Experiencing health care in rural Laos
In the Bolevan Plateau in southern Laos, renowned for its vast plantations of tea and coffee, in the village of Kok Phong Tai, a short, softly spoken 40 year old man with leathery skin appears from behind an upright bamboo pole which is used to hold buffaloes earmarked as a sacrifice for village weddings. He slowly slinks up to me and begins tugging at my arm with a hint of urgency and desperation. Pointing to a window in a hut on stilts in the background, he places his palms together, raises his fingertips to the heavens and whispers, "Please help my wife."
Following the completion of these words, a stocky woman painfully climbs down the stairs of her hut and moved towards me. Each step seems to be a struggle. I stand perfectly still and smile nervously, unsure what to expect and how I should react. When she reaches within 10 metres of me, any doubts as to why she looks apprehensive are immediately dispelled.
A large lump the size of a tennis ball appears inside her mouth and upon closer examination, it is obvious that she has had difficulty in obtaining treatment because of her location and psychological state of mind. This is her first venture outdoors in over a month.
My guide and translator for the afternoon, Phu Khaen, is sitting down and listening carefully to the scenario, and slowly begins to feed news back to me so that I can inform everybody else travelling with me that afternoon, four Dutch nationals, of the situation's seriousness. Throughout the conversation, the husband relayed the details in Lao, and his wife made inaudible grunting noises because it was the only way she could communicate without grimacing in pain.
About three months ago, she developed a minor irritation on the upper part of her gum. Instead of seeking treatment to prevent the infection from growing larger, the woman picked at the sore with her fingers and used sticky rice as a remedy to treat the infection and accompanying itchiness. For some months nothing happened and it appeared that nothing more would become of the incident. However, the growth returned with a vengeance and not only grew on her gums, but also spread to the back of her head and neck.
Upon the completion of the story, Phu Khaen and myself were surrounded by members of the woman's family. Several children had bloated stomachs. In Laos, malnourishment is a serious problem amongst children, and according to the World Food Programme, 40 percent of children in the country have stunted growth due to malnourishment as a result of not having enough to eat. Seventy percent of Laos' population survive on less than 40 cents per day.
"Has the lady seen a doctor about the infection?" I asked.
Phu Khaen shook his head solemnly. "No, they cannot afford the cost of transportation and treatment, and the next round of free basic village check-ups will not be for another year."
Laos is a country of 5.1 million people, 80 per cent of whom reside in the rural area. Life expectancy is 59 years of age, one of the lowest in Asia. There is a strong belief in the use of traditional medicines and it is now being incorporated into the public health system and newly emerging private practice. The first private hospital is due to open in Laos in 2009.
An investigation into the use of traditional medicine in the province of Champassack (Sydara, et al 2005), reveals that faith and practice in traditional medicine is quite common due to the lack of affordability and accessibility to pharmaceutical products. In 2007, the World Health Report indicated that total health expenditure in Laos reached $19 per capita per person. Households contribute 80 percent of this figure, 10 percent comes from donors and 10 percent is provided by the government. Lack of household affordability for treatment seems to be a long standing phenomenon.
Back in 1997-98, total drug expenditure amounted to $6 per capita per person in Laos, with the government allocating $1 million in the budget for drugs, or 20 cents per capita per person. Nowadays, hospitalization and drug costs are still too expensive for the average working family in Laos. The result is that serious ailments go untreated. Although the public health system covers fees of the poorest families, individuals with seriously ill conditions such as the woman in Kok Phong Tai must also overcome psychological factors in getting to hospital, far from their families in the village. Nor does it give an accurate representation of the struggles faced by families working on farming plantations such as tea and coffee.
The cost of hiring a tuk-tuk to make the two hour journey from Kok Phong Tai to the nearest town of Pakse takes 2 hours and costs the equivalent of a week's salary. The woman in this instance had not worked on the family coffee farm for 3 months since the emergence of this growth inside her mouth.
With the cost of pharmaceutical medicines high for regular families, increasing numbers of people have instilled their faith in traditional medicines such as herbs and plant roots, which are administered by a village healer. Field studies conducted by Sydara, et al involved a survey of 460 residents throughout Champasak Province and centered around the use of traditional medicines to treat illnesses and conditions. Nearly 50 per cent of participants stated that they used traditional medicine only to treat fever, gastritis, diarrhea and malaria. A similar number of people surveyed used a combination of both traditional and modern medicine to treat such illnesses. The findings suggest that residents profess some belief in the work undertaken by traditional healers substituting for health professionals in the absence of trained medical personnel.
In 2005, the ratio of professional health workers employed by the government to the population was number at 3.21 employees per 1,000 residents. In 2005, the average annual salary of a health worker in Laos was $405, or under $8 per week.
