“What do you mean, you can’t get a head CT tonight? This man is having a stroke!”
My frustration must have seemed utterly naïve to the rural emergency physician on the other end of the line. It was 0100 on a Saturday, and I was taking a telephone consultation at a hospital in northern England, about a patient who appeared to have developed classic symptoms of a lateral medullary stroke. In the heat of the moment, I had forgotten that I was no longer in my familiar comfort zones of the John Radcliffe Hospital (Oxford) or the Foothills Medical Centre (Calgary, Canada), where I could always count on an emergent CT scan for an acute stroke. Fortunately for the patient in question, we could quickly arrange for the patient to be transferred to my centre for urgent neuroimaging and stroke-unit admission.
A week later, when trying to obtain urgent neuroimaging for a relative in India who had acutely developed worrisome neurological symptoms, my family would have to endure more than a fortnight’s wait and two separate private physician consultations to get a CT scan. Talk about a lesson in perspective. Of course, we were by far the lucky ones – at least my relative received a CT scan and we could afford it. A recent study in Neurology by McLane et al (2015) that surveyed neurologists from 37 different countries found that in urgent situations, a head CT could not be obtained in a timely manner in 29% (2/7) of lower-middle-income countries (like India) and 83% (5/6) of low-income countries (like Haiti). In most low-income countries surveyed, only the top 10-20% of the population could afford neuro-diagnostic tests like head CT, brain MRI, EEG, EMG, and CSF analysis, below catastrophic levels – that is, without eating into more than 40% of their disposable household income. In lower-middle income countries, 40% of the population, on average, could not afford such tests.
This study unpacks three words in global health that physicians like myself cocooned in the comforts of first-world medicine tend to forget – availability, accessibility, and affordability – that drive major gaps in diagnosis and treatment worldwide. Availability: Does the test we want even exist currently or routinely at the patient’s healthcare facility? Fortunately, this is becoming less of a problem; the least available test, MRI Brain, was available to patients in 76% the countries surveyed. Yet, for example, EEG appears to be unavailable in Bhutan, as is EMG in Botswana, Haiti, and Myanmar. Until January 2015, there was no MRI in Laos.
Accessibility: How long can the patient expect to wait for said test? Unfortunately, this is tied intimately to Affordability, the requirement and ability of the patient to pay for the said test. Thanks to the Out-Of-Pocket-Spending that is a cornerstone of so many systems in lower-to-middle-income countries (and higher-income ones like the USA) – what Paul Farmer wisely calls an “OOPS” approach to healthcare – the ability to pay for a test becomes the key factor in determining how quickly a patient gets the test. For example, McLane et al found that 60% of low-income countries, as well as the low-middle-income countries of India and Brazil, involve wait times of over 6 months for MRI Brain for patients receiving public healthcare. Yet for privately-paying patients, all these countries reported less than a week’s wait.
However, while the economics at play indicate that patients in public systems wait longer for neuro-diagnostic tests, costs are generally lower for all neurologic tests in the public versus private systems, with tests in the public sector on average costing $159.36 lower than in the private sector. In a private system, of course, those costs come back to haunt the patient – for many families, with catastrophic consequences.
So the next time I don’t get instant gratification with my neuro-diagnostic requests, I’ll hopefully think twice before making a fuss.