The starfish dilemma

www.who.int

The age old story contained in every "Chickensoup of the soul": a man walking along the beach comes across another guy, throwing starfish back into the ocean one by one. Asked why he even bothers since there are about a million washed up on the shore that will not be saved, and with millions more in the ocean he isn't really making a statistical difference; the wise, patient man replies "it made a difference for that one".

Now this is what all young doctors and hopefully people in most professions aspire to. Making a difference in that one person's life, saving a life, influencing it for the better or giving someone a second chance is so inspiring! But in modern society, we are forgetting the true meaning of the starfish story. In pursuing healthcare the way we are today, we are not only making a difference for that one, but also neglecting the others left over because of the way in which we are helping the lucky one.

An example: South Africa's exemplary health minister recently underwent a liver transplant. Now while the reasons behind her transplant are covered up and top secret, many aren't. For an alcoholic with liver failure to be allowed on to a transplant program that person needs to prove being alcohol free for a year. That's not too difficult and depending how much money or political power the person has, the timeframe is adjusted. A liver transplant costs $350,000. Now I am not joking. Please see the website for other complicated healthcare procedures. www.crossgrove.com/ces/cihospitalcosts.pdf

Now when a government allows procedures like these to slip into the healthcare budget of a developing country, eyebrows should start raising. How, it should be asked, can it be allowed to push that much money towards one person, a person who caused his own condition knowingly, to the detriment of basic care for so many others. The fact that it makes a difference for that one, at this point, is inexcusable.

Chris Hani Baragwanath Hospital currently spends only R7m on new equipment purchase out of a budget of R1.1bn. Some newborn babies are put into cardboard boxes because there are no incubators for them. It is being argued that too much money is being spent on admin but in the same way it can be argued that health care is not being prioritised correctly.

In healthcare there is an important and oft forgotten saying "prevention is better than cure". How did we eradicate smallpox? By vaccinating everyone. How much did it cost? Less than a dollar per person. And how many lives did it save? More than two million. Prevention is cheaper, less invasive and more far-reaching than curative medicine.

Now it's not only childhood illnesses that can be prevented, saving governments thousands of dollars to use towards other, more pressing causes. The most interesting thing about prevention is its knock-on effect.

Here's an example: Get out of your car and switch off your telly = walk around for an hour every day --> prevent pollution and obesity --> prevent global warming(with all its disastrous health effects including heatstroke, malnutrition and migration for people you don't even know) and also heart attack, stroke, diabetes, colon cancer, hip fractures and all their side-effects for yourself.

Contrary to popular belief, this is well documented with studies done to prove it. See The Lancet for more info.

Another example closer to home: Stop alcoholism --> prevent alcohol induced injuries such as car accidents, fights and falls and sexual assault --> prevent the need for urgent CTscans, brain and orthopaedic operations. Also prevent unwanted pregnancy due to irrational behaviour, alcohol dependance, depression and suicide.

The elderly are a difficult example to explain without sounding ruthless. It's much easier to think of yourself in ten, twenty or fifty years' time. And then it's also very thought-provoking to hear how doctors feel when posed with the scenario for themselves: If you are 80 years old, had a stroke, are unable, to walk, talk or even write, would you want to be kept alive at all costs? My answer is no. Standing at your elderly relative's bedside, making a decision for her is much more difficult. But my decision would still be no. Modern healthcare innovations cause many such patients to survive up to five years with a feeding tube and catheter, a myriad of medications and confined to bed. They are also exposed to numeruos hospital admissions. The costs are great, but the human suffering brought on by the condition is not allayed through the costs. This is a pit no-one should drag an elderly relaive into.

Last example. Mandatory testing for HIV --> prevent undue spread of the disease and improve cmpliance with treatment --> prevent mother to child transmission, skin cancer, malnutrition, TB, meningitis, pneumonia and gastro-enteritis: the diseases that are currently laying SA's healthcare to waste. --> prevent the death of countless teachers, police, nurses, doctors, politicians, businesspeople and labourers that have skills to enrich the country.

There are a couple of reasons why societies are not willing to take a few simple steps to markedly improve the health of their people.

Politics. It's hardly ever about money, as it is simple to see that the savings involved in implementing simple preventative healthcare measures are vast. It's more about the money in the politician's pocket. If the alcohol company is allowed to advertise and sell freely, he will ensure the politician's campaign is well funded, same with the motor industry and a good few other industries!

Human nature. We are such trusting beings. So, if my president doesn't censure my alcohol use, why shouldd I? If it was bad for me, government would have regulated it, wouldn't they? If my president doesn't beileve the virus exists, what is the testing for, then?

Family bonds, or the lack thereof. It is only when there are relationship issues between family members that you would feel guilty about stopping treatment to allow them to go in peace. How many times have you spoken to your family about what you would want when you are not able to talk for yourself? Will they feel empowered to make the right decision for you? I can promise you this, no doctor I have spoken to wants a feeding tube. They all say the same thing. "I will go in peace."

Cowboys. The first heart transplant surgeon is about as useful to the average person as the first astronaut who landed on the moon. He is a celebrity. It was a major breakthrough. But was it neccessary? And to what cost? Everyone needs the best chance in life. But if I'm saving your life to prove how amazing I am, and to the detriment of a thousand others that could have been saved for a 1000th of the price, what are my primary pursuits?

In 1970 the WHO set up the Health for All in 2000 goals. These millennium goals are still not achieved even though the world has more than enough resources, money and capacity to do so. The correct channels are the only missing ingredient to vastly improving world health.

So, to conclude, instead of blindly throwing healthcare at the sickest person, it should be worked from the bottom up, to ensure that less and less people end up needing less and less healthcare. Maybe a starfish that has been washed up on the beach is already too weak to save. Maybe it's more important to ensure the others stay in the ocean where they belong. I have decided to start focusing away from the current dilemma that the current starfish is finding itself in, and maybe rather start curing the system that got it there.

over and out.