M is 17 year old girl that lives in a village one hour away from Battambang. Her family, like 70% of Cambodians, is poor & lives a rural existence. Her father can no longer work after an injury sustained working in a factory. He now, with her mother, farms their small piece of land. Her older sister works in a garment factory in Phnom Penh. M was working illegally in Thailand in construction when she developed her tachy-arrhythmia that I have written about previously ('WPW - what patients want'& 'The best thank you'). Her family could not afford the medication she needs for one week let alone her life time.
F had told me about a Cambodian cardiologist - Dr C - that could do an ablation which would prevent the same life threatening arrhythmia happening again. I emailed him & he told me the procedure would cost $1000 but I anticipated there would be many hidden costs. Rather than organise it over email or phone I arranged to meet him face to face where he is based, the next time I was in Phnom Penh.
Of course when I arrived at the specified date & time at the hospital he wasn't expecting me but looked at her ECG & told me to bring the girl to him immediately & he would do. I tried to explain to him that she was very poor & still at home. I needed to have an idea of cost as I would have to fund raise that amount. He told me I could just pay for it afterwards & he was happy to defer payment to do it as soon as possible - he said it was urgent. I could tell that as I was barang he thought that I could easily cover the cost (currently I can barely afford to cover my mortgage in the UK!) and he didn't even acknowledge that I was a doctor, drawing a child-like diagram of the heart & talking in condescending tones. Even when he asked me what I did & I explained I was an emergency medicine specialist the tone remained. Perhaps it was my gender or/& my volunteer status. Maybe it was just him.
Either way I set about arranging for M to come down to Phnom Penh the next day for pre-op work up & to have the procedure the following day. The day after that I was flying to Myanmar for a well needed (if not deserved) holiday. Thanks to D (URC office BTB) & lovely L (my VA) after numerous phone calls they had booked M & her Mother on the first bus to Phnom Penh the following morning. Daneth paid for the tickets (I still need to pay her back) & we had to negotiate only one family member accompanying her. Initially they couldn't get the early bus as the family doesn't own a moto and have to rely on a neighbour to take them into the bus station. After some to-ing & fro-ing we worked out that she lives on the route to Phnom Penh but as they had never used a bus (too expensive) they didn't realise the bus could stop & pick them up on the way. She needed to get down to Phnom Penh in order to see Dr C in the afternoon.
I spoke with URC's health equity fund (HEF - health insurance for poor patients) about covering transport & food costs - they arranged for someone to meet me at the hospital to help organise payment. For user fee & treatment costs this was not covered as the hospital does not have an agreement with the HEF, I managed to secure donations (I am really not a natural fundraiser) from a friend of mine from medical school, my old friend's sister, J's oldest friend & a few others that wish to remain anonymous.
A very BIG thank you to Ruth, Hannah, Elaine (and anon +) - you really have restored my faith in human nature & your generosity astounds me.
The following day there was an anxious wait & a few more phone calls to ensure that the bus driver stopped & they were on the bus. I thought this would be the biggest hurdle - I was very wrong.
L & I had to leave our VSO workshop to meet them off the bus & take them to the hospital. They wanted lunch but I just wanted to get them there first to make sure Dr C's promise was good. Dr C was there but seemed only interested in showing me a powerpoint presentation of all the ablations & research he has done. He didn't even look at M or say hello to her & her mother - well she is poor after all!
Whilst she had an ECG & bloods taken I went with L to get water & some food for their predicted 2 day stay. I also gave them a little bit of money for buying more food but I planned to come again tomorrow as I didn't want them to have too much money on them. If they didn't have money then they couldn't pay the bribes.
A person from the health equity fund came to meet me so we could discuss payment with administration. The admin people were rude & arrogant - this is a mild description of their behaviour & attitude. They refused to allow deferred payment at first despite me insisting that this is what Dr C had agreed. Eventually after emptying my cambodian bank account so I could pay the user fee - initially quoted as double what it actually should be until I bartered it down - I left with the understanding that treatment, investigation & other costs could be deferred 48 hours until I had sufficient funds to pay on Saturday morning. After the 40 minutes of negotiation I was given a pack for M of toothbrush, soap, comb & flannel - I hoped it would be worth it.
I felt really uneasy about leaving her & her mother alone there - my instinct was accurate.
