I have finished my medical elective in Nepal. Two more days and I will back on Canadian terra firma. Four weeks went by fast but it has definitely been long enough. I spent three of my four weeks in the emergency department.

Though it is not currently a suggestion that comes up very often, small service charges have previously been proposed in Canada to help solve the problem of our stretched-to-the-limit health services. The theory being that a nominal fee will keep people from going to the doctor unnecessarily and will prompt them to seek out the most appropriate type of healthcare, for example not go to the emergency room when it could wait for a visit to the GP the next day. I have always been opposed, almost reflexively, to this idea. The idea of reaching for your wallet when you get to the doctor's office feels wrong and unCanadian. My experience in Nepal, where people do just that, has demonstrated for me why, even small payments for access to healthcare, are unjustifiable on every level.

The hospital I in which I was located is a not-for-profit hospital in the Kathmandu valley. Because it is a well-respected hospital and the fees are less than many other places, they see many of the poorer people in the area. However, it is in the Kathmandu valley so even the poor people here are better off than others in the remote areas. In the emergency department I saw largely three types of people. The first category were people who had some dramatic acute condition; traffic collisions, workplace accidents, MIs. These people come in and are treated because it is a matter of life and death. If they, or their families, can't pay, they are referred to social work and their fees are waived.

The second group is people that have the money. The fees are low enough that they will make little or no difference in their lifestyle. A chest x-ray is about $3, the price of a nice lunch in a restaurant, so it is no big deal. These are the people that come in when their 2 year old has a low-grade fever and the sniffles for a day; the teenage girl who comes in with menstrual cramps for the past hour. I am not saying that these people do not deserve healthcare, but the emergency room is not the place for it (I believe I mentioned it is cholera season here and the same number of staff has to take care of an extra 20 beds.) However, most of these people seem to have the opinion that they are entitled to complete and immediate attention. It is unusual for someone to wait longer than 30 minutes to see a doctor and if they do there is angry complaining and threats (which I was told are sometimes carried out). In Canada people often wait much longer and, while they are far from happy about it, they accept that the doctors are working away with patients that may be sicker than they are. This type of explanation carries no weight in the hospital I was at. I don't think this difference is due to Canadian politeness or some defect in the Nepali character. I think a big thing that contributes to the outrage from Nepali patients is the cash they handed over to get in the door. The fact that they paid for service means they want to be served and served now. Moreover, they have no compunction in demanding tests or particular treatments. Why not? They are paying for them. It doesn't matter that the chest x-ray for their 2 year old is exposing them to unnecessary radiation or the antibiotics will do them no good, not to mention that they are taking up more of the doctor’s time.

The third category of patients is those that come in because they really really have to. That $3 could be three (or more) days of income for their entire family and they may have to travel a large (i.e. expensive) distance to even get to the hospital. There is an increase in morbidity and mortality from this delay in treatment that only increases the burden on underprivileged families. They have now lost earning potential, especially in the case of long-term disability. But another consequence that I found particularly discouraging is how this emphasizes all other inequalities in society as well. Gender is a big one. Kids too. The sickest cholera patients I saw, the ones that looked like dried up skeletons in renal failure needing an extra dose of luck along with an IV, were young girls from poor families. It seemed to me that people would wait longer to bring in their sick daughters than their sick sons. In economic terms sons are worth more and so it makes sense, on a certain level, that they would be more willing to make the investment. I don't mean to imply that these families are callous or calculating. They are faced with impossible decisions and it is the girls that suffer the most. And don't forget, the people I saw were the ones that made it to the hospital. There are many more that aren't even able to make the choice because they live too far or have too few resources.

It is true that Nepali society is much more stratified than Canadian. The difference between poor and 'middle class' is astronomical. But with wait times and the centralization of services, there are already a number of obstacles to access in Canada as well. There are plenty of families where it is a challenge to make the paycheck stretch across a month of groceries and any extra expenses required sacrifices somewhere else. Putting up any more obstacles for those people disadvantages the most vulnerable and that would as reprehensible in Canada as it is here in Nepal.