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Peruvian “Economic Success” in the Emergency Department: Close to Hell, No Place for Heaven

2016; Wiley; Volume: 24; Issue: 2 Linguagem: Inglês

10.1111/acem.13138

1553-2712

Ana Castaneda‐Guarderas, Ariana S. Malaga, Germán Málaga,

Healthcare Systems and Reforms

The Peruvian story of 15 years of sustained economic growth is a commonly touted success story in a region known for economic uncertainty. Social statistics show that fewer people live below the poverty line, more have access to basic education, and fewer children experience the consequences of malnutrition.1, 2 Corporations are thriving across all sectors including the private healthcare industry, which would seem to be in line with the optimistic published social welfare figures. Statistics, however impressive, can mask reality. For us, in the public and private healthcare sector, these statistics ring hollow. Peru has four different healthcare systems. Two are public, MINSA and ESSALUD, while two are private, one for the military and one for citizens. The government-run public healthcare systems are not equivalent (e.g., ESSALUD has PCI available, MINSA does not). While the country has experienced unprecedented economic growth and development, the public healthcare system has floundered. The failure of this success to "trickle down" and improve the infrastructure of the public system, much of which is crumbling and inadequate. Chronic underfunding and lack of the appreciation of the sheer scope of human suffering that continues to be present has contributed to a culture of medicine, which can often fail to appreciate the basic humanity of the individual. No place exemplifies this disparity better than the emergency department (ED) of Hospital Cayetano Heredia, a major academic hospital in the north of Lima, Peru's capital. Lima, has grown tremendously from 6 million in 1993 to almost 10 million people in 2015.3 Our hospitals, medical investment, and medical personal, however, have stagnated and the system is now overwhelmed. While changes have been made to the infrastructure of the ED, this has not contributed to better care for our patients. The halls of the ED are hot and permeated by a suffocating stench that sanitizers cannot disguise. Patients "lucky" enough to have a bed lie in uncomfortable stretchers, so narrow that turning is impossible, particularly in the advanced states of illness necessary for patients to venture into this hell. Patients tremble in this cold, impersonal inferno. Fragile and in pain, their suffering exacerbated by an inefficient, ineffective, and shortsighted system. Here, these patients' intimacy and dignity are violated, their weaknesses displayed to other patients and health workers passing by. And then they wait. A young woman with cancer cries out in pain waiting for a medicine that is not on stock in the pharmacy, and that is too expensive to get outside the hospital (no explanation from the pharmacist and no alternative medication available). An elderly grandmother, confused and alone, cries silently tied down to a wheelchair, rather than examined and reassured. An assaulted alcoholic man without family or ID is left on the floor, shivering. Admission is not a ticket out, as many must stay here, boarding in limbo, on a stretcher, a wheelchair, and some on the floor. For many, this will be their place of death. Many clinicians are overworked because they practice in both the public and the private systems. This is known as dual practice and occurs due to the increased levels of reimbursement offered by the private sector. These clinicians, often working more than 100 hours a week are more likely to experience burnout, which can manifest as a lack of compassion for the tremendous suffering that occurs daily within the walls of our ED. Overwhelmed and busy attendings and senior residents trained once enthusiastic medical students to ignore patient pleas. They learn that this is the "most efficient" way to get the work done, finish their 30+-hour shift and go back home to their families. A source of this inequity and inefficiency is the fragmentation of the health system. Peru has a private healthcare system that is better financed and better equipped and only affordable to those with resources. Why should they change the system when for them it works perfectly well? For the outsider, this state of affairs is an unexplainable nightmare. How could the system be so inefficient, the decision makers so callous, the care so absent? As clinicians who worked in this inferno, one of us for decades, we want to believe that this reality is not because lack of care by the medical professionals, but rather that the system is so broken and unsustainable as to make actually caring for patients (in the literal and emotional sense) impossible. There is an obvious disconnection between policymaking and care giving. Peru and Latin America have now entered a period of slower economic growth. With that, there is political change, which increases uncertainty, and no clear commitment to improve the situation of those living in the shadows of life. So, where do we go from here? The first step is realizing that we have a problem, and we believe that changes need to be made at multiple levels. First and foremost cultural and policy-level changes need to occur. Namely, there needs to be increased funding to the public healthcare system to improve recruitment and retention of qualified clinicians as well as improvements to the infrastructure of our hospitals. With these investments we can hopefully reduce feelings of burnout as well as give our clinicians the tools to adequately address the suffering of our patients. The same tools that are available to those patients in the private healthcare system. These changes should "trickle down" to medical education and reduce the brain drain Peru is experiencing. Further, the increased modeling of compassionate care by attendings should contribute to the development of a generation of compassionate clinicians not only attuned to the suffering of our patients but equipped to address it. Given that the poor have continued to suffer desperately during times of economic prosperity, this recent downturn does not bode well for their future. Labeling Peru as an "economic success" is fallacy that fails to reflect the reality that for many nothing has changed. When the poorest people in their worst moments of their lives are acutely ill and suffering and must face a healthcare system that violates their rights and where empathy and humanity are absent. We hope that this piece will bring to light some of the inequalities of care in our setting and it is our hope that in the future all patients can receive care in the truest sense of the word regardless of where they seek it. The authors thank Dr. Annalee Baker and Dr. Michael R. Gionfriddo for their insightful comments, and Dr. Victor Montori for his infinite patience and friendship.