“Sick in America, Aching for Africa,” New York Times, 4 November 2011
I came down with my first African disease in America. It happened after I traveled to Nigeria last April to witness my country elect a new government. I landed with notebooks and questions, but not antimalarial medication. I had been more prudent on dozens of prior stays, but, I thought, no matter: I had already been running around the continent for months with no mishaps. After three rounds of free and fair voting, I returned to my apartment in Nairobi, buoyant about democracy in Africa.
Two weeks later, during a visit to the United States for Mother’s Day, I found myself flat on a gurney, shuddering in a hallway in a bleached Chicago hospital. Fever, chills, muscle pain, dehydration: I knew I had malaria. The mosquito-borne parasite must have been brewing in my bloodstream for weeks.
Malaria is a nasty disease and a grave threat to life and to productivity, particularly in Africa. The parasitekilled about 781,000 people in 2009, mostly south of the Sahara, and is properly called a scourge of the 108 countries where it’s endemic. But the disease can be prevented by taking the prophylaxis I forgot or simply by sleeping under a mosquito net.
Upon arriving at the Chicago hospital, I told every doctor in sight I had malaria. They needed a lot of convincing. Over the next two days, I underwent blood cultures to check for typhoid, a spinal tap to screen for meningitis, and lengthy interviews with the rarely roused tropical-disease specialist. Three bags of antibiotics hovered over two separate IVs in my right arm. Curious doctors hovered over them.
Feverish and miserable, I found myself wishing I had fallen ill in Africa — anywhere where the disease is so prevalent as to be unmistakable. My nurse — a Nigerian, coincidentally — shook her head at the stream of orders and ointments coming into my room. “It’s just malaria,” she laughed with me.
Her laugh, along with the hospital’s final bill — almost $16,000, not fully covered by insurance — suggested that I may have been better off in a different cultural context. In Kenya, my home at the time, doctors treat malaria as a repeat player, not an exotic case study. A single prick of blood is enough to diagnose the illness; a spinal tap is out of the question. Thanks to subsidies from drug makers, the three-day sequence of pills used to treat the disease comes over-the-counter for less than one dollar.
The differential in cost and convenience is a result of both differing resources and differing attitudes toward risk. I’ve visited my share of hospitals and clinics across Africa, and I’ll venture to say that patients and doctors there are less cautious. Where official safety nets don’t exist, tolerance for illness and injury is high. Insurance policies are scarce. Resilience is assumed. Many hospitals are strictly pay as you go. It’s counterintuitive, but this “no frills” approach can improve outcomes and reduce waste. Absent expensive imaging equipment, doctors keep up their diagnostic instincts. Basic tasks are shifted to nurses or community health workers.
In the United States, by contrast, the most relevant thing about health care is that it does too little and costs too much: standing alone, the U.S. healthcare industry would be the fifth-largest economy in the world. Shannon Brownlee, a colleague at the New America Foundation who wrote a book about overtreatment in the United States, says that a Western sense of advancement is the result of “interventions in data management, consumer empowerment, and awareness, but not necessarily in retail care.” Doctors can outsource diagnosis to machines. Patients armed with Web research can insist on unnecessary procedures. The cost of such decisions is often mystifying to patients, and may ultimately break the bank.
I don’t wish to romanticize health systems in Africa. Africa’s advantage might not be so for a serious heart condition, or a car accident, or a mysteriously crying infant. Inadequate access to care is a real problem, especially outside of major cities. Still, if Americans have come to want it all, African patients tend to expect less, and the result may be greater efficiency.
Where’s the middle ground? Practitioners in rich and poor countries alike are looking for cheaper diagnostics and leaner models for delivering care: less of doing anything that’s possible, more of doing everything that’s reasonable. If there is a sweet spot, I’d wager that unfussy African health systems will get to it first.