RXpat

Bushmen Medicine

2010-03-16T16:16:00.000+01:00

   There's a new field of genetic research called pharmacogenomics, which recognizes that medicines work differently on diverse human populations. This diversity was highlighted by the recently published results of a genetic study of Bushmen in Namibia and Bantus in South Africa (http://www.nature.com/nature/journal/v463/n7283/full/nature08795.html). Scientists found there is such a diversity among the Bushmen themselves that they are as different from each other as a Western European person is from an Asian.
   Civilization is encroaching on the Bushmen, whom we dubbed the greenest population on earth when we stayed in a Ju/'hoan village in remote Namibia. They are the experts on plant pharmacology. Following them through the tall grasses one afternoon, we watched as they picked out one bush or plant after the other, showing us how the leaves or roots could be used to treat different medical problems. No wonder their civilization is now thought to be two million years old -- they have learned to use just what they need and no more from earth's bounty, ensuring the future by leaving something for those who follow.
   There's an old movie in which a Coke bottle falls out of the sky and is discovered by a Bushman, who had never seen such a thing before. Today, what some call, ironically, "civilization" has entered the lives of the Bushmen, often through their children, who are now going to school, and also because independence for Namibia twenty years ago has meant that more and more people are coming to what once were vast and empty lands inhabited only by these ancient people. In a democracy, citizens have to be registered for pensions and health care, populations counted, representative local governments established.
   Yet the Bushmen fight to preserve their traditions and they have much to teach us. In some areas of southern Africa, the plants they use for medicines have been taken to produce medicines or diet supplements for sale in Europe and the US, without benefit accruing to the tribes that discovered them. Fortunately, in some cases tribes have won the rights to share in the profits of pharmaceuticals made from plants harvested on their ancestral lands.
   We witnessed a healing dance in a village near Nhoma, where the quiet people we had met that afternoon as they made beaded jewelry or honed their arrows, became spirited singers and dancers in the flickering firelight in their effort to cure a small boy who was ill. The ceremony went on all night, as the little one sat quietly in the lap of the chief. The next morning the group would decide if the dance had done its work; if not, the child would be taken to the clinic forty kilometers away. If this delicate balancing act between the ancient and the modern can work, then perhaps the Bushmen and other isolated populations like the Himba can preserve their distinctive cultures.
copyright Sharri Whiting 2010

HEALTH CARE "ABROAD": TELL US WHAT YOU KNOW

2009-11-10T10:43:00.000+01:00

The goal of RXpat is to add to your understanding, give you an opportunity to comment or share experiences, and build a searchable knowledge base of information to call upon no matter where you are in the world. We welcome comments and information about countries where you have experienced the health care system.

Where is "home" and where is "abroad" differs depending upon who we are; wanting to know about medical care is a need we all share, no matter where we happen to be living or visiting. It's not only a matter of acculturization, it can be a matter of life and death for ourselves or our families.

The idea of a forum on medical issues abroad arose when we lived in Holland in 2003, where we knew there was excellent medical care, but had to learn the system, lose a bit of our modesty, become accustomed to a different style of nursing and doctor visits.

In the United States, the interest in medical care abroad has been heightened in recent months by the discussions of health care reform. As a result, more information about medical care in different countries has become a hot topic. The New York Times has initiated a blog called Health Care Conversations (http://www.nytimes.com/interactive/2009/09/29/health/health-care-conversations.html#/13/); one of those conversations is about health care around the world and you may find the comments useful.

T.R. Reid, a correspondent for the Washington Post, has written a book, "The Healing of America," in which he describes his experiences traveling the world to compare the kinds of treatment he would receive for his injured shoulder. His insights make good reading for those of us who live, work or study abroad.

Sharing your own experiences here at Rxpat can be valuable to other expats -- living in a place, as we all know, is different from being a visitor. We are looking for longer term relationships with our doctors, to know where to go for emergency care, as well as non-emergency hospital stays. We want to know what others like us have experienced. Please send us your points of view, wherever you may be.

For travelers, it is important to know what to do and where to go if things go wrong: your medicine is stolen, you have a heart attack or other life-threatening occurrence, you get run over by a truck in the street.

In our new post, we will have an interview with a cardiologist who was trained and practiced in the US and who returned home to Italy a few years ago. He will give us advice about how to handle having a heart attack away from your home country.

copyright Sharri Whiting November 2009

The Patient Patient: Day Two in the Italian hospital

2009-11-06T10:03:00.014+01:00

This is the second part of an account of a stay in a regional Italian public hospital, in Terni, Umbria. The patient is Italian, his wife American.

