* Five Days, Four Nights In Limbo Images: http://www.flickr.com/photos/dylananderson007/sets/72157627684090682/
Sunday, September 18, 2011
I have read and heard a lot of rhetoric and hyperbole about healthcare. The very word, “healthcare,” invokes a response from my eyelids akin to sleep on the cusp of coma. If I hear one more expat pensioner living off the American tax payer, tell me endlessly that they, “damn well don’t want no ‘obamacare,’ cuz no one tells an American what to do,” (which I always found funny coming from guys whose patriotism rarely extended further than their wallets and spent their entire life, usually in the service, rarely in combat, being told what to do, by senior NCO’s), I will shoot myself; Which ironically, would really score the point of my story. Healthcare, particularly in America
Marilyn seemed to be doing as well as expected following Maya’s delivery in a typhoon, in the hands of our midwife, who’d been up all night with her hands in someone else’s uterus. I have often worried about the fatigue factor in matters of medicine, piloting, and sharp instruments; no one ever died from a bad photo, at least not physically. On August 2, following nine days of bed rest, Marilyn’s reasoned, and not unexpected post partum bleeding, became serious as she began to hemorrhage that terrifying Tuesday, made all the more traumatizing because summoning an ambulance here is a lot like finding gentle currents in a riptide. It is difficult to describe the feeling when confronted by someone you love lying in a bed of blood, in obvious panic, losing all color and consciousness. I managed to flag a trike a block from home and directed the driver immediately to the medical birthing home of our midwife, being the closest medical facility I knew. It was raining, and Pinoy trike drivers generally act with the urgency of a lizard sunning itself; When the driver stopped to let a security guard wave out some vehicle from its parking space and into our traffic, I told him in loud and clear terms he could understand, that I would physically throw him off the bike and drive it myself if he didn’t get around the car and drive like his own life depended on it, (which at that point it did). I used language a bit more colorful than my mother likes to hear, but life is not always an experience in gentility. It seemed to have the desired effect, as the guy suddenly exhibited a proclivity reserved for race car drivers and road rage pursuits; apparently the sight of blood alone is not enough to motivate the Filipino. Never underestimate the motivational power of well placed rage and vitriol, just choose your battles wisely, especially in the republic.
Arriving at Grace’s, well guarded panic gave way to terror, and a kind of breathing best reserved for kidney punches, as blood and clumps of bloodied flesh, (what I latter learned where latent elements of the placenta – discharged with the hemorrhaging), marked Marilyn’s path to the examining table. Clearly all that the midwife and her nurse could do was attempt to evacuate what were now toxic elements of placenta that had not been properly evacuated. As I waited those rarely felt but decidedly surreal, “hour long minutes,” for the ambulance to arrive, I remembered the horror of looking at Marilyn and thinking she could die and, with no humor to help wash down the idea, my worry regarding fatigue in matters of medicine, piloting, and sharp instruments stuck in my throat.
As Marilyn was placed into the ambulance I told her the lie people in such situations tell others, “Everything will be ok.” It’s at best a hope, it’s not a truth, and it tastes like a lie on the lips you hope will not prove fatal. Traffic was expectantly terminal, with mongering jeepneys and darting trikes competing with a minority of private vehicles and an endless interruption of Filipinos on foot intersecting traffic without any care to corners, crosswalks, or their own life. I’ve come to believe that many Filipinos, subconsciously accepting their fate, have a latent death wish, but that’s another story. As we cut through the congestion and endless streets, lined with humanity, goods, and food stalls, I silently placed a call to god, but I never seem to get a confirmation, just a lot of hope that the line is clear and the signal strong. Maybe today I’ll be the ninety eighth caller to GODX FM. I suppose, to paraphrase Woody Allen, that’s the paradox of faith; It’s a small hook to hang your hat on, but its all we get.
