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.

1000 mense in SA sterf vandag! Onvoorkombaar...

Vandag is n vent dag. Hierdie vent is 2 jaar "in the thinking" en dateer uit my gemeenskapsdiens jaar in Bethlehem,dit gee 6 fundamentele redes hoekom SA se pogings om HIV die see in te dryf so misrabel misluk. Die post is in engels geskryf want ek het dit op helium gepubliseer en hulle spellcheck aanvaar nog nie afrikaans nie. Geniet dit.

Talking about the effect of AIDS on Africa is like talking about the effect of global warming on the arctic ice cap. The full force of the situation only hits you when you're in the thick of it and realise that, probably, the tipping point has already been reached and the cascade is unstoppable.

When you stand in front of a giant glacier and watch it crash in to the sea, the inevitable catastrophe sends shivers down your spine. Walk into any government hospital in South Africa today and you get the exact same effect. Chilling. Walk by the myriad of fresh graves in any graveyard in South Africa and you would be excused for thinking the country is at war. Maybe it is.

The effect of AIDS crosses all boundaries. It is redefining culture, economics, religion, political stability, education, health and healthcare.

1. Not only are Africans faced with the dilemma of having to face up to the fact that their traditions are no longer protecting them against evil but their very definition of intimate relationships is also being redefined. A woman is getting AIDS from her husband, he got it from a far off city where prostitutes and shebeens have been a way of life for a long time. Women are giving it to their children. Who else is supposed to nurture and care for their children? Who else can take on that role. No-one, nature has us up against the wall.

2. Inevitably the economics of any country ravished by AIDS will suffer. The very workforce, the drive of the economy is dying, and with it competition, consumerism and all efficiency. South Africa's saving grace thus far has been the large amount of "reserves" not partaking in the economy at all. A country with an unemployment rate of 25% and no doll has a few willing hands to spare. Not for long, though. In certain areas the shortfall is already being experienced.

3. The education sector is badly understaffed with most schools not running at full capacity. 20% of teachers are HIV positive. This has a direct effect on the quality of the country's future workforce and thus on it's competitiveness in the global arena. An individual's education is the only thing that gives him/her the power to choose a different way of life than the well-known road of poverty, child prostitution and crime.

4. Not only is the healthcare system being stretched to the limit by the influx of new patients, many healthcare workers themselves are infected, on treatment, dead or dying. 1000 People die of AIDS in South Africa daily. The recruitment cannot keep up with losses because few of the unemployed masses have the right qualifications to work in healthcare. Many basic nursing duties in primary level clinics are already being carried out by volunteers with no training receiving no payment. This, of course increases their chance for infection too. The devastating effect of TB in conjunction with AIDS falls beyond the scope of this article.

5. Religion and traditional beliefs also have to be redefined. Many know of the furor caused by the spread of the superstitious belief that raping a virgin will cure you from AIDS. Many of South Africa's girls lose their virginity through rape, not some. The deputy prime minister's stint in court when he proclaimed that having a shower will protect him from any infection didn't improve the world's view on SA's arrogance and ignorance. Women need to prove fertility before being offered marriage, how can condoms then be a viable option for them? Many people still go to the local sangoma or church for miracle cures before going to the hospital, inevitably arriving "at death's door" due to procrastination, leading to the widespread belief that hospitals are the cause of death.

6. Many government policies directly oppose HIV prevention strategies. An impoverished woman cannot get a state subsidy for herself, only for her children. Her children only get grants up to the age of 14. Now, how in their right minds are these young girls going to abstain from trying to reproduce? Furthermore, the state pays a subsidy for AIDS but not for HIV infection. It also pays a subsidy for active TB which stops once treatment stops. Now, it is understandable that the government needs to draw the line somewhere because there is only so much money available in the national treasure chest. But to the man om the street it is pretty obvious that he is being paid to be sick.

Government is going about the management and prevention of AIDS the wrong way, it started much too late and is dragging it's feet unneccesarily. Government had to be taken to court by the TAC to be forced to start antiretroviral therapy for pregnant women, prisoners and finally the general populace. It does seem like an easy equation to let the people who are the biggest burden on government subsidies and healthcare and invariably then the country's economic stability rather just die. On the other hand, it also sounds alot like genocide if the health minister backs up her decisions by maintaining the disease simply doesn't exist.

The future for AIDS in South Africa looks rosy. The future for the people of South Africa? The Chinese have a saying- may you live in interesting times. It's up to you to figure out if it's a blessing or a curse. The battle against AIDS happens on a one by one basis. You make your decisions. You choose. You choose who you sleep with, you choose who to trust with your health, you choose to take the medication offered to you, you choose which charity to support, you choose to pay your taxes, you choose for whom you vote. Remember, you choose.

Oor en uit