Day Two, Monday

This hospital is so quiet at night it makes you wonder. Where are the nurses who laugh and talk outside the rooms at 1 am? Where is the crash and bang of the cleaners as they empty the trash at 4 am? Do the ambulances arriving at the Pronto Soccorso (emergency room) turn off their sirens before they reach the hospital? Why isn’t anyone taking vital signs when the shifts change? Aren't they going to shake awake the patient during pre-dawn REM sleep?

The first night we had the entire room and I slept in a patient bed. Neither of us got much sleep: we were worried, stressed, nervous, as everyone is before general anesthesia and major surgery. Perhaps Piero wasn't visited in the night by nurses taking his BP or temp because he hadn’t yet had surgery. Still. . . .

At 6 am, the first nurse came in to check on him. She carried a blood pressure monitor, a clipboard, a thermometer, a stethoscope. None of the equipment was electronic, there was no computer on wheels to track the data, no rolling BP machine. She did her job the old fashioned way and left.

Before they took him down to surgery at about 9:30 am, Piero had to shave off the rest of his beard himself. They said he would be getting a roommate, so we opted to move him to the bed by the window. I would bring in my cot, as the doctor had suggested, and open it under the window. I walked alongside the stretcher as they took him into surgery, promising myself not to cry or look anxious. At the door to the operating theatre, I told him goodbye and the big doors closed behind him. I went to sit in the “Reanimation” (recovery) waiting room with my sudoku, my iPhone and a few old New Yorkers passed along by my friend Mary.

The surgery was supposed to take 1 ½ - 2 hours. After almost three hours, I noticed that the families of other patients who had been there when I arrived had been replaced by other families of other patients. I got up and looked out the door of the waiting room. There was no information desk, no one to ask, so I went to stand by what I thought was Recovery and waited for someone to come out. When a woman in a white uniform exited on her way to lunch, I stopped and asked her how to find out about my husband. She said to wait. I waited some more. The crowd was thinning out, as family members and friends went up to the rooms with their loved ones and staff members passed by laughing and talking on their way to lunch. No Piero.

I stopped another white-coated woman and she sent me downstairs to a narrow room where FOPs (family and friends of patients) were putting on green hospital gowns and booties marked with the names of “their” patients. There was no De Masi written on any of the folded gowns on the table. A man also looking for information knocked on the door; it was opened by a woman in greens. She went to look for De Masi and someone named Pippi and came back to say the equivalent of “never heard of ‘em.”

I went back upstairs. Piero’s sister called from Rome and I told her I was frustrated at not finding out information. She launched into an attack on the Italian public health system, but had to get back to her work in the sound studio before finishing her tirade. Finally, another FOP, an Italian woman waiting for her father, suggested she go with me back upstairs to Piero’s room to find a nurse to ask. On the way, we stopped a doctor rushing in her scrubs from one operating room to another. She was what I have come to see as the typical middle-aged female surgeon in Italy – smart, professional, friendly, a little bit blowsy, caring not a whit for her appearance. She said to go back down to the operating suite and ring the doorbell until someone answered. So, that is what we did.

We rang the bell two or three times before an orderly finally opened the door. He said he would look for Piero; a few minutes later he opened the door, producing the information in the form of my husband. Piero looked pretty awful, his face creased with pain. I was very glad to see him; my mind had started to wander in dangerous directions. He spent much of the rest of the day sleeping; the pain was primarily from a sore throat coming from the insertion and removal of tubes. He was hooked up to an IV for nourishment. Later I found out Piero waited over an hour for his procedure after being taken down to surgery.

A young Italian surgeon who trained in Boston at one of the Harvard hospitals came in several times, as did the endocrinologist, a severe and petite woman who slipped into bitchiness when a Dutch doctor friend of ours came by and asked her questions about Piero’s status. Instead of seeing him as a concerned friend who happened to be a colleague in the practice of medicine, she seemed to take it as an insult that foreigners (a Dutch doctor and the patient’s American wife) wanted information. She was arrogant and offensive in her behavior, while the young man who worked at Beth Israel in Boston had a completely different attitude. This woman definitely has issues, but there is also a prevailing attitude among some Italian doctors that it is none of our business what is being done to our bodies. This is changing as many young doctors go abroad for further training and come back acquainted with patients' rights, pain management and concern for families, as well as patients.

