DR. RONNIE ENRIQUEZ BATICULON
Dr. Ronnie E. Baticulon is a pediatric neurosurgeon, teacher, and writer. He posts his stories in his blog, http://ronibats.ph.
Feedback welcome at firstname.lastname@example.org.
Recently, a medical intern’s photo of the emergency department of Philippine General Hospital (PGH) circulated online. It showed the triage area filled to the brim, packed with patients lying on bare metal stretchers, fazed watchers, and not surprisingly, only a handful medical personnel. Because of a change in the start of the academic year, the student workforce had been reduced to a third of its usual number. “Madness. We need help. (Crying emoji)” part of the caption read.
I trained in PGH for 10 years: Five as a medical student and another five as a resident. The image was not at all an unusual sight. Having been a neurosurgical trainee in the country’s largest government hospital, I know all about endless days and personal sacrifices for the sake of patient care.
While most people in social medial reacted to the photo with dismay and frustration, I noticed that quite a number have expressed either distaste or plain apathy to the situation. It is, after all, fairly easy to dismiss the post as a millennial medical student rant. To shrug things off, just because “Ganyan din naman nu’ng panahon namin” (We experienced the same thing in our time) or “Ganyan din naman sa ibang public hospitals sa Pilipinas” (You find the same condition in other public hospitals in the country). Ergo, stop complaining?
Problem—accepting status quo
Therein lies the problem. When we accept the status quo just because that is how things have always been, we deprive the Filipino people of the health care that they deserve. The work in the hospital could always be accomplished at the end of the day, but at what cost? At worst, maybe a few needless, nameless deaths.
The emergency room (ER) photo forces us to at least acknowledge this truth: What we have is a tenuous public health system, perpetually low on resources and dependent on an overworked yet underpaid workforce. It has always been teetering on the brink of collapse, and it would take only the slightest pressure before eventually giving way. Today it is the shortage of medical students. Maybe tomorrow, it’s a mega-earthquake or a virulent strain of influenza.
My colleagues and I have known this all along. We have lived through this horror story every day in training. The reality is that if you are a sick Filipino and you do not have money, you are more likely to get delayed treatment or suboptimal care, and to ultimately die from your disease, compared with your richer counterparts. One does not need a scientific study to prove this. Ask anybody who has ever worked in the Philippine public health system and that person will agree in a heartbeat.
I have seen patients die just because their families could not afford antibiotics or chemotherapy. I have attended to patients who deteriorated in the ward or in the ER, when they could have been more closely observed in a proper intensive care unit. Poor access to timely and appropriate health care also means that many patients present to PGH either with significant complications or their financial resources depleted from previous admission in a private facility. Some have been unlucky to be both.
The Australian scenario
I have just returned from a year of training in Australia. Working at The Royal Children’s Hospital (RCH), a government-run pediatric hospital similar to Philippine Children’s Medical Center and National Children’s Hospital, that was where I witnessed the great disparity in health care between our country and theirs.
Let me give you two scenarios:
Suppose a 10-year-old boy in Melbourne comes to his parents complaining of headache that has been ongoing for two weeks. His parents bring him to the general practitioner, who requests for a computed tomography (CT) scan of the brain that is done on the same day. The scan unfortunately shows a brain tumor and the radiologist calls the general practitioner, who then gives me a ring to organize hospital admission, I being the neurosurgery fellow on-call.
On the same night, as soon as the patient is admitted, I can organize a magnetic resonance imaging (MRI) scan of the brain and spinal cord to give us a better picture of what we are dealing with. I speak to the family to obtain consent, while the nurses ensure that they have the social and emotional support that families dealing with a new cancer diagnosis often need. No doubt the family will be anxious, but at least, they will spend the night in a well-equipped, comfortable private room.
As early as the next morning, my consultant and I will be operating on the patient. On the following Wednesday, the case will be discussed with a multi-disciplinary team. If it is confirmed to be brain cancer, plans for subsequent chemotherapy and radiotherapy will be made right there and then. It is no wonder that five-year survival rates approach figures I only get to read in journals and textbooks, often even better.