Amado Garcia Hospital is located on a stretch of Rizal Street that is actually home to three hospitals and medical centers, no less than ten birthing homes, peppered expectantly with pharmacies and topped off by a generous dash of carenderias, where a plate of adobo or a piece of fish can be had with some rice and a drink, on the cheap, and on the fly, for those ensnared in medical row. Once we traversed one last river of trikes, screaming to fill a fare or disgorging one, our ambulance found safe harbor at the street side doors to the Amado Garcia ER. Exit ambulance and enter the absurd dance that is the Garcia experience, a Grateful Dead concert paled in comparison to the carnival madness. Marilyn was immediately attended to - more to do with the familiar face of our midwife and a tall foreigner with a baritone bark. Clearly, the site of a ghostlike woman covered in blood does little to rejoin much reaction as I was to learn, observing similar situations play out over the course of my week wandering about the ‘Hotel Garcia.’ We got Marilyn’s started on an IV of antibiotics and another of Dextrose, (no IV in the ambulance), and she was typed for her blood and a transfusion ordered. That’s as far as the good news traveled. Instead of immediately initiating said transfusion I was handed a prescription and directed to the cashier. Words escape one at moments like this, “welcome to the Buko Republic
One minute you’re in shorts having breakfast, covered in milk and children, the next you’re in an ER, covered in blood, but in the republic you better not forget your wallet and don’t even think about American Express - it’s definitely not welcomed here. Pay for your loved one’s blood or if solo pray you went down with a wallet containing cash or contact information because that’s the status quo. Pay or die, I exaggerate not. I presume that if one was brought in without any identity documentation, (or identity bracelet as I’ve come to consider), alone and dying, the authorities would attempt to make them comfortable, but little more. Choose your battles, and your alert methods, wisely. I went forthwith to the cashier where I obtained the holy ‘OR’ official receipt which cleared me to make haste to the blood bank and initiate my first of three blood purchases. Words simply elude one regarding the obscenity of clean and orderly insanity.
Marilyn was eventually transferred upstairs to a private room, which strangely, was only a few hundred pesos more than the public ward, which was as sanitary as the crew quarters of an eighteenth century sailing ship, and mercifully filled to capacity. A friend remarked, days later, that if you ever want to contract an airborne contagion, hit the ward of any hospital in the republic and you’re as good as infected with some manner of airborne pot luck. At this point I should mention that Garcia is a private hospital, and there exist something in the area of seven hospitals in Angeles, six of them private. The one public hospital is named Ona, which should be named, “ano,” which is the tagalong word for, “what.” Ona is where people go to die, whether they know it or not. I was there once, for as long as it takes to walk in, walk about and walk out. I had dengue fever, it was the start of the height of the rainy season in ’09 and even in my delirium I had the presence of mind to run. Ona actually makes the crew quarters of said referenced eighteenth century ship look like heaven, and that would be after a six months at sea, in bad weather. I don’t think they even have a blood bank on site, and only until this happened did I ever think of the word blood bank as anything other than a euphemism. Welcome to the republic.
Marilyn’s room was quiet and secure and she was as comfortable as a heavily sedated person can be, which is to say, she was resting peacefully. I on the other hand was consumed by fear, concern, and grief, least of which was how we were going to pay for all of this. Oh, and the realization that the hospital had no cafeteria, and nothing resembling so much as a coffee machine. I can find a coffee machine in the oldest mall in Luzon , so the rational behind this just flummoxed me, but hey, who am I to want coffee in a hospital at 4:00 a.m. Fortunately, as mentioned, Rizal’s hospital row has a well justified assortment of eateries, but everything locks up by midnight, also astounding. They had posted visiting hours, which I regarded with the dedication of a teenager to curfew. I slept on the room’s bench and when she was more stable I shared the bed. Apart from wandering Rizal Street
Four walls, a clean bathroom, that little bench, and a tank of oxygen; certainly not Cedar Sinai but I was grateful that she was stable and the room was clean. She had a total of four intravenous bags delivered through two veins, including blood, antibiotics, dextrose, metrondazole, various injections of things I didn’t have a chance to inventory, and a steady flow of oxygen administered intranasally. She would be monitored that first day, night, and into the following day, to see if she would respond to the antibiotics treating the infection and the blood transfusion. There is nothing quite so lonely or heartbreaking than sitting under a fluorescent light in a third world hospital at four in the morning, watching someone you love fight for their life while you face the totality of your predicament without the aid of sleep, where no one speaks your first tongue, hoping your infant children are safe. I have often said it’s hard to calibrate misery but that’s got to be a personal watermark.
