This is almost too crazy to be true so I’m going to explain
it as if it is a hypothetical situation. That way its just part of my imagination rather than reality pissing me off.
Imagine it is the height of malaria season in one of the
poorest countries in the world. Most adults who have lived in the area get over
this illness without much difficulty because they have built up good immunity
after dealing with multiple infections throughout their lives. However, young
children and pregnant women regularly die from this disease. These days there are
a limited variety of available drugs to treat malaria. Because the country is
so poor, with the average person completely unable to pay the market price for
these medicines and with the government not even close to being able to
generate enough revenue to supply the country’s health centers with an adequate
supply of these medicines, it relies upon places like the United States to
supply the malaria medications.
Over the past year and beyond, there have been more and more
reports about healthcare workers in the country stealing these donated drugs
from the hospitals they work at so that they can sell them on the black market
for 100% profit. Albeit slowly, the United States has caught on to this
nefarious behavior and has decided to crack down hard. All health centers must
now record the basic information of each and every individual receiving these
medications. This new record keeping is in addition to the typical records for individual
patients and pharmacy inventory—both of which are notoriously inaccurate. A new
list of those receiving the medicine and where each of them lives must be
available so that the cranky Americans can come at anytime and crosscheck this
list by going into the community and making sure those who reportedly received
the drugs indeed received the drugs. If there are any discrepancies, the supply
of these lifesaving medications will be cut off. It turns out that many health
centers aren’t organized (or motivated or aware or whatever) enough to even do
this new record keeping. There is an entire district that can’t produce these
records, and they just lost their entire donated supply of malaria medications.
Adjacent to this district, there is a large mission hospital
that has been able to relieve some of this devastation because it is relatively
well organized. Although their staff is completely overwhelmed this time of
year with spikes in admissions due to severe malaria, they have been keeping
good enough records that the Americans haven’t cut off their supply of malaria
medications (yet). The people in the district nearby without any medications
flock to the mission hospital in search of care. This hospital was already
overwhelmed to begin with, and this further influx of patients further stresses
its capacity. Furthermore, the patients coming from the district without any
medicine are traveling long distances to get there and often arrive after much
delay so that their illness is very severe by the time they get to the
hospital.
To add to this, there is a parallel story that demonstrates
the mission hospital’s difficult predicament: for many years, they have had a
service level agreement (SLA) with country’s government. With the SLA in place,
they received enough funding to subsidize basically all patient costs at the
hospital. The SLA also allowed them to spray insecticides in houses throughout
their catchment area of 80,000 people on a yearly basis before each rainy (ie
malaria) season. This insecticide spraying is a powerful public health
intervention for preventing malaria in endemic areas. While the hospital was
doing this spraying over the past few years, they have seen a large decrease in
the number of admissions and deaths during the rainy season. (There is an interesting story of natural selection and how the mosquitoes have rapidly gaining resistance to these insecticide sprays, but we'll have to save that for another day.) Unfortunately, due
to a variety of reasons (including government officials stealing almost all the
money from the treasury while the former president was visiting the USA a few
years back) leading to depletion of funding for the program, the country’s
government had to break the SLA a few months ago. As a result, the impoverished
patients now encounter a fee for service billing structure. Word spread quickly
that everyone now has to pay when going to the hospital, and many (not just
those traveling from form the neighboring district) are now delaying to go to
the hospital until they become very sick. Hospital staff also think that more
people are seeking help from traditional healers rather than going to the
hospital. Not only do these traditional healers swindle the poor with hoax
therapies, but many of these therapies are dangerous. Only a small fraction of
the hospital’s catchment area was sprayed prior to the current rainy season,
and this is thought to be another big factor in the recent increase in overall
malaria cases, death rate, and total death count.
Last week, the medical director of the hospital went to the
Ministry of Health to discuss the possibility of reimplementing the SLA. He was
armed with lots of facts about how detrimental the dismantling of the SLA has
been over the previous months. The meeting never took place because there was
no one there to talk to. Just before this meeting was planned, over 60 officials
in the Ministry were fired because they mishandled funds from the CDC.
At this point, healthcare in the country is in complete
disarray. But it has more or less always been this way so there’s not really
any general sense of urgency to improve things in a meaningful way.