There is not much food in this hospital for FOPs. There is a coffee bar downstairs; though they have wonderful cappuccino and cornetti for breakfast, that's it. Gemelli Hospital in Rome has a huge cafeteria, as well as a coffee bar with sandwiches, ice cream, etc. I go back across the street and buy a piece of pizza made around the time the hospital was built in the 60s. After my dinner, I sneaked across the hall to the handicapped bathroom and took a shower.

This afternoon, while Piero was sleeping off the anesthesia, we our roommates arrived. They are from a village on Lake Trasimeno and the man will have some tests tomorrow. He is short and small boned, probably in his late sixties; his wife is short and a bit round, the same age. He sits in the bed in his pajamas and she smoothes the sheets, pours him water, pats his leg. At nine o'clock, about the time Piero finally is alert and I am ready to talk to him or read, our neighbors announce it is time for bed and we should turn off the lights. We look at each other. Piero nods. He turns off the light. Everyone settles down. The man in the next bed relaxes, his wife has pulled up a straight chair from the table and she sits in it with her head resting on the side of the bed for sleep. Piero soon drifts off. I lie on my cot, reading Ethan Frome, which I have downloaded to my iPhone.

Night, John Boy.

In the morning the nurse comes in and says to get rid of the cot before the head nurse sees it. They need more space around the bed in case of emergency, something I had suspected.

Piero is feeling better, so I go home to feed the cat. He's discharged the next morning. There is nothing to sign, no co-pay, no bill.

copyright Sharri Whiting 2009

The Patient Patient: Day One in the Italian hospital

2009-11-06T09:28:00.006+01:00

In the US, controversy rages about how and how not to change the health

system in the United States. This account of a stay in an Italian hospital run by the

national health system, the ALS, is the second in a series of documented actual experiences as an in-patient abroad. The patient this time is an Italian citizen; his wife is an American.

This wasn’t supposed to be Day One, but the doctor called Piero this morning and said he should check into the hospital this afternoon to be sure of getting a bed.

This would be convenient since he is supposed to have a thyroidectomy tomorrow. He is to ask when we arrive if they have a private room he can have as a paying “guest” so that I can stay with him; otherwise, she suggested I bring a folding cot. The hospital is an hour’s drive from our house.

We arrive about 6 pm and are given the only room available, one with two beds and no one else in it. If the census doesn’t go up too much tomorrow, we can keep this room and pay for it; otherwise, I will have to unpack the cot from the car and set it up next to Piero’s bed. If he has to share, it will be interesting – there is no curtain or other divider between the beds, no privacy at all. There is a bathroom, nice and clean, with toilet, bidet and sink, but no shower.

There are no soap, no towels and 1/10^th of a roll of TP. We ask the nurse about it, thinking the room hasn’t been touched up by housekeeping. Nope. She was surprised we didn’t know to bring our own soap, towels and toilet paper, along with Piero's personal pajamas and medications.

I’m very happy to have a bed. There is no a/c, so we have the windows wide open because it’s really hot in here. Piero’s dinner arrives at 6:30: fish filet, some kind of soup, fresh tomatoes and olive oil, green apple, water. Unlike in Virginia, where Mother was hospitalized in the summer, there is no provision for a guest tray. I’d rather have the bed. I walk across the street to the little market, where the owners serve the family and friends of the patients. They must make a fortune. I spent 40 euros on a six-pack of toilet paper, a 2-bar pack of soap, four flimsy towels, two little bags of cracker, some Philadelphia Light, a package of prosciutto, 2 packages of cookies, some fresh wipes, 2 bottles of mineral water and a 250 ml bottle of red wine (for me).

I come back and have my dinner at the little table where they serve the patients. Italian hospitals are very civilized -- those patients who are able to get up are served their meals at a table rather than in bed. I don’t make an issue of having the wine; probably they wouldn’t like it.

While I was gone, the nurse came to shave Piero’s chest and neck. They have not yet taken his vital signs, but he is wearing his pajamas. The nurse has an electric razor that zips through the beard hairs. He doesn’t take off the whole beard, just the part below the chin. There is a handwritten sign taped to the end of Piero’s bed: Digiuno, meaning “fast” -- he can have nothing to eat until after the surgery.

I am much more comfortable having a bed in the room with Piero than I was trying to sleep in the huge ancient armchair in Mother’s hospital bed in Virginia. I know I will get some sleep tonight if it’s not too hot. We have the windows wide open and there is a breeze. There is no TV, only a little shelf above the closet where a TV used to be. We have brought i-pods, sudoku, books, old New Yorkers that my friend Mary passed along. I can check my email on my iphone and write abbreviated answers when necessary.