Dr. Theresa Belmonte, hospital staff OBGYN, and friend of our Midwife, was courteous, and articulate, but kept bankers hours and was frequently vague as to the true nature of the problem we were facing. She usually visited late morning following Marilyn’s ‘scheduled’ breakfast, which like all three meals, continued to come, although she under strict instructions not to eat. Should I say something? Choose your battles wisely, besides I was hungry! It’s strange how much faith and trust you place in relative strangers, like the good doctor, (and real estate agents – ouch), at times like these, add to that the incredible stress, hopelessness, and sleep deprivation, and your pretty much a child lost in the mall looking for a big hand to help you.
That second day brought only mild improvement in her Marilyn’s condition and she continued to run a high fever. The antibiotics and intravenous fluids were helping but as feared she was not stabilizing and x-rays and ultrasounds were ordered. In all, three 450ml bags of B Positive blood were transfused, which is about 1.5 liters, factoring in that the average male has about ten pints/five liters of blood and the average woman has about eight pints/four liters of blood, she had lost more than 1/3 of her bodies blood supply. I shudder to think what would have happened if we had gone to Ona AKA O-NO. It’s only amusing now, and even now only mildly so.
The bottom line, as best the bottom line was to be drawn that second day by Dr. Belmonte, was attributed to various indefinite sources including, but not limited to; The uterine wall not adequately healing where the placenta attached; Also that previously undiagnosed anemia was a plausible cause of abundant bleeding, (which does not cure question of cause); and almost as an aside, the doctor mentioned, and I quote, “the existence of possible residual placenta,” I can promise you that the memory of Marilyn’s blood and “possible,” placenta on the both the floor of the birthing home and the hospital made me begin to feel that I was talking to John Dean about Richard Nixon before Dean cleared his desk. The relationship between our midwife and our physician clearly served to cloak the definitive source of the problem, and the elephant in the room was actually pretty easy to obscure when your audience is a semi conscious woman and a sleep deprived man desperate for any kind of answers. In time it would be revealed quite clearly that the placenta, insufficiently evacuated at birth had turned toxic and worse, had almost killed Marilyn. Ultrasounds and X-rays bore this out and dictated immediate surgery that evening. Thoughts of concern mix with fear, and exhaustion, along with the staggering realization of the increased costs associated with surgery, to say nothing of unscheduled surgeries; Costs, which, as we were to learn, would be due in full before one was released from the hospital. In fact I later learned that only owing to our doctor’s advocacy was the surgery even ordered without prior payment. Why she did this I will never know with any finality or certainty. Life in the republic is painfully cheap, a neighbor of ours, only seventeen, died a few months ago when a previously undiagnosed heart problem rendered his parents merciless before the hospital staff. He was apparently sitting outside his house when he began clutching his chest. He died in the trike on the second leg to Ona, having been refused admittance for lack of funds. I hope I never again meet anyone whose fate comes to that crossroad, which is traversed in the republic daily.
