an ethical dilemma

Well, this week has been our busiest yet with Pr Nacro away. We are seeing about 10-12 patients / day that are new to us (followed by Pr Nacro); each one takes a while because we can't just prescribe ARVs without knowing anything about the child. Plus, our followups. We're up to about 15 or so patients / day, sometimes more. We're seriously limited by space in our 1 room clinic. Each morning we seek out a free consultation room because we can get through many more kids with 2 rooms.

From about 8am - 10 or 11am each day one of the pediatricians does consultations. So patients come and line up (and its a shared waiting space with our patients for now). Between when the morning doctor finishes and when the on call intern starts (which can be 4 hours or more), there are no physicians to see acutely ill patients. Sometimes the nurses see the most critically ill patients, but even things like stiff neck & fever (in the middle of meninigitis season) waits for the intern. So, often we get patients at our door wanting us to see them and generally, we refuse. On one hand, they're sick and they need to be seen. On the other, there is a system in place (of sorts) that we don't want to disrupt; also, our mandate is to care for the HIV infected and exposed kids, and to help on the wards. If we start seeing those patients, we may have negative systemic consequences. On the other hand, we feel terrible about making them sit and wait for the intern.

My last patient of the day was a child who accidentally got into our "line" - neither HIV infected or exposed; however the patient was so sick that I decided to see him anyhow. It was a 3 month old refered for poor feeding. The child weighs 2.8 kg; which is what he weighed at birth. So, I did the history and physical, wrote my first admission orders in 3 years (it was so routine in residency!). Then comes the dilemma of how to execute the orders. The mother of course had no money for the medicines and infant formula (mom has minimal breast milk). We scrounged up most of what we needed from hospital supplies. And I went out and bought 2 cans of infant formula and brought them back. 3 hours after leaving the supplies etc with the nurses, I checked back and nothing had been done since I left; the baby hadn't been fed, no oral rehydration solution had been given, nothing. I stood in the ward until we got things going.

The thing is... there were 10 other kids in the Urgences ward, as sick. Some can't afford their medicines either and just go without. The wards are full of kids who's parents can't pay for their medicines.

So ethically its tough. On the one hand, I want to do good to my patient (who I shouldn't have even been seeing). I can't sit and watch him die because his mom can't afford the $4 can of formula.
On the other hand, what I am doing is unjust. I am not paying for all of the kids, and some are going without medicines and food because their parents can't afford it. Also, foreigners stepping in to buy some kids drugs is not sustainable and potentially weakens the health care system.

And what is really unjust is that some of these children are dying for lack of $2-3 worth of medicine. That the system (imposed by the World Bank and the IMF) demands that the poorest people in the 3rd poorest country in the world pay for their own health care costs - something that Canadians, with all their privilege and all their disposable income for SUVs and TVs etc etc etc, don't have to do. The economic theory is that health services will be more valued and health care usage will go up and quality will improve with a pay as you go system. In fact, several studies here in Burkina suggested that the exact opposite happened when Burkina instituted those changes.

These sorts of things tear me up.