Santa Maria is an old hospital. It’s clean, with wide halls paved with green linoleum. The patient next door was shouting earlier tonight and his family was trying to calm him as I passed on my way to get my suitcase out of the car. The building wanders this way and that, having been added onto over the years. There is only one wing that looks newer than the year 1965. (In Foligno the hospital is brand new, but Terni is the better place for this procedure). The patient beds are stained wood and manually controlled, not as massive as the huge beds you see in American hospitals. I’ve been in hospital in Rome twice, both times as a private patient. The first time was in a private clinic for eye surgery, where the beds did nothing at all, but the nuns patted my cheek and soothed my troubled brow. At Gemelli, in the Solventi section (for people who are solvent; in other words, you are paying), I had the big, electronic hospital bed one would expect on the floor where the pope stays when he’s sick.

We don’t know what time Piero’s surgery will be tomorrow. There are four thyroidectomies scheduled and a woman will be the first. After that operation is over, they will decide who goes next. I hope it’s Piero.

copyright Sharri Whiting 2009

Breast Cancer in Oz, Part III

2009-08-18T14:38:00.005+02:00

After my lumpectomy in Rome, I had a private visit with a radiation oncologist, a woman who commented that her colleague, the female breast surgeon, had done an excellent job. I remembered that, early, on the dottoressa had promised me she would be mindful of aestethics when operating on my breast. I was so upset at the diagnosis of breast cancer that all I wanted was to have the tumor gone, without regard to how pretty my breast would be afterwards. Today, I am grateful for her attention to this not small detail -- looking normal is very helpful in getting back to feeling normal.

I had done some homework online at cancer info sites recommended by the New York Times and came prepared with questions that it turned out were answered for me before I had a chance to ask them. As I hoped, I was a good candidate for the three week course of higher dosage radiation and, if I chose to go that way, I would be finished with radiation by early March. I said yes.

I was then sent for a nuclear scan of my bones, a bone density test, blood tests, liver scan and one or two other tests, all courtesy of the national health system. These results would be the benchmark for the future. Savvier than before, I now arrived at the hospital with a bottle of Valium drops to salve my claustrophobia in case of tests in tunnel-like machines. I knew that getting anti-stress meds wouldn't be easy in an Italian hospital. These people are used to patients who buck up and suffer through. The nuclear test wasn't supposed to be in a confining machine, but after sitting in the "radioactive waiting room" for the nuclear material to infiltrate my bones, I got a look at that machine. Uh uh, no way. I asked for more time -- the 10-15 minutes it would take for ten Valium drops to relax me enough that I could pretend to be lying on the beach while the huge machine passed half an inch above my face. They were nice about it and we got it done.

Radiation in the Italian national health system wasn't bad. The first day I was given a bar code. From now on, for privacy reasons, I would be 14A. I was to swipe the bar code when I arrived everyday, which would enter 14A into the system. There were tv monitors positioned around the waiting room, rather like the ones used in airports to announce flights. I could watch 14A inch its way to the top of the list -- when my number blinked, it was time to go into the back, where a radiation specialist would lead me into the room for my treatment. I could see the department's framed certificate from the American radiation oncology certifying board, which had a calming effect. Five minutes later, I was on my way home, without my name ever being called in front of the other patients. The three weeks passed quickly and it was over.

I will take an aromatase inhibitor for five years and be checked regularly. In the end, I have been satisfied with my treatment in Italy, both in the private and public sectors. I like having the option of private care when I need it, but I respect very much the Italian national health system. Of course, I fault it for crazy things like not having a test kit on hand because the financial side of medicine insists supplies must be ordered in the fiscal year they are to be used, or that I must visit the general practitioner for my area every month in order to have my drugs without paying. And, as I've said before, there is the dreaded month of August, when much of the system almost stops because everyone is on vacation.

Here, if you have cancer or diabetes your treatment is free. (Depending upon your income, you may be asked to pay up to about 30 euros for some medical tests in the national health system for other illnesses). A person with diabetes who needs insulin or other supplies can walk into any hospital or pharmacy in Italy, show a card from the Italian national health and be given those things for free. In the US, my 85-year-old mother spends thousands a year in co-pays for her medications and treatment for Type II diabetes, as well as her Medicare supplemental insurance. No elderly person here would every have to do that.