The following day L called M who said they wouldn't do the procedure as the staff were waiting for me to come in to pay first. I rang Dr C & he assured me that he would do the ablation at 10 am & I needed to arrange with admin deferred payment. I explained I had already paid the user fee & arranged deferred payment with admin so surely it was all systems go.....errr no actually. At 9 50 am Dr C called me saying "you come here now & pay $1000 or I will not do at 10 am and she will lose her slot. I will keep her in hospital for a very long time which will mean you will have to pay a much bigger bill at the end". I calmly pointed out that this was slightly different to the promise a day earlier that he would do without payment & was happy to defer or the arrangement I had already made with admin.
This is Cambodia. No money, no life.
I asked L later - In Cambodia do you go to a restaurant & pay for the fried rice then eat it after?!
I called Jn, from URC, who arranged for health equity to go & pay as admin were now requesting - they paid for the user fee again plus treatment. By this time however she had missed her slot but after further phone calls it was established she would have the 1 pm, which didn't actually fit with the earlier threat from Dr C. Funny how money talks & what it says, here in Cambodia. This makes me sick - quite literally - I get palpitations & chest pain still thinking about this whole incident - I'll be the one needing an ablation next!
At 4 pm Liong told me that M's mum had called and "She has not had it done yet!" - I went ballistic. As we were in the middle of the VSO workshop I took outside to get further details. Translation error - I had to explain to L that "She has not had it done yet" is not the same meaning as "She isn't out of surgery yet"! We both anxiously waited to here how it had gone.
After the workshop L & I hurried over to be greeted by an anxious mother - 5 hours & still no sign of her daughter. This could mean one of two things; 1) the procedure was technically too difficult for Dr C to do or 2) there had been a complication (as a doctor I am including death as a complication). I was being increasingly aware that the more time I spent at the hospital the higher the final bill would be. I texted Dr C who I presumed was busy in theatre with M. We waited with M's Mum - I tried to be reassuring. I rang J & ranted down the phone at her about the Cambodian health service until my credit ran out.
I received a text from Dr C - he could not successfully do the procedure it had turned out to be too difficult but he assured me that in February an American cardiologist was visiting and would do it then for free - but there is no such thing as free health care in Cambodia I have learned.
Before going to the airport the following morning I went early to the hospital to visit M & check on her well being, also I wanted to make sure they had enough money for food & transport home. The first thing I was presented with was a bill for investigations that I thought had been paid the day before, a little bit like the user fee. I was beginning to feel like a walking $ bill. No one had spoken to her about the result of the procedure, future treatment plans or asked her how she was feeling, so I did that too. Regarding payment they had been previously told by the HEF that they should not 'bother me'. Regarding payment I suggested they called HEF & just to be sure got L to do it before I left for the airport. I also called Dr C who said she needed to stay another day as she had pressure bandages on both femoral arteries - ker-ching!
I met a friend at the airport, who the evening before had been visiting the same hospital & had mentioned to a member of staff there that she knew me - "Oh! Is that the doctor from England that pays for treatment out of her own money?!" had been their response. Neither true or what I really want people to think about me.
Whilst we had breakfast together & caught up - concluding that our destiny was to grow old, remaining single & childless, meeting to discuss international health in unlikely places all around the world - I received a call from HEF saying that I needed to come to the hospital & pay another $1000. By this time I was very close to the edge of my patience with the whole rotten, corrupt, crappy situation but managed to defer him to Jn, who had calmly reassured me earlier she would sort out any further payment issues & we could settle later after I was back from my fortnights holiday & was a little less stressed!
I think L has developed a stomach ulcer during the whole debacle, I had to give her the last of my Omeprazole as I feel responsible for her work stress related illness!
M was actually kept in for a further 2 days, for what medical reason I am still not clear. She has been told to go back for a 'check-up' soon. Not sure how they expect a family that lives on $2 a day to afford the journey down & back for a clinic check-up appointment. If it is for a repeat ECG & medication then obviously as a female volunteer I am clearly totally incapable of reading an ECG or reviewing her medications.
Luckily I have enough donations now to cover the 3 months of medication she requires until the repeat surgery in February. The $1000 treatment cost ended up being $1500 & with no positive result or cure, one can only guess what the 'free' treatment will end up costing next February.
