The Price of Progress

This being my fourth visit to Addis over 6 years I have seen many things change at the hospital.  And with each new development the cynical part of me wonders – occasionally out loud – whether this is truly progress or whether in adopting a western model of medicine …………

There is now an “emergency department” for the hospital.  Alongside this, there has been the development of the specialty of emergency medicine.  To me, it seems more like just a name change.  Previously, the same space had been called the OPD = Outpatient Department.  Granted, the area is a bit larger but it remains a zoo of ill patients crammed into a too-small space.  In the year since I was last here they have expanded to put patients in the hallways as well, thereby creating an additional 10 or more beds.  Patient beds are lined up approximately 3 feet apart.  Only a handful of beds have curtains for some modicum of privacy.   Like the admitted patients there are several family members always present to help care for their loved ones.  The net result is a large open space with way too many people in it – many suffering all kinds of ailments and adding their wails to an already overly stimulating environment.  Most of the patient here at any one time are in fact admitted patients – ones for whom services like ours has deemed require admission but for whom there is no actual floor bed available.  As a result, they languish in the ED often for days awaiting their actual admission.  The “waiting for a bed” situation is not unlike what is often experienced back home in Canada, where I trained, although far more extreme.  While still in the ED here they fall under the purvue of that department and as a result are usually suspended in some form of medical virtual space in which they get some basic minimal care but are often not actively investigated or treated, it seems, until the admitting service can finally take over.  In short, from a neurosurgical perspective only, I am not convinced that the development of the emergency department has resulted in anything more than a slightly enlarged waiting room for patients………..

The availability of advanced imaging.  When I was first in Addis 6 years ago more then 90% of the patients whom I saw with head traumas had skull xrays as their primary and only form of imaging.  Even if you are not in the medical field, you probably recognize the inadequacy of this in the 21^st century.  This included those who had a GCS score less than 8 (i.e. comatose).  The reason for this was twofold.  Firstly, I was told patients could not afford to pay out of pocket for scans costing just over $100 USD.  Secondly was availability.  There had been a CT scanner in the hospital the year before but word on the street was that it had been intentionally broken by one or more of the owners of the 3 private CT facilities in the city at the time.  As a result, these comatose patients would have to get transported across the city – often in the back of a taxi cab – in order to get scanned, if they could even afford it.  Oh how times have changed.

Now, almost all patients get scanned prior to admission.  The hospital did get a new CT scanner earlier this year, although that is not the reason – it has already “broken down”.  For one thing, each private imaging center now owns its own private ambulance which will conveniently come and pick up patients and bring them back for a price that is included in the cost of the scan.  Secondly, patients now appear to be able to afford these advanced imaging studies.  I do not understand this latter explanation at all.  I am pretty sure the population is not any richer than it had been previously.  Definitely the scans have not gotten any cheaper.  Despite my interrogating multiple sources no one has yet to give me a good explanation for this sudden acquisition of wealth.  The residents tell me that people are not as poor as they claim to be and that if you insist it has to be done then it will be.  Knowing that a CT scan costs more than half the monthly salary of a publicly employed physician (which is why most also have very active private practices on the side), makes me truly wonder how the average blue-collar worker could afford one of these tests.

All of these imaging studies have lead to a couple of interesting quandaries for us now.  The most significant it the treatment plan for these patients.  Just because a patient now has an MRI which clearly demonstrates extreme spinal cord compression following a bad fracture dislocation – something that was already suspected based on history, clinical examination and Xray – is that going to change the patient’s treatment plan or admission?  There still are no beds for admission.  Their life expectancy is still reduced to one of months or a few years regardless of whether we do surgery or not to stabilize their spine as nothing is going to cure their paralysis.    And, with often several such patients arriving daily at the hospital but OR time to manage maybe 1-2 of such cases per week, not to mention the extremely limited spinal equipment, most will never be admitted.   Meanwhile, the emergency room physicians order these studies before they are even assessed by neurosurgery.  I almost feel, given the helplessness of this situation that they are forcing these poor patients and their families to pay out unnecessarily.  Certainly back home these types of patients would get the “million dollar work up” with the associated highest level of care but here…….  Some would argue that we would now have radiological proof of their diagnosis.  Although I cannot argue that their might be some academic knowledge gained from these imaging studies, I try to point out that more clinical proof I do not need.  No one seems to pay me much attention on this point.  They are already fighting too many other battles.

The other interesting off-shoot of the availability of imaging in Addis is the emergence of the back pain patient.  As a spine surgeon, back home my clinics are filled with patients who want to see me about their neck pain and their lower back pain.  According to statistics, over 80% of people will suffer from this type of pain at sometime in our lives.  Most of them end up inevitably with MRIs.  After age 30, most patient’s spinal MRIs will contain some sort of abnormality – whether or not said patient is actually having back pain, or not.  In the USA, back pain + abnormal MRI = request for surgical consult although for the vast majority of them, the abnormality is not the main source of their pain.  Ergo, much less than 5% patients who present in this fashion are actually surgical candidates.

It used to be in Addis that those patients who came to clinic with back pain usually had some serious issues.  Some had infection, others had tumors, still others had significant spinal deformities as a result of congenital abnormalities.  Granted, I have still seen a few of these in clinic over the last 2 weeks, the vast majority of patients who come in complaining of back pain now have a normal examination and an MRI with some minimal degenerative changes only.  I have no problem telling them no surgery – and in general they understand that.  What I have difficulty answering is the question – now what?  Back home there is a whole potential team of people who can help these patients out including Physical Medicine and Rehabilitation Physicians, pain management doctors, physical therapists, chiropractors.   In Addis, there is me and me alone.  I can give them some anti-inflammatories and a note to rest, and most are happy.  All request to see you again in a few months time.  I notice from the patient’s chart that some of my counterparts here have been seeing them in follow-up 3-month intervals.  With an up to 6-month waiting list to get in to see a neurosurgeon in the public hospital system, an average 1/2 clinic day in which we see over 30 patients each, and so many other patients presenting with advanced pathologies I think seeing these clearly non-surgical patients in follow up is unethical.  Not that I want any of them to suffer but with the system already overloaded the way that it is I have been discharging every one of them that I see from further neurosurgical care.

Reflecting on the scenarios now it makes me consider the price of progress.  The side-effects, if you will, of effecting change in one aspect of the medical system without anticipating all the consequences.  Six years ago, when I was first here, the thought of developing an emergency room seemed ideal – somewhere where patients could get immediate and urgent care.  The reality is so much different than that dream, atleast from where I stand.  Likewise, the lack of advanced imaging studies on patients with neurological injuries used to be so frustrating to me.  Now that we have those studies I am no less frustrated, and possibly more so, as most of them still can’t be helped.   It makes me wonder if we can truly call this progress…………….