For this woman to have any chance of improving her quality of life, and at least finding out about her condition, the four Dutch nationals that accompanied me to Kok Phong Tai village developed a plan to have treatment organized in the nearest large town of Pakse. This meant dealing with an ethical dilemma and the real possibility that a terminal illness may be confirmed, and the task of informing the woman's family would not fall upon a group of strangers that could walk away and deal with a guilty conscience, but upon the woman or her husband that had to actually deliver the news in Lao. As a team, we attempted to justify our action plan by arguing that early intervention and action is better than living with a potentially deadly medical secret.
The second issue of taking the woman from her village into a major town for an examination without immediate treatment and permission also weighed heavily on the minds of everyone. The compromised solution was to request a photo of the offending visible symptom. This image would be taken to a private pharmacy or the hospital in the hope that all five of us (the four Dutchmen and myself) could return to the village the following day with some medicine to commence treatment. If we could somehow obtain the necessary medicine, it would eliminate all associated fears in taking a petrified woman from her home village into a large town, away from the security offered from the darkness of the family home.
At this stage, nobody had in fact figured about how to return to Kok Phong Tai the following day, or if any tuk-tuk would indeed be available.
The greatest obstacle was legal responsibility in the case of any unforeseen consequences arising. With nobody having a medical background, a list of clauses was drawn up, similar to a contract and signed by the 5 foreigners taking part. These points set the conditions for providing any assistance, and included the following:
1) The five foreigners involved will pay for petrol spent for 2 return trips between Pakse and Kok Phong Tai and for the cost of one X-ray to be taken at Pakse Hospital;
2) In the event of an operation being deemed necessary by a medical authority, the foreigners would not be held responsible for any medical malpractice or for any accident occurring during the transportation between Kok Phong Tai and Pakse and;
3) The parties will not be responsible for any raised expectations on behalf of the patient or her family as a result of any errors in translation between the English and Lao languages or vice versa.
Even the best of intentions require some form of legal agreement.
Upon returning to Pakse that same evening, the Dutch team and myself walked around the town of Pakse, raising money by requesting as many donations from all foreigners in the city centre. The ultimate aim was to pay for not only the x-ray, but for all medication and hospital after care. Initially we budgeted for an overnight stay following the operation, although we were prepared to accept the possibility of a much longer stay if doctors requested time to monitor the recuperation process.
Within three hours, a total amount of $195 was raised. The vast majority of donors expressing sympathy for the plight of the woman, but not everybody believed in the necessity of donating aid, with some criticisms being directed over the provisions of a band-aid solution that would not actually benefit the family in the long run and encourage a cycle of dependency.
As expected, coaxing the lady to attend a hospital in a major town required extra assistance. Covering our bases, we were accompanied the following day by two uniformed police officers, invited to help transport the patient and provide "protection for the foreigners." Later in the day, I learned of why the officers insisted upon coming along; to place psychological pressure on the woman and her family to accept any assistance being offered to her through gentle persuasion, and prevent her from having a change of heart by refusing to come along to seek treatment.
Eventually, the lady did agree to accompany us with her husband in tow. He carried several blankets and clothing items, and it seems that he was prepared for a lengthy stay, as well as providing moral support. As the tuk-tuk made its way along the bumpy roads, he sought to smother his wife's nose with a rag containing methylated spirits for short lengths of time. This helped to contain her painful screams as a result of the growth inside her mouth. For that afternoon, the discomfort showed on everybody's faces; the husband spent much of his time praying to Buddha as he tried to comfort his wife.
Inside Pakse Hospital, the doctor confirmed with us that the woman had an infection with her cheek muscle. He immediately announced that there would be no need for an x-ray and set to work at the operating table, making an incision where an operation would take place. Following the operation, and most probably against the husband's wishes, the lady was ordered to have a 10-day resting period, firstly in the traumatology unit alongside victims of motorcycle accidents, amputees and patients waiting for skin grafts, then intensive care, and finally in a private ward. Just having located a bed within the hospital proved to be an achievement. In 2005, the World Health Organization reported that just over 5,000 beds were available throughout Laos, with the country in the grip of a bed shortage, and it seems that the situation had changed little over the time that I was in the country, something most evident in Pakse Hospital.
The resulting breakdown of costs is as follows, with the exchange rate at the time being 8,800 Lao Kip to $1 U.S. Dollar.
Transport - 550,000 Kip
Hospital surgery after care and initial 1 night stay - 260,000 Kip
Extra 10 days hospital accommodation - 500,000 Kip
TOTAL COST - 1,310,000 Kip ($USD150)
The remaining $45 was donated to a local village school for minority groups in Kok Phong Tai.
Since the operation, news has filtered through that the woman has returned to the family tea and coffee plantations near her home village. Giving the gift of renewed hope towards recommencing a livelihood need never know any boundaries.