A Darker Side of the Maldives

If you’re into uber luxurious travel, taking a seaplane to your private island resort, and being served by a team of staff dedicated just to you in a picturesque overwater bungalow with price being no concern then the Maldives is your dream. But, if while on one of your champagne yacht diving excursions you happen to suffer some devastating injury, or that extra “who cares I’m on vacation” fried chicken leg finally catches up to your failing coronaries the Maldives just became your nightmare. 20150217-DSCF6402

While in the Maldives I had the fortune, or misfortune (I’m still not really sure) to peer into the underbelly of their health care system, and it was a bit terrifying. I seem to keep forgetting the lesson that just about any remote place on the planet tends to have health care standards that are quite far removed from acceptable. What I think surprised me about the Maldives is the sheer influx of billionaire cash that comes from their tourism industry and the complete lack of health care support to that industry. I guess the contrast was just so stark. 20150216-DSCF6383

It all started when Liz started spiking intermittent fevers with severe joint pain and other GI symptoms. We were on the more remote island of Maafushi about two hours away by ferry from the capital Male. Maafushi had a small clinic that could do some basic labs, but no malaria test which is what I was concerned about the most. Given that she wasn’t getting any better we decided to go back to Male in order to get her to the hospital so she could get the appropriate tests. Given that she was sick, but not that sick there was no urgent need to move her quickly, it did beg the question what happens when a patient needs to get somewhere fast in an emergency? The answer really is that they don’t! Asking around I learned that speed boats are typically hired to move critically ill or injured patients from the outer atolls back to the main hospitals in Male.  From Maafushi a speed boat was only a 30 minute ride, but from the far outer atolls a speed boat can possibly take up to seven hours to reach Male. Not to mention there are no medically equipped speed boats. There are sea planes, but as far as anyone knows they have never been utilized in an urgent evacuation scenario. We visited one of the remote resorts on a day trip and swung by the clinic and met the pleasant Indian doctor who ran it. He was there by himself with a very small clinic and just enough meds to manage simple outpatient complaints like coughs and colds, and some simple injuries. He was proud of the fact that he had just received oxygen from the resort. The idea at least in this clinic of acute stabilization by way of cardiac drugs, ventilators or tourniquets was a lost concept. It’s possible that in the more super luxury resorts they are better equipped, but I’m dubious. 20150211-DSCF6294

Of course this lack of health care in the outer atolls is an even bigger issue for the indigenous Maldivians. There are actually inhabited islands, and it’s not just a bunch of rich Russians on holiday believe it or not.  In the recent past the government realized the issue that people in urgent medical need would not be able to afford the trip back to Male, or the option to travel just didn’t even exist. So they underwent the project to build regional hospitals at all the major inhabited islands. Speed boats were even allocated to the hospitals for patient transport from the outer islands they supported. From what I can tell the theory seemed to be sound, and may have even worked for a time, but problems started to creep in. First they allocated the speed boats, but did not allocate any funds or personnel to maintain them. It wasn’t long before maintenance was needed and they sat dead in the water due to lack of central funding. Eventually the military came along and took the boats under their larger budget, but instead of maintaining them for the hospitals they just took them. The second event was the continuous influx of tourism that brought more transportation options to and from Male by either private speed boats or a newly launched affordable ferry system. Overtime patients were electing to simply go to Male for medical care as the transport burdens were beginning to be eased. This soon resulted in an over utilization of the central health care system in Male with an under utilization of the peripheral network in the atolls. What this came to look like is the present day situation of overcrowded, resource choked hospitals in Male, with under populated ghost hospitals that are now under manned due to the relative lack of utilization in the periphery of the system.  IMG_1022

(photo of a local woman being medical transported by ferries)

In Male I did my proper polling of the locals and determined that ADK hospital was voted as the best private hospital in Male. Ingrid Ghandi memorial hospital was the main public hospital and I heard a couple of horror stories about how bad the standards were, so I was somewhat hopeful walking into ADK with Liz. ADK was a small operation. A front bank of windows greeted the entrance where people waited to be seen for either “consultation” or “investigation”; unsure, we took a number for each. The first floor had two hallways with “consultation” offices. The upper floors housed the lab, some specialty clinics and a handful of inpatient beds. It was in reality more of an outpatient clinic. Long ago I was in Thailand and went to a large private hospital after I fell off a moto. It was empty inside except for a few backpackers. I was seen within five minutes, given a prompt X-ray, handed a bag of medicines and was on my way in all of 30 minutes. The waiting room at ADK looked like the train station in New Delhi and smelled like an African bus—it was clear this was not going to be the same “private hospital” experience. After some time our number was called and we were instructed to see a doctor in one of the consultation rooms. IMG_1018