The Manila scenario
Now, suppose I have an identical 10-year-old boy in Manila with the same brain tumor. When the family presents to the ER, one of the first questions that the parents would be asked is, “Saan po ba kayo magpapa-admit, sa charity o sa pay?” (Would you like to be admitted as a charity or a private patient?) There is often a follow up question, “Magkano po ang dala ninyong pera?” (How much money have you got?)
I used to have a readymade script explaining to families that nothing is free in PGH anymore. CT and MRI scans are not free. Operating room supplies and medications are not free. PhilHealth insurance may be able to cover some of the costs of treatment, but that is not always the case. The parents will spend days and nights running around the hospital to facilitate lab results, buy medications, obtain blood donors, and speak to social service for financial assistance. They will look for the most comfortable cardboard box to lie on, and if they are lucky, they will have a nice little corner away from the sun and next to their loved one.
Busy operating room schedules contribute to delay in timing of surgery. Prolonged hospital stay leads to more complications and worse outcomes. Even if the tumor were taken out completely, the family would still have to find money for subsequent chemotherapy and radiotherapy, leading to unwanted tumor recurrences. It is always frustrating to realize that treatment decisions often rely on financial capacity rather than clinical efficacy.
Perhaps the only thing truly identical in both scenarios is the desire of both families for their child to get better and to return to his previous, normal life, as if nothing has happened. And I have seen that, of course in Australia.
Whether rich or poor, parents bring their kids to RCH, a public hospital, not because they do not have a choice. In fact they do, and they still choose RCH because they believe it is the best hospital to treat their children. I would do my ward round in the morning not knowing which patients were private and which ones were public (Yes, I was told not to call them “charity”). I finished training without knowing where to find the hospital cashier, only because I never had to bring up money when talking to families.
Are you able to get the same level of care in the Philippines? In the big private hospitals, yes. In fact, even in the private ward of PGH, you could. The question had never been about expertise of medical personnel.
Fixing the system
Fixing the public health care system for 100 million Filipinos will take time, considerable effort, and genuine leaders who understand that it is an interplay of psychosocial and economic factors that result to 68 Filipinos dying from all forms of tuberculosis (a treatable disease), another 26 getting diagnosed with HIV (a preventable disease), and seven mothers dying from childbirth (not a disease at all) every single day.
The TRAPOs (TRA-ditional PO-liticians) only become aware of the situation in public hospitals when their drivers or helpers need urgent medical care, because if it were their own family, they would of course choose the best private hospital in town. I long to see the day when our government officials would realize that the public health situation cannot be alleviated by intermittent medical and surgical missions, with the ulterior motive of name recall for upcoming elections.
The viral photo may have shown PGH ER, but as pointed out by some netizens, that could very well be in any other public hospital in the country, others no doubt much worse. The local and regional hospitals have to be strengthened both in equipment and human resources in order to decongest hospitals like PGH. It is both hard and unfair to blame Filipino doctors and nurses who choose to work abroad when the opportunities and incentives back home are limited, if at all existent.
It is a gargantuan task, but we have to start somewhere. We begin by acknowledging the shortcomings and failures of the system. Shrugging them off does not create a solution. I have no training in public health and I only have a vague idea on public health funding, but having been at the forefront for so long, I know that we could do so much more for our Filipino patients. And by we, I refer not just to medical and paramedical staff, but to everyone who cares enough for this country to continue living in it. Perhaps with President Rody Duterte and Vice President Leni Robredo, there is a spark of hope for the Filipino patient.
Status quo is nowhere near acceptable. If you think it is, I dare you to walk into PGH ER as a patient and lie on that metal stretcher. Perhaps then, amidst the chaos and confusion aggravated by constant humidity and unadulterated human suffering, you will realize that your life is no more important than any PGH patient’s, and that you do not deserve to die a needless death, just because you happened to be poor and Filipino at the same time.
July 2016 Health and Lifestyle