Health Care Part Deux

"Where are you? Are you in 'the bush' somewhere?"
I wrinkled my forehead. "Erm, I'm in the capital."
Dead silence, then "What? Well, then, there must be good medical care there."
"I had a sterile needle."
"Don't some Westerners live there? Don't they see physicians?"
"This is the best clinic in the city."
"Don't they speak English?"
"They do."
"Well surely they must be able to do these tests, then." Some other equally misplaced assumptions followed. I waited, idly itching at...a mosquito bite.
When I could get in a word, the only thing I could think of to say to try make it clearer to my doctor why it is that I am not going to be able to get more tests easily was a statistic.
"Life expectancy here is 44."

HIV prevalence here is only now a bit below 5 percent, and tens of millions of people are living well below the poverty line, which often means no clean water, vaccinations, or basic medical care. Throughout being sick, I've known that I'm very fortunate to get good medical care, and throughout I've also become ever-more aware of the challenges medical practitioners here face. Even in the best clinic, my Nigerian friends tell me, it's not rude to ask them to open the needle in front of you. No matter how many times I tried to explain to my US doctor the situation here, what limitations the clinic had for testing, she couldn't understand it.

This all came up when I went back to the clinic yesterday and was diagnosed with bronchitis, a souveneir of my trip to Lagos. So, now my total intake -- I'd qualify it by saying it's my total medicinal intake, but I'm really not yet eating much either -- is my original anti-malarial, fat lot of good it did me; Artesunate; curious-looking brown multi-vitamins; unnamed, powdery white pills for fever; and Avelox for whatever infections I've become host to in the meantime.

The pharmacy, from which I got the Artesunate, is actually the hotel gift shop and kids' store. The process of diagnosis and treatment consists of taking an elevator to the clinic, waiting for a while in a small waiting room, then stepping a few feet away behind the small divider to the nurse, who takes blood pressure and asks for your name and contact information only. No symptoms, known allergies, or family history information is given. Wait again in this chair for the physician on duty. Communication opens up somewhat at this point, but you still have to volunteer any and all information and complaints, and there's no physical exam. Maybe because they don't have time? My chart is two sheets of white paper stapled together with handwritten notes. There are no computers or electronics in the office.

The first time, I simply requested a test for malaria. The doctor called the nurse, who emerged from a back room -- rather, the back room -- with a metal pan that with two cotton balls in it. She set it down beside a wrapped syringe, a vial, and a length of clear plastic tubing. I stared apprehensively at the tubing, hoping it wasn't meant to transfer my blood from needle to vial. Not to worry. It was my tourniquet, and as it turns out, the entire syringe was to be inserted directly into the veins atop my left hand.

She tied off my arm and inserted the needle into my hand with some skill, but then proceeded to yank back the plunger so quickly that pain shot up my arm. I weighed my headache, fever, chills, and violent muscle aches against the pain of the blood draw and decided to wait it out. I waited for her to use the needle on the syringe to transfer the blood to a sealed vial. Instead she removed the needle from the syringe and carefully poured the blood to the vial. They didn't have sealed vials, I don't think.

I was charged N400 for taking the blood to the lab across town. I parted with my US$3.20 happily in exchange for not having to trek across town to what promised to be a bad neighborhood, given her reluctance to send me there, in my state. She said it would be an hour for the test, then an hour and a half. They were waiting on the lab. By the third time I called, three hours later, I was informed that, in fact, I did have malaria.

Five floors down, I got a prescription, a bag of vitamins -- I could swear they're the same ones I helped hand out in Honduras -- and some pills for fever. They directed me downstairs to the pharmacy. I went one floor down, thinking it would be on a floor with offices. No luck. I asked the guard -- every one of the guards always says hello, and they're always helpful -- and he directed me down another flight and a half. Surely not. That would be gift-shop territory.

A few minutes later I found myself standing next to some children's toys and some mysteriously transplanted Body Shop goods. I handed the prescription to a woman who might, in fact, have simply been shopping there. I was really disoriented. She handed it over to the pharmacist, who walked over a few feet to the metal shelving along one side and reached down to a small stack of boxes next to the Dove hand lotion. Artesunate. She plunked the box on the counter and asked for N600. That's US$4.89.

Still not feeling much better on the second morning, and now experiencing more problems breathing, I stumbled back down to the clinic at 2:30 pm. They promised they'd call when the doctor got in, but offered that she'd be back shortly. I waited. And waited. On the couch perpendicular to me was a little boy sweating out his own case of malaria really bravely. I can't imagine being that sick so young -- it's worse in young kids, too.

Finally I went back to my room and decided just to call every 30 minutes. Getting no response, I went back down after another hour. No doctor. Went back up. Tried calling again, and finally got an affirmative. I went back down to talk to her.

I asked for blood count and liver enzymes, per my doctor's (and mother's) instructions. She told me to come back the next day. Without examining me, listening to a few complaints about respiratory symptoms, she concluded that I probably also had an infection. She asked no questions, but when I asked if Avelox would work she said she'd prefer Augmentin. Okay, sounds good. Except that the hotel pharmacy charges exorbitant rates. I would shortly be grateful for it.

The doctor checked the price at another pharmacy, N2000 or US$16.27. The nurse offered to pick up the Augmentin so I wouldn't have to go out for it, deciding that I didn't look like a good candidate for forays into the city. I emailed my mother to update her.

I got her reply that night. Turns out I'm allergic to Augmentin. It's in the penicillin family. Don't want to know what capacity for handling allergic reactions the clinic has. Prefer not to think about it and take my Avelox quietly and gratefully.

This morning when I showed up for blood tests, the second time I had my blood taken, it was the nurse and not the doctor who attempted it and after two sticks, and collapsing two separate veins, she managed only a few ccs of blood. For some reason, she refused to try the veins in my elbows. I tried not to be insulted. They're good veins, after all.

After these two abortive tries, having noticed her tendency to push back on the syringe when she was drawing blood, I begged out of a third attempt and asked her to try to have the lab do the tests with that blood. I know just enough about drawing blood to know that it's dangerous to push back on a syringe, especially when it might have air in it. She poured the small quantity of blood from syringe to vial, spilling some of it on her ungloved hand (!).

Given that I do feel better now, by day's end, both re: malaria and bronchitis, I'm staying for another week. I canceled my ticket for tomorrow and have significant flexibility for rescheduling.

Thank you to everyone who wrote me to get well soon. I do appreciate it.