Using medical services in developing countries

This posting comes in 3 parts:
1. Medical emergency
2. Elective medical treatment by foreign doctors or dentists
3. My observations about medical services

Medical emergencies
I am an avid traveller to developing countries - having been to about 30 of them. In that time I have avoided serious medical ailments, though it has at least given me an idea of what I can expect in different countries in terms of costs, services and competency, as well as the risks from poor food preparation. So let me describe those situations.
1. Haiphong City, Halong Bay, Vietnam in 2001: This is a few years ago now, but I'm quite sure nothing has changed. I was sweating profusely with a bad fever. I went to a local first aid hospital where I managed to find a doctor that spoke English. He was rather young looking, but in my search for symptoms I noticed a yellow spot on my leg. I thought maybe an iodine deficiency or something. Actually it was just an old bruise. Anyway he seemed to have less of an idea. Really I got no help. So I decided to go to Hanoi, as I know there was a international hospital there with western doctors. Within an instant I was diagnoses flawlessly. I had food poisoning from a local restaurant where I was eating daily. Sick despite being very selective about what I ate. The other issue I had in Hanoi was a fungal infection. Basically a big 'moon-shaped' inflamation around my anal passage to be medically correct. Well I paid $US120 for that profound advice, which didn't bother me much because I was just relieved I didnt have some rare skin disease, but they charged me $20 for a generic fungal cream that would cost $6 in my country, and $3 locally. Well I will be wiser in future. They are really praying on the fact that you dont know if foreign medicines are available in the country, and where to get them. Because whom do you ask for advice - few speak English, and who knows where a drug store is unless you've need one in a developing country....well its not easy in Vietnam...but Philippines is easy.

2. Lipa City, Batangas, Philippines: Lipa is a small city 80km south of Metro Manila. It has a small hospital. I paid Y600 ($US12) to see a GP. Being a foreigner I pay alot more, but the good news is that I go to the start of the queue (20-people long). I suspect they are free patients. He gave me little time, in fact he had an assistant gather all the info, so I spent just 1minute with him...I did however get the chance to sit down. In that one minute he referred me to a urologist. The urologist had the same system, a queue outside, which I didnt have to wait through, but that was little comfort because he kept me waiting for 90mins inside his office along with 6 other people - not patients mind you, but sales people from pharmaceutical companies - Pfizer and a competitor. I thought this highly suspicious, but I guess at least he is letting them compete against each other. I'm just wondering to what extent commission will feature in the selection criteria. But anyway...he kept me waiting so long...then again....he offers me just a 30sec appointment which cost me P800 ($US16) because he has another appointment. On reflection I am paying about $US720/hour for services that would cost me $US350-400/hour in the west...and I'm waiting twice as long as any western medical centre....go figure. I didnt even get to sit down, and he sends me off to the lab. The lab seemed to be where all the work was done. Yet that cost me just P220 ($US5). I didnt bother returning to the specialist for an opinion...I just interpreted the results myself.

3. Medical Central, Robinsons Galleria Shopping Mall, Ortigas Centre, Metro Manila: I went to a local medical centre in Metro Manila. This is by no means an upmarket one. A nurse gets your pulse, and asks you the basic questions, then you wait 30-40mins for a doctor. At this place I was treated like any other patient. Thats a good thing. The service at this place was much better though since I had a 15min consultation, though I found that the staff has a low level of medical knowledge.
Another ok medical centre I found was on the 5th floor of the Shangrila Mall in Ortigas Centre, Metro Manila. Its the place I would go for minor ailments.

4. Medical City Hospital, Ortigas City, Metro Manila: This is a private hospital, and is considered one of the best in the Philippines. I found the standard of medical care equal to, if not better than any I have received in the western world. The catch though is that I paid for it. I had a blood test, stool test and scan of my intestinal organs and 2 consultations for P16,000 ($US320). Not cheap by any means. But problem resolved....I was tired after 3 weeks of non-diagnosis.....thats 3 weeks of diarhorea...and the advice....you have a bacterial infection...drink more water, avoid alcohol and oily foods. :) There are 2 other private hospitals in Metro Manila which have a similar standing of service:
5. Asia Hospital - further info coming??
6. St Lukes Hospital - further info coming??
7. Another??