PS I should mention that I asked for a second opinion in the US following my radiation. I was seen at the Mitchell Cancer Institute by a well known oncologist who has received numerous grants for research into breast and other cancers. The doctor spent an hour with me, going over all my records and doing a physical exam. He agreed totally with the treatment plan followed by my doctors in Rome, though he will also check me again when I go back in a few months. Here, too, I made it out of the hospital without being tackled by a bill collector.

copyright Sharri Whiting 2009

Breast Cancer in Oz, Part II

2009-08-18T14:04:00.004+02:00

Having breast cancer in Italy has given me a whole new appreciation for both the Italian and US systems, as well as a reminder that no medical system is perfect. My surgery went well and I was treated by a whole team of women doctors, each of whom seemed particularly sympathetic with what I was going through.

I was given plenty of pain medication post-op and woke up in my lovely room to see the nurse setting a table by the window with white cloth and china plates. I was expected to get out of bed for my dinner, which was a light meal of a minestrina (pasta in chicken broth sprinkled with parmesan), a slice of fresh Roman bread, sparkling water and a pudding. I managed to eat most of it and then was helped back to bed.

By the following morning, I was back in my own pajamas. My breasts were tightly swaddled in an endless layer of elastic bandage, I was given plenty of pain medication, and the doctor came in to talk about my surgery and spent more than twenty minutes with me. She had done a beautiful job -- I would have no disfiguring scars because she had made the incision around the edge of my nipple and then sewn it back together.

I spent two more days in the hospital and then walked out on my own steam. Still no wheelchairs. There was a classical piano concert going on in the lobby -- in the audience were at least a dozen people wearing their pajamas and bathrobes. Nearby, in the big Italian coffee bar, baristas served as many patients in their nightgowns as they did white-coated staff.

We stopped at the business office -- no American hospital would have let me out without settling the bill. We had chosen to do the surgery privately so that I could have it very quickly, during the Christmas holidays, rather than wait until the last half of January. As my insurer did not have an agreement with the hospital, we would have to pay ourselves and be re-imbursed. We arrived in the business office on December 31, only to be told that the bill wasn't ready, come back next week.

Looking over my shoulder in fear that I would be held hostage by one of his colleagues until I coughed up the money, I remembered my stay two years previously in a hospital in south Alabama. After my gall bladder surgery, on the morning I was to go home, the business office called and informed me that they had not been able to reach my Italian insurance company and I would be expected to pay in full before leaving. Mild panic ensued, calls to Italy followed, and then all was settled. 100% of the bill would be paid by my insurance company. Here in Italy, nobody seemed worried that I was going to skip the country without taking care of the charges.

Weeks passed before we ever got the final bill. When we did, the total, including private hospitalization, surgeon, anesthesiologist, medication, everything, came to 13,000 Euros, as promised, a fraction of what it would have cost in the US.

Immediately afterwards, the dottoressa moved me seamlessly into the public system to have follow up care. I visited her several times in the breast center in the hospital, where she checked my incision and drained fluid from my breast, thinking that each visit would produce the final lab report vital to determining my course of treatment.

The initial lab tests had revealed no lymph node involvement, no metastasis, a Stage 1 tumor. What we were waiting for was to know if the tumor was the more aggressive HER2-positive, which would mean months of chemo followed by radiation. It was the end of January (my surgery had been December 29) when she, obviously embarrassed, informed me that the test result wasn't ready. She had gone down herself to the lab, only to be told they had no money for test kits to start the new fiscal year. I suppose she flipped out; I certainly did. I would have bought one and brought it to them if that would have solved the problem. This was a side of the national health system I hadn't seen and I was incredulous.

The next morning at 9:30 she called me. We were on the highway going back to Umbria from Rome. I grabbed a pencil out of my purse and noted the test results: I was not HER2-positive and, therefore, would not need chemo. I could have my life back after a few weeks of radiation, which I would receive from the national health system in the same hospital. I would receive a phone call with a appointment time to see the radiation oncologist.

Breast Cancer in Italy: a Trip to Oz

2009-01-15T04:51:00.007+01:00

Italy has excellent doctors. Finding one usually takes networking: asking your friends, family, colleagues and, if you have one, your GP or internist. Should you wish to discuss your body and its ailments in your own language, you may have a challenge on your hands, but even that is do-able.

There are top notch breast specialists here -- as someone remarked, "Italians love women's breasts, so it's no wonder there are so many good breast specialists." I doubt that's why these doctors became oncologists specializing in the breast, but it's a good story.

