The Inverse Care Law
The healthcare system of Peru is made up of a public sector and a private sector. The public sector is funded by two main types of health insurance – the Social Health Insurance (EsSalud) and the Comprehensive Health Insurance (SIS). While EsSalud is a mandatory insurance paid by the employers of all formal sector workers, SIS is an insurance funded by the government and international aid, which aimed to provide free or low-cost healthcare to those living in poverty and extreme poverty. Each of these insurances has their own healthcare facilities. While the EsSalud facilities provide more comprehensive and modern medical treatment, the SIS facilities only provide essential medical treatments with an emphasis on maternal and child health.
Before I arrived, I did not know how important the hospital I was placed in, Hospital Antonio Lorena, was to the people of Cusco. Cusco is one of the major cities in Peru, situated at 3500m above sea level, in the valley of the Andean mountain ranges. The city is the main commercial centre for the Quechua-speaking indigenous people of Peru; many whom still reside in the surrounding villages. In contrast to the Peruvians who live in the urban areas, who were literate in both Spanish and English and who were the beneficiaries of the EsSalud insurance, there was a high level of illiteracy, poor living conditions and transgenerational poverty amongst the indigenous people. Their rights were often neglected. There was no health insurance for this group and thus, no modern health care until the SIS was introduced in 2002. While there are many EsSalud hospitals in Cusco, Hospital Antonio Lorena is one of the two hospitals dedicated solely to the SIS beneficiaries in Peru.
When I arrived at Hospital Antonio Lorena, I was shocked to see the hospital buildings were made up of blocks of shipping containers. This was different from the photo of the hospital I saw online. The gate of the hospital was shut tight, with a big banner saying ‘National Doctors’ Indefinite Strike’. There were many doctors congregated outside the buildings, shouting, raising their placards and drumming. They seemed to be protesting about their low pay. There were another group of people outside the hospital’s gate, shouting, raising their placards and drumming as well, but they seemed to be protesting about an entirely different issue – ‘Save our Hospital!’ was written on one of their placards.
Fortunately, I could register myself for my elective. Initially, I planned to do three weeks of Emergency Medicine. Due to the doctors’ strike, I did not have much choice but was placed in Paediatrics for two weeks and Infectious Diseases for one week.
Later, I learned that the doctors had not been paid for months and this indefinite strike had happened a few times since last year. I also heard that the original Hospital Antonio Lorena was undergoing a major refurbishment. Therefore, this was just a contingency hospital until the work completes. However, doctors told me, even though it has been three years since the work started, the new hospital was nowhere near done and will probably take at least another three years to complete. I visited the construction site of the hospital, but there were no workers there at all on a Wednesday afternoon. What about the group of people protesting outside the hospital? I learned that they were probably the representatives of the poor. Instead of funding the refurbishment of Hospital Antonio Lorena, the local authority decided to channel the funding to building a new international airport in a nearby village to boost the tourism industry to Machu Picchu. The work on Hospital Antonio Lorena was therefore halted.
Unlike EsSalud or other social insurance schemes, SIS’s budget is fixed and does not adjust to the increasing number of beneficiaries. It also does not help that the General Government Expenditure for Health in Peru has remained stagnant at 4-5% GDP for decades. In the past decade, the government worked hard on the issues of inequality in access to health services. However, due to political corruption (a pervasive ‘culture’ from the ministers to the farmers, as the Peruvians put it), the opportunities to boost the personal economic situation took precedence over the welfare of the people. In this adversity, the poorest group suffered the most as they were left with almost no accessible health services.
Fuelled by the poor access to health services, poor public health education and high illiteracy rate, the vulnerable rural population bears the brunt of nutritional deficiencies, maternal and perinatal death and communicable disease in Peru. These patients often present to health services, if at all, when the conditions are dire. In Paediatrics, I saw a 5-month-old boy with Kwashiorkor disease and globally-delayed development due to parental neglect; In Infectious Diseases, I saw cases of severe mucocutaneous leishmaniasis and advanced AIDS. In a short period, I saw many extreme pathologies which I thought only exist in textbooks. More appallingly, these diseases hardly exist in the metropolitan of Lima, just few hundred kilometres away. Based the Dahlgren-Whitehead rainbow we learned in our Public Health lectures, I knew that to resolve these heart-wrenching problems we will need to tackle the wider social determinants of health. However, in reality, how much influence do health professionals have over these factors?
The effort to reverse the Inverse Care Law
While I was overwhelmed by the inequality I saw, a few doctors in Hospital Antonio Lorena showed me how they maintained professionalism and improved the lives of those who needed them most. For example, several paediatricians chose to stay in the ward and care for their patients instead of joining the indefinite strike with their colleagues, because they knew that no one would be saving those children if they choose to walk out indefinitely. Besides, even with the constraints of funding, they tried to deliver an evidence-based practice. When first-line investigations and treatments were not available in Hospital Antonio Lorena, the doctors were resourceful in seeking evidence-based alternatives for the patients to achieve comparable outcomes. Even with the little they had, they were relentlessly helping those neglected by their society. Therefore, at times when I am fixated with the disputes we have in the NHS, these Peruvian doctors’ attitude towards their patients reminded me to look beyond these dissatisfactions and to be a doctor who truly cares for the people.
Unfortunately for the Peruvians, there were times when the second-line treatments and investigations were not available in Hospital Antonio Lorena. During these times, the patients could buy those services and items from third-party laboratories and pharmacies in town. This creates a strange picture which there were many pharmacies and laboratories situated right outside the hospital’s gate, and patients would bring along their cannulas, saline intravenous solution and drugs to the clinics and wards. However, this also means that these services, which are available only on out-of-pocket payments, are not available to those who just cannot afford to pay anything at all.
Conclusion
In conclusion, this elective gave me an experience which I did not expect at all. When I departed from Heathrow, I expected this elective to be an extension of the Infectious Disease placement we had in clinical school. However, it has taught me much more than clinical knowledge alone. This elective showed me what ‘lack of resources’ truly means; it is a harsh reality for millions in the Latin America. It had taught me to appreciate every little thing I have been taking for granted in the NHS: the ubiquitous Hibiscrubs in Addenbrooke’s, the freedom to do audits and to access the latest scientific articles, the capacity to order fancy investigations, the support each of us has to groom us into a safe and competent doctor and so much more. It has also taught me that if an opportunity arises in the future, I could and I should contribute more to the developing nations either directly, by being a doctor for the people there, or indirectly, through doing researches which the results are easily accessible to the doctors in these developing nations.
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