I had about an hour to contemplate our predicament between the reading of the X-Rays, and ultrasound, which felt more like a reading of my own will, and tentatively slotted time for the surgery itself; In that intervening hour I tried desperately to get an answer as to even an approximate cost for the surgery; forget the cost of the anesthesiologist who was performing a spinal tap, and forget the perpetually administered drugs, procedures, room, technicians, doctors, and, dare I forget, the blood. I attempted to ascertain cost from the Billing department with whom I felt like I was trapped somewhere between a bad Abott and Costello routine and the movie Brazil
Marilyn went into surgery, that evening, on schedule and I had to sit in a hallway and contemplated our life together in this place, in my own valley, which was becoming increasingly cold. The overhead hallway speakers were piping really bad pop songs, somehow you’d think they could pump in some Handel or even a little Strauss, some choral music, even a waltz, or Jazz. I’m not asking for Coltrane just some kind of auditory elixir that bore some resemblance to reasonable auditory mellow. Sitting in the isolation of a surgical waiting area while its raining pop music is cruel and unusual, and prone to drive one already lost in existential reflection to a darker place where there is no light. I ticked away the hours looking out over the city in its own waning light and wondering, as I often do, what all those little ants, I will never meet, were doing, and if they were happy, and if they were as worried and as scared as I was feeling
I was allowed into the surgery room before she was moved to recovery; I had to wear top to bottom scrubs. Everyone but one attendant and an orderly remained, the detritus of the surgery still being cleaned up. It was surreal. I held her hand. I didn’t speak and she could not talk. It’s amazing how solemn certain simple actions can be. She was transferred to recovery and back in her room around midnight. Dr. Belmonte told us that the decidedly toxic material was now a thing of history, and medical waste, (save for a medical grade sample I still have possession of), and that the infection and fever should now abate over the course of the evening. I spent that night monitoring her. Occasionally wondering the three floors and six nurses stations, where, on one of my rounds, I found every nursing personnel and the overhead lights dead to the world– I exaggerate not. I also spent a few hours in the chapel on the third floor where I prayed silently and then contemplated the Stations of the Cross.
The following day, early afternoon Thursday, Marilyn awoke and was able to eat for the first time in almost three days. She was placed under continued observation by Dr. Belmonte and it was and hoped that she could be discharged the following day. At 3:00 pm, as I had done everyday I went to the ever present billing office to get a daily print out of the expenses; it was an odious but almost endurable total sum. I had been led to believe that the doctor’s surgery fee and anesthesiologist would bill separately and that those costs could be paid to their respective practices over time. I continued to believe this and it appeared to be the case when I got the daily update of expenses on Thursday afternoon and found the surgery room on the list of billable but not the professional fees. I spent that day and evening calculating, and by liquidating every single reserve we had managed to build, and call in debts owed, we’d be able to crawl out from under this calamity. The thought of seeing our children and knowing there mother was safe was enough to make the repercussions of the financial disaster almost tolerable and I finally let lapsed into sleep around two in the morning.
The sun failed to appear on Friday though word of its existence was promised to me. As is the habit in Filipino hospitals various liturgy of catholic devotion echo the corridors of healing at differing times day and night, and as the sun made its alleged rounds that First Friday of the Catholic calendar, so too did the repetition of rosary prayers. I’m a big fan of the holy mother but I find it hard to defend curative healing with pleas to pray for us now and in the hour of our death more than thrice, while body, mind and soul cry out for a quieter nature called sleep. I understand the simplicity of form in making the liturgy accessible to all, just not delivered through that blasted overhead speaker system. I confess, I was feeling a tad less Christian by the tenth Hail Mary and the lure of peaceful meditation had clearly eluded me. I was risen and so I surrendered and sought out one of the numerous coffee carts plying their trade in the gentle, but unending rain of that week. Marilyn was sleeping like a baby while I wondered off to think over the true nature of democracy in the republic, the existence of god, and the fiduciary apocalypse on the other side of this first Friday.
Late morning brought our neighbor and the Filipina insistence on the curative power of food; it is well known that the general solution in the republic to almost all matters of concern begin with the utterance, “lets eat,” or in this case, “let’s make her eat ‘til she rises from the bed!” I was dispatched in earnest to retrieve as many calories as possible in the form pork based soups and sweet breads. The fever had abated, color returned to her complexion and Dr. Belmonte cleared us for departure when she stopped by for a few moments. In retrospect she seemed more interested in my take on the American debt ceiling fiasco, and, as the bill reflected, I did indeed pay for this thirty minute symposium. In retrospect, I wonder if she’d have been receptive to a counter bill, for services rendered. Following our doctors visit I made my daily pilgrimage to the sacred billing department and said hello to the cashier, with whom I was now on a first name basis. The additional day rate had been tacked onto the bill, along with the doctor’s room visit. I anticipated no surprises, which is always a mistake in the republic. One hour later, bags packed, and Marilyn cleaned and dressed, I went to pick up the final bill and came face to face with the black heart and hypocrisy that is the Philippine Medical establishment. The final bill had more than tripled with the now very apparent addition of all surgical fees. Amazing how no one could tell me what the procedure would cost, and no one even bothered to include the most important disclosures until the eleventh hour. It was then that I learned what I have previously alluded to; All fees are due and payable before patients are permitted to exit the premises. I demanded explanation, received none, and was eventually told someone would come to the room and explain the policy. As I walked upstairs to the room I thought of Edward Norton’s narration in Fight Club: [voice over] “Please return your seatbacks to their full, upright and locked position”. This can’t be happening, it’s not a movie, and it’s not a prison. “We have just lost cabin pressure.”