What became apparent to me is that hospitals are very good because they offer a higher standard of care, they have the capacity to carry out most tests you need to perform...though I suspect if I wanted to get tested for the antibodies that would prove I had celia disease, I might need to go to a western hospital. But as it was I just had an intestinal infection and not a gluton intolerance. The cost of a room in a public hospital is about the same as a hotel (P2000 or $US40 per night). Consultations and testing might just be P1000-2000 ($US20-40) compared to P15,000-20,000 ($US300-400) at a private hospital.

Elective Medical Treatments
There are alot of skin treatment places in the Philippines though I have no idea as to the quality of care. I suspect they are not high because of the lack of codification of standards. There is however certainly a trade-off between standards and price. I'd hate to risk using a dodgy service provider who sees $$$ without any duty of care.

I met a foreign guy who was friends with a Filipino girl who recommended that I go to a certain dentist for care. I was accustomed to paying $US110 just to clean and checkup in Australia, but I paid just P600 ($US12) in the Philippines. But get this - I went to an upmarket dentist in the Rockwell Centre, Makati City, Metro Manila. This guy is well qualified and attends conferences in the USA. His equipment was more modern than anything I'd seen in Australia. Dont know why Australian dentists are so tight with their equipment. Never found one with digital cameras..but maybe that has changed since. I can tell you that the level of care and attention that I received from this upmarket dentist far exceeds anything I received from the 5-odd dentists I've been to in Australia.
Though I note that when it came to receiving 'significant care' like the recapping of 2 teeth, the cost went up considerably. I was quoted $US750....and I suspect this pricing was more in line with western prices. I suspect the motive was that I no longer appeared to have a Filipino friend. So the moral of this story is...you will get more competive prices if you have Filipino friends....better still if they ngotiate for you over the phone.
I believe there are similar opportunities to avail of cheap medical services in Thailand and India. But dont go to westerners in developing countries, as they will charge you more for the privilege, and its just possible they are there because they breached some ethical standard in their home country. Such doctors can more readily pay off an official in Asia to get a licence here. Asia is so corrupt. Alot of Asian doctors are educated in western countries....to varying degrees.
Actually my observation is that the quality of formal medical education is not so bad in developing countries, but that the low attention to medical standards and training after they have graduated is the problem. Perhaps someone can comment on this. The reason I say this is because I think you might learn alot of theory at university (in whatever subject you do), but without training in applied medicine, you are likely not going to develop into a fine doctor. That observation comes from personal experience and talking to a young medical graduate from the Philippines. He's a smart guy, and I think the lack of institutional support in the Philippines on the training side would have undermined his capacity to provide good service. So I think its more important to recognise doctors that have worked overseas as opposed to have studied their full degree in the USA. Another qualifier I will make. I think in diagnosing conditions, critical thinking is an important capability, and I dont think Asian culture is conducive to those skills. Even the western world tends to marginalise critical thinks in adulthood, but its worse in Asia. So if its not familar to them, they are unlikely to offer helpful advice.

My observations about health service
As a foreigner there is a tendency for them to charge you a 'foreign price' as opposed to the local price. They dont tend to do that however if you are accompanied by a Filipino, or better still the initial inquiry is made by a Filipino national. In case you are wondering...servicing foreigners is a very controversial issue in the Philippines. Every year the best graduate doctors, programmers and others from the best universities get offered jobs overseas. Critics argue that some of these people received free education yet render no service to Filipinos. The reality is however that these Filipinos repatriate huge amounts of money back to the Philippines - equal to 30% of the national GDP.

How to manage your health affairs

The topic of this post might make you wonder - what are 'health affairs' - isn't that some government bureaucracy? Well yeh...and it exists because individuals fail to take responsibility for their personal affairs - in this case health.
I have learned the hard way that its important to have a systematic and deliberate strategy and plan for managing your life, and that the earlier you develop such a strategy the more fluid the system will operate and the less cumbersome adminstrative challenge it will become. The intent of my health strategy is to know ahead of time the way I should live in order to maximise my capacity to enjoy it, as well as to prolong my life as long as possible so I can achieve as much as possible within the limits of my 'human capability'.
It is my firm believe that having a strategy is not a waste of time. I believe that the time I spend researching health issues, understanding my body and developing my strategy is going to be repaid in several respects, which I think will become apparent over the course of this posting.
Of course there is a trade-off. I am not suggesting that we need a study health issues for years. I am well aware that there are doctors who do that. I am saying that you need to take personal responsibility for your health issues, because unless you are wealthy enough to have a personal health care expert managing the health aspects of your life, I can guarantee that you know more about aspects (symptoms, medical history) of your health than your doctor. The problem with way health is currently managed is that:

1. Division of responsibility: There is no clear demarcation of responsibility when you visit a doctor. Its not readily apparent what role you should perform, what your job is. Many of us just turn up and expect them to know. Certainly no one helps us, which is why we have to take pro-active steps to prepare ourselves to get the best possible outcome.
2. Personal interest: Apart from the initial interest in your personal history, I think doctors tend to take little interest in patients personal care. That is a sad testimony to the level of empathy that doctors generally have. I truly think most of them hate their jobs...sticking fingers up people's arses...and the need to always be there. Its a job that requires a genuine paternal care, but I think alot of doctors grow weiry of that concept over time...which was perhaps idealistically conceived. Or perhaps its because they are dealing more with foot fungus and sexually transmitted diseases than with life threatening diseases.
3. Conflict of interests: Often you have medical centres with their own pharmacy (drug store). It might be 'seemingly independent' but rest assured if its in the same building, there is a relationship with the owner. Its worth finding out the cost of various medicines at various stores because I have found big differences...even huge mark-ups for late night service. Your doctor might recommend a medicine that he believes will do the trick, but is that because he receives a commission from a pharmaceutical company or the pharmacy. Is he rejecting a cheaper generic product or a home remedy. I am amazed when doctors and dentists claim that the results of the medical tests you undertake is their property by virtue of them holding them. Find out your doctors policy on that issue. Since the ascension of medical centres, I think the 'commercialism' has perhaps given away to the need of patients for flexible options.
4. Unorganised structure: Professionals are amongst the most self-indulgent and poorly organised people on earth because they always want to do their own thing - and doctors are no exception. Consider that its only now that we are seeing computerisation of medical records, which means doctors can actually read another doctors writing. It means a doctor can have access to a patients full medical history, and easily transfer these records to other doctors.
5. Lack of relationship: Unless you have been able to retain the same relationship with a family doctor over the years, its likely that your doctor has joined a medical centre, where they share facilities and administrative staff. There are pros and cons to this set-up. The benefit is that doctors can make more money sharing facilities, as well as have more flexibility with working hours. The problem is that patients no longer have a relationship with their doctor, and it means that bad doctors tend to be supported by this system. Why? Because you get a 2nd opinion rather than returning to the old one.

So I offer the following health care tips:

1. Be selective: When you go to a medical centre, never accept just any doctor, becaus you will be assigned to the doctor that no one else wants an appointment with, whether its because they are incompetent, impersonal or inexperienced. A better strategy is to ask for any specific doctor from the list on the wall. If they are not ready, have another choice. I have routinely found that if you dont ask for a doctor, you get a bad one. Often some immigrant doctor with poor training, offered a resident work permit because of the shortage of skilled local doctors. Rural areas have little choice unfortunately.
2. Know your risks: Few people have the spare time to get a medical degree, or to spend weeks learning about their health isues. However it is worthwhile understanding the top 10-20 biggests threat to your gender. These lists are often provided in the newspapers and are easily found on the internet. By researching these ailments and making some notes about threats, preventative measures you can take to avoid, and symptoms you can expect to identify.
3. Be prepared: I dont know about you, but for years I was going to doctors and expecting them to determine my health issue with little help from me. I simply didnt give it much thought, and they showed no concern for my lack of knowledge too. The implication is that they had to search for symptoms as opposed to me telling them. I could say I was in pain, but was not particularly sure where it was. I have since learned to attend a doctor's appointment PREPARED, which means that over the 3 day period in which I am ill, I will make a note of what symptoms I feel (note anything out of the ordinary), when it occurs, how frequent, where it is, and its nature. Writing a note on my PDA ensures I dont forgot it, since its always with me.
4. Know your symptoms: Another aspect is knowing how to describe how I feel. Often I found I didnt have the vocabulary to describe what I was feeling, or even what constituted a symptom. But its ok if you write down unrelated issues, as the doctor will know the difference. You can find a list of symptoms that you can check on the internet. Dont rationalise a disease - so read through the list dispassionately before you attempt to match a condition to it. See www.wrongdiagnosis.com.
5. Do your own research: I cant understate the importance of researching your condition on the internet. Many of my doctors are impressed when I display some knowledge of my condition. My family has a history of Celiac Disease - simply a gluton (wheat) toxicity or intolerance - yet a great many doctors didnt know about it. There are websites that allow you to type in your symptoms to get a list of possible conditions. My advise is to independently research those conditions to see if you have a match. You might identify other symptoms that were not readily apparent to you. Its important that you let the doctor diagnose rather than tell him his job. Tell him you did some research on the internet...ask him why he thinks your condition is not ...... since you display symptoms ..... By keeping your doctor accountable, you can have greater confidence in his professionalism. If you are in doubt, seek a second opinion before you self-diagnose. Doing research can actually save you money and time. Knowing that I needed to fast before taking a blood test, I didnt take any food or fluids for 10 hours before my appointment. Of course you might not care if you have a free health system.
6. Ask questions: You need to establish whether your doctor is credible becaus you need to know whether he is in a position to know your condition, and if not whether you need to seek a 2nd opinion. Doctors are humans, so if they have a low self-esteem or pride in their position, they might not willingly convey their ignorance on a medical issue, but look for other signs, eg. Body posture or tone. But by far the best approach is critical thinking. Asking probing questions is the best approach, and research is intended to help you identify those. A good doctor will respect you for taking an interest (I have found), insecure or incompetent doctors will get defensive and attempt to derail you. Dont be perturbed, they are telling you they are not capable of helping you at the standards of service you require....so dont see them again.
7. Understand the doctors perspective: Understanding the motivations of your doctor can help you get better service and save money. The longer time you spend with a doctor, the more he will treat you like a human being. The more you corner him, or attack his diagnosis, the more defensive he will be. In some countries (Philippines) doctors are illegally selling medicines directly. This can bias the doctor's judgement and result in you being prescribed medicines that have more severe side-effects. Avoid these doctors as they are crossing an ethical divide. Doctors often have deadlines for meetings or a queue of patients. Dont be surprised if they short-change you on service so they can alleviate these pressures. Protect yourself.
8. Prevention: Determine what is a healthy way of living. I am a great believer that our bodies give us a great deal of information about our health condition. Try different diets and see what impact it has on you. Consider your level of energy, gastro-intestinal condition, flatulence, weight control. You should get blood tests for cholesterol (HDL/LDL) as well. Doctors are only concerned with our health at times of ailment, but many conditions are discovered too late, and can be avoided through prevention. I am skeptical that there is 'one diet' for all people....maybe it depends on your genetic makeup. Maybe our bodies adjust if we adopt a regular diet. Regardless, you cant ignore empirical evidence of what constitutes a healthy body.
9. Family History: Ask your parents and grandparents if there is any medical condition or affliction that is affecting your family that might have a genetic link. Upon identifying any such issues, research the ailment and make notes. Dont forget to provide your information to other family members. I found out that my family had incidences of celiac disease and a rare (rubbing) eye condition. Fortunately pretty good with respect to cancer.
10. Standards of comparison: You really dont know what a good doctor is until you've had one, so experiment with some. I dont mean just a few at your local medical centre. Go to some up-market suburbs 20km away to see what type of service wealthy people are receiving, and what they are paying for it. Professionalism is mostly the result of personal ethics rather than anything genetic. Wealthy people are accustomed to paying more for service, so expect doctors in those communities to know better. If it costs more, then economise....just go there when you have a critical ailment as opposed to a common cold.

Alot of the advise here does not just apply to personal health. I dont know much about cars, but I apply the same critical thinking skills to car mechanics. Mechanics and other tradespeople are famous for over-servicing customers with no knowledge of their field. So ask probing questions to determine how necessary a certain component replacement is. The chances are they will be applying very 'high' standards to your car, or very conservative 'replacement policies' in an attempt to increase their profits. Alot of them aren't 'directly' dishonest, but they are not acting with regard for your best interests if they dont make you informed, and that is a breach of professional standards of care for the interests of the customer.