Knocking on the door, the assistant opened the clinic room. We sat down at the desk and the assistant sat across from us. It then dawned on me that she was not the assistant, she was the doctor, and I hold true to saying she was no older than 23. Without much of glancing up she snapped, “What happened?” What a great way to open a patient encounter, I thought. I instantly thought of all the jack ass responses I would have received in New Orleans if I ever opened up a clinic encounter like that. “What happened”: the ludicrous responses were endless. All I really wanted was for her to scribble some meds on her pad and order a malaria and maybe a dengue test. She took a broken history for about 30 seconds. Her English was good, but her attention was poor. She seemed bored and kind of irritated with us. She asked what meds Liz had taken. A few nights ago her worst complaint was body aches and fever so she doubled down on Motrin and tylenol. She quickly chastised her for taking Motrin as it can only worsen GI distress. As she completed her very brief physical exam she said without surprise that it was simple acute gastroenteritis and Liz should take some antibiotics and drink coconut water. I took a deep internal sigh at this point as she was missing the point why we had come in the first place. I let the cat out of the bag and I said I was a doctor and that I brought her here because I couldn’t clinically rule out malaria or dengue and I told her our travel history. “Did you know she took Motrin?” was her first response. What I knew at this point was sitting across from me was a young overly confident, under educated, likely very overworked female physician in a male dominated Islamic culture who had probably been beat down all of her very short career. Having a vivid imagination of the system she must have come from, I felt a little bad for her and I let her have any upper hand she wanted and fill her ego with whatever she needed; in the end she grumbled about any lab tests, but she managed to give into the malaria test, but demanded a  stool culture.

Back into the main lobby we located the room for specimen collection. A young lab tech sat alone in a sad cold room of questionable hygiene as we entered. Liz handed her a paper, the young girl sat her down, pulled out a small rubber tube, made a quick tourniquet, cleaned her arm and drew blood without putting any gloves on. She then took the needle and threw it in some kind of box. It all happened so quick I couldn’t really say anything. Next was the stool sample. The tech pulled down a specimen cup for the shelf and handed it to Liz. No sterile bag, no instructions except go shit in this small cup. She was instructed to then bring the cup back to the same tech who would then probably take it with her hands and continue her day of drawing blood without gloves. At this point I said, “Is there a bag we can put it in? The cup will get dirty.” The response of “a little dirty Ok” was not what I was looking for. Liz went to the bathroom, the only one was in the main lobby. Inside there was no toilet paper or soap. She did her best with her own toilet paper she had brought and some hand sanitizer. Liz brought the specimen back to the tech and put it on the shelf, not giving the tech the opportunity to grab it. As we left ADK we talked about the complete lack of any universal precautions. Almost at the same point we thought about the needle. I said I was pretty sure it was a new needle: they couldn’t be that bad. But, I could see the panic setting in. “Do you want me to go see if she reuses needles?” I asked. “Kind of,” she responded. I walked back into the collection room unsure how I was going to phrase this question.

On the road of travels and life I’ve learned some subtle lessons about how if you just act a part, be confident and toss out a good amount of confusing bullshit people will typically be swayed. I boarded a plane in Taiwan with a cup of obviously hot coffee. The boarding agent told me that no hot beverages were allowed on the plane. Without missing a beat I replied, “It’s cold coffee, used to be hot, not anymore.” She even radioed ahead that my coffee was cold and not a concern. We use the mantra “cold coffee” now to symbolize that just playing a role well enough will solve most problems on the road.

“Hi, so we were in here just a few minutes ago. I’m working with the ministry of health, just kind of helping the hospital out with a few survey things. I was just wondering where you get your supplies?” “Um, well..I’m not really sure,” she replied with a nervous smile. “That’s ok, I’ll figure it out later,” I said, “So tell me do you discard needles each time?” “Oh, yes” and she eagerly showed me how she goes through the whole disposal process. Thankfully they at least understood that much.

To conclude the story, Liz didn’t have malaria, she eventually got better and it was probably just a nasty virus. I later learned that a large amount of aspiring doctors in the Maldives are funded by the Maldivian government to get their education in India for five years when they are 18. They then owe the Maldivian government four years as a full on physician, after which time they typically peace out to greener pastures, so there is a huge amount of brain drain on the system, and I wasn’t far off from the doc being about 23. Lesson is, if you’re ever in the Maldives do take care of yourself. I can’t even fathom what the operating rooms must be like. Also, if you have a seaplane and a couple million to invest I have a business idea for contract casualty evacuation company catering to six star resorts I would like to talk to you about…20150210-DSCF6284