I really tried to do what I thought was the best for M but as is so common here it just came back to bite me, turning out not to be the best thing to do at all. What is left now is the hope that she will make it to February in good health & that the corrupt, flagging health care system won't fail her then.
Anyone who dares to complain to me about the NHS at the moment will have ignited the blue touch paper & should just stand well clear!
F had told me about a Cambodian cardiologist - Dr C - that could do an ablation which would prevent the same life threatening arrhythmia happening again. I emailed him & he told me the procedure would cost $1000 but I anticipated there would be many hidden costs. Rather than organise it over email or phone I arranged to meet him face to face where he is based, the next time I was in Phnom Penh.
Of course when I arrived at the specified date & time at the hospital he wasn't expecting me but looked at her ECG & told me to bring the girl to him immediately & he would do. I tried to explain to him that she was very poor & still at home. I needed to have an idea of cost as I would have to fund raise that amount. He told me I could just pay for it afterwards & he was happy to defer payment to do it as soon as possible - he said it was urgent. I could tell that as I was barang he thought that I could easily cover the cost (currently I can barely afford to cover my mortgage in the UK!) and he didn't even acknowledge that I was a doctor, drawing a child-like diagram of the heart & talking in condescending tones. Even when he asked me what I did & I explained I was an emergency medicine specialist the tone remained. Perhaps it was my gender or/& my volunteer status. Maybe it was just him.
Either way I set about arranging for M to come down to Phnom Penh the next day for pre-op work up & to have the procedure the following day. The day after that I was flying to Myanmar for a well needed (if not deserved) holiday. Thanks to D (URC office BTB) & lovely L (my VA) after numerous phone calls they had booked M & her Mother on the first bus to Phnom Penh the following morning. Daneth paid for the tickets (I still need to pay her back) & we had to negotiate only one family member accompanying her. Initially they couldn't get the early bus as the family doesn't own a moto and have to rely on a neighbour to take them into the bus station. After some to-ing & fro-ing we worked out that she lives on the route to Phnom Penh but as they had never used a bus (too expensive) they didn't realise the bus could stop & pick them up on the way. She needed to get down to Phnom Penh in order to see Dr C in the afternoon.
I spoke with URC's health equity fund (HEF - health insurance for poor patients) about covering transport & food costs - they arranged for someone to meet me at the hospital to help organise payment. For user fee & treatment costs this was not covered as the hospital does not have an agreement with the HEF, I managed to secure donations (I am really not a natural fundraiser) from a friend of mine from medical school, my old friend's sister, J's oldest friend & a few others that wish to remain anonymous.
A very BIG thank you to Ruth, Hannah, Elaine (and anon +) - you really have restored my faith in human nature & your generosity astounds me.
The following day there was an anxious wait & a few more phone calls to ensure that the bus driver stopped & they were on the bus. I thought this would be the biggest hurdle - I was very wrong.
L & I had to leave our VSO workshop to meet them off the bus & take them to the hospital. They wanted lunch but I just wanted to get them there first to make sure Dr C's promise was good. Dr C was there but seemed only interested in showing me a powerpoint presentation of all the ablations & research he has done. He didn't even look at M or say hello to her & her mother - well she is poor after all!
Whilst she had an ECG & bloods taken I went with L to get water & some food for their predicted 2 day stay. I also gave them a little bit of money for buying more food but I planned to come again tomorrow as I didn't want them to have too much money on them. If they didn't have money then they couldn't pay the bribes.
A person from the health equity fund came to meet me so we could discuss payment with administration. The admin people were rude & arrogant - this is a mild description of their behaviour & attitude. They refused to allow deferred payment at first despite me insisting that this is what Dr C had agreed. Eventually after emptying my cambodian bank account so I could pay the user fee - initially quoted as double what it actually should be until I bartered it down - I left with the understanding that treatment, investigation & other costs could be deferred 48 hours until I had sufficient funds to pay on Saturday morning. After the 40 minutes of negotiation I was given a pack for M of toothbrush, soap, comb & flannel - I hoped it would be worth it.
I felt really uneasy about leaving her & her mother alone there - my instinct was accurate.
