Thursday, June 8, 2017

[Second Opinion] Why my patient sold his cow to buy antibiotics

by Gideon Lasco
Philippine Daily Inquirer

During my medical training at the Philippine General Hospital, among my memorable patients was “Tatay Leonardo,” who had diabetes. He was admitted into the Internal Medicine ward for diabetic foot—a condition in which one or both feet are so devoid of blood circulation and nervous sensation that they become easily wounded, infected, and subsequently gangrenous.

Managing diabetic foot is a multidisciplinary effort: The diabetes itself is taken care of by internists, often with the assistance of endocrinologists; the foot is managed by orthopedic surgeons, sometimes with the help of rehab doctors. And because diabetes is a systemic illness, there are many coexisting conditions that necessitate more specialists as part of the management team.

Alas, just when we were beginning to make progress with Tatay Leonardo, he developed cough and fever, and after two days we diagnosed him with hospital-acquired pneumonia. Because the bacteria that thrive in hospitals are difficult to treat, we had to prescribe for him an intravenous antibiotic called Meropenem—which costs P9,000 per day of administration.

I told Tatay Leonardo and his wife about the new diagnosis. The antibiotics, I said, must be started right away so we could prevent the pneumonia from worsening. In one of my rounds, I overheard them discussing how they will finance the IV medications. “Tell them to sell the cow,” I heard Tatay Leonardo say.

Fortunately, he recovered soon, and just before I finished my rotation in Internal Medicine, we sent him home. As I processed his discharge papers, I thought of his return to their farm: Surely there will be a celebration, but surely there will be consequences over the loss of a cherished farm animal.

Why did they have to sell the cow?

We could point to the fact that Tatay Leonardo had no money or health insurance, and in this he is not alone. Many Filipinos live without any financial protection from “catastrophic illnesses” like cancer and chronic ailments like diabetes.

We can also ask why the diabetes was allowed to progress: Diabetic foot is after all a sign of an illness that has been uncontrolled for so long. Had Tatay Leonardo received preventive advice like reducing sugar intake, had his diabetes been well-managed, perhaps he wouldn’t have required hospital admission in the first place.

Even so, the antibiotics wouldn’t have been necessary if not for the infection that he acquired. Had the wards been less crowded, and hand-washing more strictly enforced, perhaps the pneumonia could have been prevented. Or, if not for the rise of antimicrobial resistance, a cheap antibiotic would have sufficed.

Finally, we can point to the prohibitive cost of medicines in the Philippines. Meropenem is 40-60 percent cheaper in India, and Metformin—a common antidiabetic drug—costs just P.60 there, compared to P3.75 here even for generic brands. This disparity remains an inconvenient truth for which the pharmaceutical industry must be held to account.

The picture, however, is not all that bleak. Thanks to the Sin Tax Law, more Filipinos now have PhilHealth coverage; in public hospitals, indigents receive more financial assistance. Though it has shortcomings, the Sin Tax Law has been a real breakthrough and we should not allow Congress to water it down. In fact, it should be expanded to benefit health facilities and human resources.

But improving hospital care is not enough. As the prevalence of noncommunicable diseases like diabetes and hypertension rises, we also need to promote preventive measures like exercise and healthier food choices. Moreover, we should also make it easier for people like Tatay Leonardo to seek treatment and follow-up by having accessible primary care doctors, health centers, and a strong referral network.

All of what I have outlined constitutes a responsive, patient-centered healthcare system—one that considers health from various perspectives. For as long as we do not take bold steps toward this direction, many Filipinos will be paying for healthcare with not only their cows but also their futures.

This piece was originally published in the Philippine Daily Inquirer: http://opinion.inquirer.net/104609/patient-sold-cow-buy-antibiotics

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