Hobson's Choice

Photo of the week

Highlight of the week: A slap up meal. Our reward for screening staff at Thornicroft Lodge.

Lowlight of the week: We drive straight past Lucy, stalking in a gully in Wamilombe. Oblivious. Her spotty camouflage immaculate.

Maximum temperature: 34 degrees Celsius

Rainfall: Still waiting patiently

It's 03:00. Dark. Silent. Out of the ether, the bat phone starts to trill. A sound that immediately wakes us. Our pulses and blood pressures shoot up. A phone call is never good news at this time of the night. But the duty phone expects immediate action. Not just an answer. But action. Responsibility.

We are both suddenly wide awake. Galvanised. Adrenaline surges to compensate for the lack of cortisol. Is that the Valley Doctor? Can we have some help please? Our caller has an unknown number. Keith takes their name. And the name of the patient. It’s not a name on our list. The caller is not a member of the medical fund. They do not have automatic access to the Valley Doctor. We have no contractual obligation to speak to them any further. Sleep beckons. A little imp on Keith’s right shoulder. Keith’s conscience fights the imp away.

It’s Hobson’s choice. No real choice at all.

Let’s rewind a bit. It’s the 5^th July. A momentous day. A date that will have meaning to many of you. Know it or not. For the 5^th July is a double whammy day. Firstly, for the last 58 years it has been my birthday. Not exclusively you understand. Unsurprisingly, others have claimed that birthday before me. Notably, the National Health Service. In 1948, the British NHS came into being on this day. We are perhaps kin, of a sort. But the NHS is somewhat longer in the tooth. So, the 5^th of July is a big day.

The NHS has many tenets. But two key tenets come to mind. The first is that the NHS treats all people equally and without prejudice. Whatever your age, background, religion, nationality or sexuality. The second key tenet is that care is free at the point of delivery. It is non-transactional. It should not be based on one’s ability to pay. That does not mean that the care is cheap. It is certainly not free. We all pay for the NHS. In our taxes. So, we need to ensure that we get value for money. That we don’t waste resources. And that the care provided is good enough. It may not always provide Michelin starred food or five starred accommodation. And it is certainly not perfect. But I would challenge anyone to come and live and work in rural Zambia. And to not return home cherishing our NHS.

Working as a volunteer here has its challenges. The care we deliver at the clinic for the local population is free and non-transactional. But we are greatly limited in what we can and cannot do. Drugs. Tests. Treatments. Follow up. We can only provide what is available in the clinic on any particular day. The Zambian health service. With a very definite lower-case h. Is not a patch on our beloved British NHS. Chronic disease management in particular leaves a lot to be desired.

But for the tourists and the members of the South Luangwa Medical Fund (LMSF) it is a very different story. The LMSF is a registered charity. It does not provide a private medical service. But money does change hands. Access to the Valley doctor is very much based on the ability to pay.

Membership of the LMSF provides staff and clients access to us valley doctors. To join the LMSF there is an annual fee. There are individual memberships; tourist camp memberships; and business memberships. If a tourist camp joins the scheme, they can call us out in the event of a medical emergency. We do not define what an emergency is. If a tourist wants to see us, they see us.

We offer face to face visits to camp clients. Telephone or video consultations. Or, if they can bear to miss a game drive, we will happily see them in our dark and sweaty Kakumbi clinic. Each of the options has a different cost. Not optional. Each client is asked to donate to the medical fund.  The donation is receipted and claimed back on their medical insurance. For us NHS trained doctors, this is a bitter pill. Our care is suddenly transactional. But at least we can deliver a higher standard of care because of this cold hard cash. A necessary evil. Even volunteers have overheads.

There is a volunteer doctor in the valley 365 days per year. 366 in a Leap Year. Four doctors in rotation. Each serves for 3 months. The doctor has a house to live in. A car to drive. Fuel expenses. Medical insurance to pay. A work permit. A medical license. A contribution towards air fare. A modest monthly stipend. All this comes to $40,000 dollars per year. Paid by the charity. The LMSF. And indirectly by the donors: members of the medical fund; and users of the service. Without donation requests, the LMSF would not exist. There would be no Valley doctor. Chicken and egg. The service is provided by, and for, members of the LMSF. If we see people outside of this, the system will fall apart. No chicken. No egg. So, what should we do when a non-member calls for help?

Non-members call us from time to time. Not all the camps in the valley have joined the LMSF. Some tourists these days are independent. Staying in self-catering accommodation. Not on organised trips. Should these people be denied access to care in extremis?

We have a protocol for coping with these chancers. For coping with safari goers who are not in our club. Those who do not pay their stamp, so to speak.

There is an eye watering donation request that makes non-members think twice before they darken our doors. We explain this over the phone. We ensure that people are provided with options. We tell them about the Kakumbi Health Centre clinic. Clinic care is free. But the queue may be long. This will undoubtedly impact on their fun packed safari schedules. And at the clinic they are unlikely to see a doctor. Unless we happen to be there, and our clinicians ask for our help. Of course, we will always respond in a dire emergency. But otherwise we have no duty of care.

Another option is to go to our lovely new hospital. Near the airport. A beautiful building with skeleton staffing levels. No tests. Beautiful new equipment. All still in the box. Let’s call it a hotel for now.

