that hardly a day passes in Nepal without several motorcyclists dying on the road. I am happy that I am alive even if I am not kicking.