The following day L called M who said they wouldn't do the procedure as the staff were waiting for me to come in to pay first. I rang Dr C & he assured me that he would do the ablation at 10 am & I needed to arrange with admin deferred payment. I explained I had already paid the user fee & arranged deferred payment with admin so surely it was all systems go.....errr no actually. At 9 50 am Dr C called me saying "you come here now & pay $1000 or I will not do at 10 am and she will lose her slot. I will keep her in hospital for a very long time which will mean you will have to pay a much bigger bill at the end". I calmly pointed out that this was slightly different to the promise a day earlier that he would do without payment & was happy to defer or the arrangement I had already made with admin.
This is Cambodia. No money, no life.
I asked L later - In Cambodia do you go to a restaurant & pay for the fried rice then eat it after?!
I called Jn, from URC, who arranged for health equity to go & pay as admin were now requesting - they paid for the user fee again plus treatment. By this time however she had missed her slot but after further phone calls it was established she would have the 1 pm, which didn't actually fit with the earlier threat from Dr C. Funny how money talks & what it says, here in Cambodia. This makes me sick - quite literally - I get palpitations & chest pain still thinking about this whole incident - I'll be the one needing an ablation next!
At 4 pm Liong told me that M's mum had called and "She has not had it done yet!" - I went ballistic. As we were in the middle of the VSO workshop I took outside to get further details. Translation error - I had to explain to L that "She has not had it done yet" is not the same meaning as "She isn't out of surgery yet"! We both anxiously waited to here how it had gone.
After the workshop L & I hurried over to be greeted by an anxious mother - 5 hours & still no sign of her daughter. This could mean one of two things; 1) the procedure was technically too difficult for Dr C to do or 2) there had been a complication (as a doctor I am including death as a complication). I was being increasingly aware that the more time I spent at the hospital the higher the final bill would be. I texted Dr C who I presumed was busy in theatre with M. We waited with M's Mum - I tried to be reassuring. I rang J & ranted down the phone at her about the Cambodian health service until my credit ran out.
I received a text from Dr C - he could not successfully do the procedure it had turned out to be too difficult but he assured me that in February an American cardiologist was visiting and would do it then for free - but there is no such thing as free health care in Cambodia I have learned.
Before going to the airport the following morning I went early to the hospital to visit M & check on her well being, also I wanted to make sure they had enough money for food & transport home. The first thing I was presented with was a bill for investigations that I thought had been paid the day before, a little bit like the user fee. I was beginning to feel like a walking $ bill. No one had spoken to her about the result of the procedure, future treatment plans or asked her how she was feeling, so I did that too. Regarding payment they had been previously told by the HEF that they should not 'bother me'. Regarding payment I suggested they called HEF & just to be sure got L to do it before I left for the airport. I also called Dr C who said she needed to stay another day as she had pressure bandages on both femoral arteries - ker-ching!
I met a friend at the airport, who the evening before had been visiting the same hospital & had mentioned to a member of staff there that she knew me - "Oh! Is that the doctor from England that pays for treatment out of her own money?!" had been their response. Neither true or what I really want people to think about me.
Whilst we had breakfast together & caught up - concluding that our destiny was to grow old, remaining single & childless, meeting to discuss international health in unlikely places all around the world - I received a call from HEF saying that I needed to come to the hospital & pay another $1000. By this time I was very close to the edge of my patience with the whole rotten, corrupt, crappy situation but managed to defer him to Jn, who had calmly reassured me earlier she would sort out any further payment issues & we could settle later after I was back from my fortnights holiday & was a little less stressed!
I think L has developed a stomach ulcer during the whole debacle, I had to give her the last of my Omeprazole as I feel responsible for her work stress related illness!
M was actually kept in for a further 2 days, for what medical reason I am still not clear. She has been told to go back for a 'check-up' soon. Not sure how they expect a family that lives on $2 a day to afford the journey down & back for a clinic check-up appointment. If it is for a repeat ECG & medication then obviously as a female volunteer I am clearly totally incapable of reading an ECG or reviewing her medications.
Luckily I have enough donations now to cover the 3 months of medication she requires until the repeat surgery in February. The $1000 treatment cost ended up being $1500 & with no positive result or cure, one can only guess what the 'free' treatment will end up costing next February.
I really tried to do what I thought was the best for M but as is so common here it just came back to bite me, turning out not to be the best thing to do at all. What is left now is the hope that she will make it to February in good health & that the corrupt, flagging health care system won't fail her then.
Anyone who dares to complain to me about the NHS at the moment will have ignited the blue touch paper & should just stand well clear!
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