Free healthcare! At what cost?

Imagine you live in the mountains of Nepal, and you’ve had chronic stomach pain for years.  There’s no doctor in your town, so you saved up money to travel the 8 hours to Kathmandu to see one.  It helped for a while, but the pain came back.  You plan to just bear it, until one day you hear on the radio that foreign doctors are coming to town with free medicine to give to anyone who is sick!  You wake up early and walk 5 hours, wait 2 hours in line with hundreds of people, see the specialist for 5 minutes, then get some medicine in time to make the 5 hour walk back home before dark.  This is a typical health camp experience.  

 A shot of how long the lines can get at health camps, this one in Western Nepal. 

A shot of how long the lines can get at health camps, this one in Western Nepal. 

Now imagine you’re a medical professional from a rich country.  You want to do some good and travel to a beautiful place at the same time.  You gather with colleagues, get lots of medicine donated, then travel clear across the world to trek into the hills of the Himalayas with all of it.  Your presence is advertised widely, you set up a temporary clinic, and wait for the hundreds of patients to roll in.  After a few days of seeing back-to-back patients you are exhausted, proud you’ve helped so many, but vaguely concerned about who might refill your prescriptions.  This is also a typical health camp experience.   

 That vignette is almost a true story of our 2013 camp.  Here's the crew being thanked by local health workers for our service.  

That vignette is almost a true story of our 2013 camp.  Here's the crew being thanked by local health workers for our service.  

For many, health camps are the only way to see a doctor locally, but health camps are a very controversial way to deliver healthcare.  The ethical questions and sustainability challenges are innumerable.  How are patients meant to get follow up care or refill a prescription?  How can we know if the treatment was effective?  Whose job are health camp doctors doing in the first place?  What motivates foreigners to come do this job?  What impact does the health camp have on the local economy, local attitudes and expectations about health?  Is something really better than nothing?       

I organized health camps in 2012 and 2013, so these are questions I’ve turned over in my mind for years.  I put the idea to rest for some time, both because I didn’t really like my answers and because a health camp is basically the antithesis to naturopathic philosophy.  We can rarely treat the root cause of disease at a health camp, because doctors aren’t equipped to help their patients get access to clean water, clean air, nutritious food, and a livelihood throughout the year.  That's why in the years since the last camp in 2013, we have been working on uprooting some of those causes, and focusing on building organizational infrastructure and human capacity to sustain the services we are able to provide. 

 My friend then fellow medical student, taking vitals at our triage table in 2012.  At that point in our education we still felt nervous to take vital signs.  After about 100 patients, we were pros!   

My friend then fellow medical student, taking vitals at our triage table in 2012.  At that point in our education we still felt nervous to take vital signs.  After about 100 patients, we were pros!   

This model of healthcare delivery has a really fascinating history in Nepal, so let me put it in a nutshell for you.  It was popularized in the 1970s, as an efficient method to sterilize a lot of men and women at once.  That’s right, sterilize.  Overpopulation was a major health threat at the time, and “family planning camps” were the solution.  At the same time, massive surgical camps targeted conditions with surgical fixes like cataracts and uterine prolapse.  These interventions made a hugely positive and easily measurable impact in people’s lives.  In the 70s and 80s, Nepal’s government was as shaky as ever, and they never got around to building a healthcare system like the ones we enjoy (and gripe about) in Western countries.  Conveniently enough, this was also a time of booming foreign aid.  Aid organizations and their dollars flooded into the country.  Simply put, they filled the healthcare gaps the government had neglected with health camps.  In the 90s and early 2000s, Nepal suffered greatly in a civil war.  Medical supplies were scarce, foreign aid had dried up, and travelling to the city was a life-threatening task.  Health camps, though co-opted and politicized by warring parties, were one of the only feasible ways to provide healthcare services to rural poor. 

Now it’s 2017 and Nepal faces the same development problems as ever – a lack of doctors, and the absence of a healthcare system that adequately reaches rural folks.  In our working area, it seems people have grown accustomed to the health camp model; they continue to include health camps in their plans for the community.  And in our participatory work, we are accustomed to taking seriously the ideas of local people.

So then, let’s not forget all the good that health camps can do.  A patient’s life can change from one interaction, just one treatment, and that’s priceless.  The camp is a chance for them to receive medical care of a higher quality than potentially ever in their lives, a chance for them to learn something new about their health, a chance to be cared for by a professional.   And patients and providers both have the valuable experience of cross-cultural learning and communication. 

Good can come from judiciously planned health camps.  As we move forward with plans for the next one, we’re first focused on doing no harm.  From my experience and what I’ve learned from others, these two key elements have the most potential for harm:   

1.       The medicine – No matter where you live or how much money you have, it’s not likely that your cure is going to be found in a pill.  Additionally, cultural differences, language barriers, and the fast and furious health camp environment make the chances of irresponsible prescribing are considerable.  What would a health camp without medicine look like?  It might look rather naturopathic!

 At our 2013 camp, we hosted a workshop where we taught local ladies home care tips to treat common complaints.  

At our 2013 camp, we hosted a workshop where we taught local ladies home care tips to treat common complaints.  

2.       The perception – While I can’t imagine how Nepali people truly think and feel, I do know that flashy projects like health camps reinforce ideas that the best help comes from the outside, and that when you see a white face, aid is likely to follow.   Also, doctors and patients alike know that health camp care is a bandaid-on-a-bullet-hole kind of fix.  How can a health camp be designed to help deliver on the basic human needs of clean water, clean air, and nutritious food?  There’s a question worth asking. 

The time for health camps is hopefully fading away in Nepal.   But in the meantime, I think the need for thoughtful well-planned health camps remains, so let’s keep the conversation going and keep doing our best.  There's always room to do better!