So once again our principles are challenged. We pick and choose. Only seeing those who are in our club, and those who can cope with the eye watering bills. Tiered care, so to speak.

Usually, we don’t handle the money. It feels dirty somehow. Beneath us? Not really. But it just changes the dynamic between doctor and patient. Nudging the relationship. It starts to feel more like shop keeper and client relationship. Removing the imperative to prioritise health. Always chasing the money. Needless investigations. Expensive and potentially dangerous treatments. Patient choice gone badly wrong. Money might make the world go round. Normally, we give a donation receipt to the camp. That fee is added to the tourist’s bill. The client pays the camp. The camp pays the medical fund. Peter robs Paul and Peter hands their bootie back to the medical fund. The Valley doctor stays firmly out of the loop.

The separation between the provision of care and payment seems important. But occasionally our hands are forced. Sometimes we have to make an exception. But it can cause ill feeling. During our last tour of duty, we had a call from a member camp on a Saturday. One of their clients was flying out of the Valley that day. They had some medical symptoms. The camp was deep in the park. But they would be coming through our village en-route to the airport. Could we please see them as they pass through? Of course, the answer was Yes. But how to deal with the donation?

That particular Saturday we let our guard down. We put our principles to one side and agreed to take cash, directly at the point of care. The camp bill had already been settled and: It would really help us out. Was the plea.

So, we see the tourist. He is on holiday, with his mother and his son. His problem is mundane and easily sorted. A quick prescription and a plan. No need for us to drag this one out, to justify the fee. But the tourist, happy with his care, decides to ask for more. My son has a similar problem, what should he do? We start from scratch, but fail to negotiate a fee at the outset. His teenage son’s illness has some similarities, but some important differences. Nonetheless, in a moment of weakness we decide to give the family a 2 for 1 deal. A little awks to ask for another donation at that point.

We present the donation receipt to the tourist’s mother. Without highlighting the BOGOF deal. Only to be met with vitriol. She remarks that the bill is steep. How can you call yourselves volunteers? When I have to hand over five crisp clean fifty dollar bills? Can’t we have a discount for paying in cash?

Deep breaths. Silence. I eat my words and pull back my counter punches.

I explain, calmly, that Keith and I do not get paid to be here. In fact, I pay to be here. Because there is only 1 valley doctor. I pay for my own medical indemnity insurance. Medical license. Employment permit. I get no contribution to my flight. No stipend to live off. I explain how much it costs to put a single doctor in the valley. How lucky they are to be able to see a doctor at all.

The family are about to go to Lower Zambezi. There is no doctor whatsoever. Here they have seen a GP and a consultant paediatrician. 2 medical consultations. 1 charge. We have already done her a deal. The tourist and his son have the decency to look a bit ashamed. The tourist’s mother counts out the dollars with pursed lips. I give her a receipt. They leave.

Money changes everything.

Sorry for the digression. Let’s go back to our 03:00 phone call this week. This patient was already at the Mambwe District Hospital. Our patient is a 2 year old child. I can hear her in the background and I already know the diagnosis. The correct treatment. She has croup. A distressing condition. But largely self-limiting. Her breathing is very noisy. She is breathing fast. When she coughs she barks. Rather like a seal. She needs steroids. A single dose. The clinical officer is the one who phoned us. We tell him to stop the nebuliser. To give a big dose of prednisolone. And wait. It will take 2 hours for the steroids to kick in. The parents thank us profusely. We say goodbye and hang up. Sleep comes quickly.

But 30 minutes later, that dreaded noise again. The duty phone. A follow up question from the family. She spat out most of the steroids. What do we do now? We suggest repeating the dose. Using yoghurt to disguise the chalky texture. Brief intervention. No charge. Sleep broken twice.

The following morning. Jaded by broken sleep. We get a call from the parents. Thanking us. And asking us how they can pay. This is a pleasant surprise. We had mentally written off charging for the advice. There is no set charge for a non-member having an emergency phone call in the middle of the night. The call-out fee for a non-member is enough to make a grown man cry. We would only charge this if we had talked to the client beforehand. Consent and a promise to pay. Our instinct at 3am is to survive. Make a spot diagnosis. Share the benefit of our wisdom. Make a sharp exit. Wham. Bam. Thank you maam.

Our grateful parents push us to compensate the medical fund for our flexibility and sage support at such an antisocial hour. We graciously accept their offer, but take the sting out of the usual non-member bill. We send them a more reasonable, standard donation invoice for a phone consultation.

Non-transactional healthcare is great. But the UK system does mean that most patients have no idea about the value of the health care that they receive. In Zambia it can be awkward to discuss payment. Why should rich people deserve better access to care?

But the bottom line is that care costs. Without the deep pockets that pay for the Luangwa Safari Association Medical Fund, there is no Valley doctor. No doctor to support the staff in our local clinic. No care for the staff that provide safari services in South Luangwa. We are volunteer Valley doctors that come at a cost. We know which side our bread is buttered. But at least we can offer our Zambian colleagues and patients bread whilst the tourists have butter.

Spare ribs

I'm brave

Unpacking donated goods with Saulos

Screening at Tribal Textiles