The Bad

I'm sitting in class now. :) Psych; it seems like it will be interesting. I spent the last few days readjusting to life at home. I started by buying myself a new razor on Saturday, to reward myself for having survived the summer. I finally tried it out on Monday morning, and man was it awesome. I also hit Nelly's for breakfast on Monday and then Tuesday before class; mmmm.

Anyways, I have also been spending a lot of time ruminating about the summer. As part of the process, I'm currently reading, "Petals of Blood" by Ngugi wa Thiong'o. It's full of all the problems that were so obvious in Tanzania today; the book was written about post-independence Kenya.

I think I've already mentioned how the setup of society in Tanzania was so shocking to me. The education systems and health care systems are set up in such a way as to deny the lowest classes the possibility of hope. Education beyond primary school is priced beyond the means of a large percentage of the population, and health care is another problem altogether.

First of all, let me say that I met a lot of terrific, dedicated doctors there. Docs work for a piddly income compared to anywhere in Europe or North America, primarily out of a drive to help their patients. Our primary preceptor was really inspirational, given the hours he worked, and the skill and caring he showed in dealing with his patients.

However, those docs were primarily working in the private system, where patients are primarily the wealthy: either they are rich enough that they pay for all their health care with cash on hand, or they are lucky enough to have health insurance provided by their place of work (this would only be a small percentage of the population).

The government system, on the other hand, is supposed to be accessible to the majority of the population, serving even the poorest people, with fees waved according to need to pay. (For Canadians, I'd have to say that the system closely resembled the Alberta government's proposed, and abandoned, 'Third Way' of public-mixed-with-private health care.) Great, it sounds like everyone in the country has access to health care, right? The rich get to go to private hospitals for enhanced services, while the poor still get a basic standard of health care provided to them at minimal or no charge, correct? Wrong.

The problems begin with the minimal up-front payment that patients must pay, in order to see a doctor. Typically, this is in the range of US$17; half is to register, and half is to see an actual doctor. This is in the same range as your typical co-pay in the US, or as the now-illegal user fees were for a short time in parts of Canada. That may not sound like a terrible amount to a North American, although even here co-pays are primarily designed to prevent people of lower income from going to see a doctor, thus lowering costs to insurance companies. But, in Tanzania, where your typical lower-class person is lucky to make $50 a month, and lucky to save 1/10th of that, that is a huge quantity of money already. Next, that inital fee doesn't cover any tests whatsoever, which all must be paid for by the patient. So, need a CBC? Gotta pay for it. Need an X-ray? Hope you have another $20. A biopsy? Good luck. Don't have the money? Then, sorry, no tests for you, and a clinical diagnosis is all you'll get.

An expense I haven't mentioned so far is tea money, a.k.a. bribery. Doctors and nurses at the government hospitals are paid very little, and so a system of bribery is well established, with service often being withheld or delayed if the appropriate bribe of a few dollars here, a few dollars there, is not paid. It starts at the registration desk, where a bribe can get your up-front fees reduced or partially waved, continues with the nurses, where a bribe can mean the difference between getting that IV put into your dehydrated baby or not, and finally with the doctors, where a bribe can make the difference between being seen today or tomorrow or next week.

I said that based on need, you could be given free health care. In theory, that's great, but in practice, the system is almost non-functional. Noone was able to explain to me how people could qualify... I suspect that you qualify by bribing the correct people. In a sad twist, financially the best diseases to have seemed to be HIV and TB, where a positive test resulted in free medication and doctor's visits, provided for by foreign governments, pharmaceuticals, and Bill Gates.

I'll finish off this subject in the next post.