Instead of picking up our packed bags, x-rays, and miscellaneous unwanted purchases, (forks, spoons, toilet paper, gauze, everything is sold at a retail premium), and leaving the madness of Amando Garcia we were now veritable prisoners of the hospital, pending full and complete payment of a bill that was now circling north of one hundred thousand pesos. The per capita income in the Philippines
I believe the only reason we were not charged per procedure was because one, I am a Caucasian foreigner, and two, Dr. Belmonte was working in some degree of complicity with our midwife, who rather apparently been negligent; proving that point the republic is another story, but I digress. - I used to muse that I was like a phoenix rising, but this is more ash than I’ve ever had to lift before, a man can truly only take so much. I demanded someone from accounting come to the room and defend this policy of full payment and I got Tweetle Dee and Tweetle Dum at four pm on a Friday. I already knew what was going to transpire; if these two identically dressed bookends could dance enough double talk for an hour and skate we’d be someone else’s problem and they could snake out of the hospital lying to us that they’d send someone of higher authority to our room, which is exactly what they did; a supervisor was promised to be sent and no one ever came. When I went to billing an hour later it was dark and vacant. Welcome to the republic – pass the buck, or peso, and run. I went through this in a prior email, but, in short, Garcia’s admittance agreement regarding fees, states no such full pay policy and is utterly ambiguous regarding payments, stating nothing more than, “payment be paid in a due and timely manner.”
I am tired of learning about loss. I remember pacing back and forth in front of my window overlooking the hills in Hollywood while Sue Silvers stewardship piloted my home into an ice burg and thinking how life had been filled with so much suffering; I used to muse that if the Anderson brothers had not more day of suffering that we had seen our quota of loss to last a lifetime. How far from the threshold I, for one, was to find myself. I have always considered myself a progressive realist, seeing the glass neither half full or empty; I see the glass as nothing more than a glass, and I will never be the one saying the end justifies the means but I am grateful when I see my son and my daughters faces smiling back at me, and frankly happy even when they are screaming, shitting, puking, pissing, vomiting, upon me and best of all when they hug me and laugh. I love them and for that I have seen some sense in my suffering.
Make no mistake about it this experience was devastating to us, emotionally and financially. We overspent our closely regulated monthly budget by about a year. The path back is just that, a headlong battle that is far from won. I have to deal with a back molar that cracked and I’ve decided that the pain is tolerable. Dylan is late on his latest vaccinations and Maya still needs her first series of newborn vaccines. I will cover Marilyn and the children with Phil Health, which offsets about fifty percent of any future medical emergencies. I am not eligible. In the days and weeks that mark Marilyn’s recovery I dedicated myself to the shop, for better and worse, and the care of my family. I also, through research, learned what I had always believed but never clarified; that the infrastructure, of the archipelago, both private and public, simply does not provide the level of healthcare needed to sustain a civilized and healthy nation; Never mind the commercials endlessly selling things every family “needs,” all the formula, clean clothes, and food products in the world won’t cure you of your ills should you dare to face a medical crisis. Because serious illness strikes without the impact of a tsunami, families devastated by a medical crisis suffer in silence and isolation amongst their fellow citizens. There is nothing headline grabbing about one families devastating medical emergency, though it may leave in its wake more damage than the worst of fire or water or wind. The ability to cure does indeed exist, but the will is absent to create or implement any coherent public or even private remedy to the crisis of medical care in the archipelago. You fall seriously ill and you pay or you will be shut out! Period! People die everyday here because they can not procure the impossible sums mandated to live in the face of an emergency, and can not even take on the yoke of mortgaging their life to payoff the purchase of one’s very health.
At the national level, The Philippine Health Insurance Corporation or PhilHealth was created in 1995. A government owned corporation, PhilHealth attempted to achieve universal coverage for the archipelago. However, PhilHealth has faced predictable corruption and is currently working with something in the area of a twenty billion peso debt and projected to go bankrupt by 2017, unless the government bails the program out. It also has dramatically reduced coverage benefits and services in the face of increased subscriber claims. It remains our only real option and I am hoping to get Marilyn and the children covered when we can afford to. At the most basic level of medical remedy exists the barangy medical center which is little more than a band aid station where you can get an aspirin and have vital signs checked. It feels daunting and depressing as I write and contemplate all this, I suppose because it is so, most emphatically disheartening.
To paraphrase Tony’s tribute to Wayne Gretsky, “I always miss 100% of the shots on goal I don’t take,” but Dorothy Hamill would have a better chance getting a hat trick, during the Stanley Cup finals, than we’d have getting any punitive settlement for our troubles. Choose your battles wisely and know when to set your sights on another hill. The rule of law is simply not an equitable solution to problems in the republic. As my friend Jamie reminded me, never forget where you are. The thing about the archipelago that you have to remember is that under the thin veneer of beauty and good natured joviality is the incontrovertible fact that the republic represents one of the worst examples of systemic corruption you can think of outside of Africa and the Middle East . Its constitution is less than twenty years old and it only emerged from martial law under the Marcos Dictatorship in 1990. Just consider, if you will, the greatest personal experience of corruption you can recall, now imagine trying to remedy the wrong within a system of justice whose workings turn with the speed of cobweb covered gears on the slowest engine you’ve ever seen, whose very parts are being scavenged as they turn.
I liquidated most of our remaining assets to repay the overnight loan from my buddy Charlie, stateside; his international monetary fund represented the lion’s share of two sources I had sew out of the night’s air; which in no uncertain terms, along with our savings, afforded Marilyn’s escape from the clutches of Amando Garcia in-hospitable hospital cum penitentiary. Charlie is in no position to loan money, but he knows the predicament of one in the midst of medical malaise, Filipino style, having done a good bit of his residency in Angeles. His righteous assist as a medical practitioner leans less on the crutch of irony and more likely stands as a pretty firm reason for helping us out; He knows medical emergencies loom with a special darkness in the land of sunshine, like a tsunami on a moonless night. Needless to say it was a small victory to repay him and balance the scale he couldn’t well afford to tip. We have one last loan to satisfy, which a cousin married to a geriatric pensioner proffered, likely under duress, and owing, (no pun intended) to the advocacy of his child bride. The poor of this land and expat pensioners share a common life on the line, the poor living from peso to peso and the pensioners living from government check to government check, usually spent before its cashed by post adolescent concubines . I’ve heard told that the pensioners are sympathetic to the plight of those facing calamity, but unless its in a dress speaking pigeon English, said sympathy lasts about as long as a bar room confession of love, which is to say, not much longer than the rising sun. So that loan gets paid off this week and we go on the rice and soy diet. We also can not face another medical emergency which makes me more grave and stoic than usual. Its strange how much light and love children bring into your heart and how sobering life appears when they’re raised in the midst of so much peril. I’m proud of myself, but its odd how doing my best and being a good person has bears fruits that can’t be shared. I protect my children and love them and that is its own reward. Their mother is safe again and cared for with all an endearing love born of suffering. I pray her health, my own, and that our children will be in good care for a very long time to come. It was two more months of barbarous trials peppered by the brilliance of Maya’s birth. Here’s to tomorrow, may it shine with something resembling the promise of the North Star. Sometimes I feel like we are the lost tribe, or maybe I just feel like I’m in a curious kind of exile, like Ulysses, trying to find my way home and keep my crew safe. An old Irish fisherman’s prayer echoes in my head, “Oh God thy sea is so great and my boat is so small.” Amen.