Italy has some beautiful well equipped hospitals and private clinics. What the country lacks is in the infrastructure. It's like taking a three star Michelin chef and putting him in a fabulous kitchen in the most posh restaurant without kitchen help, modern systems of food prep, the best ingredients. Your chef may be brilliant, but he won't be producing the kind of meals he was trained for. Your doctor may be brilliant, but if the support staff and systems are outmoded or were never there, she will struggle to do her best work for the patient.

Dealing with this as the patient is like living the plot of the Wizard of Oz. My doctor is Gwendolyn, the good witch. I am Dorothy. Just when I think I've got it figured out, the next thing that comes along is totally out of sync with my expectations and I am running for my life.

After holding my breath to get through the cloud of cigarette smoke at the front entrance, where both staff and visitors (and patients?) stood around huge ashtrays full of butts, I checked into the Gemelli Hospital, the teaching hospital of the University of the Sacred Heart med school, which is owned by the Catholic Church. I was glad I wasn't going in for treatment of emphysema because running that gauntlet of smoke could have sent me to ICU.

The "Solventi" area is the wing reserved for patients who can pay rather than use the national health service. Gemelli is a huge teaching hospital, considering one of the best in Italy. My room was private, with wonderful medical bed, and expensively decorated with hardwood floors and oak cupboards. There was a safe for my valuables, a little frig in case I needed to chill my vino, and a table in front of the window, where I would be served my meals on linen table mats, overlooking the dome of St Peter's in the distance. If the Pope gets sick, he stays in a room about four doors down, where he can keep an eye on his earthly kingdom at Vatican City.

I had a great doctor, an exceptional hospital room, and my confidence level was rising. Then I was asked to follow a doctor down to radiology for some pre-op tests. Another patient came with us, along with my husband and her companion. We were led down elevators, up and down hallways, through the front lobby in our pajamas, in a convoluted path to radiology. I didn't see any in-patients in wheelchairs, which is SOP in the American and Dutch hospitals I've been in.

I was first up with a beautiful young female radiologist who said she was going to do a sonogram of the area designated for surgery. Next thing I know, she is holding a foot-long length of wire, which she plans to insert into my breast without benefit of anesthesia.

"No, no, no," I say, "my doctor promised I would not feel pain". I'd had two excrutiating biopsies by then and discovered that Italian-style meant no painkillers. "This won't hurt a bit," she says, cracking open the plastic cover that held the wire. Of course, it was awful and I emerged, tearful and upset, with a wire sticking out of the side of my breast. "You can find your way back to your room, right?," the doctor asked. Sure. We wondered around the labyrinthian hallways, got on the wrong elevators and became absolutely and completely lost. Where was the wheelchair and the nice orderly when I needed them? Nowhere in this hospital.

Finally, we re-traced our steps and arrived back at radiology, where we found our Charon to lead us back across the Styx to my lovely room in Solventi.

copyright Sharri Whiting 2009

Health Insurance for Expats

2009-01-15T04:17:00.006+01:00

Often, having a health insurance policy as an expat individual means you front the money for hospital stays, major surgery, and a variety of the other services contained in your coverage and the insurance company pays you back after you file the claim (and, hopefully, before your credit card bill comes due). This can raise your blood pressure while it drains your bank account. You can only hope you don't have to be repatriated and pay up front for a private jet and a couple of nurses.

Exceptions to that general rule come when you live in the same country where you insurer is located or there is a system of agreements in place between the company and international medical care providers. For example, an Italian policy that went out of my life too quickly had agreements around the world -- when I became ill on a visit home, they paid both doctors and a hospital in the US directly, 100 %, without a penny from me. Sadly, they said "they weren't writing that policy anymore" when it came time to renew.

My current provider is British-based, though calling the claims line takes me to the US. The Italian hospital where I was going has no agreement with companies outside of Italy, so I had to go through the pre-approval process, get my funds in order, and then be ready to file my claim. Despite repeated requests, the hospital was unwilling to bill the insurance company directly, despite promises they would be paid within five days.

The irony is that it is now more than two weeks after my discharge from the hospital where I had surgery. Two trips to the business office have still not produced a bill. The insurance company is wondering what's going on and so am I. In the US, they wouldn't let me into a hospital, much less out of one, without paying or a payment guarantee.

This is like waiting for the check in an Italian restaurant. I've had a great meal. I just want to pay for it and be on my way.

copyright Sharri Whiting 2008

Breast Cancer in a Country not my Own

2008-12-22T09:52:00.008+01:00

Yes, I did say before that the results of the biopsy of my breast were negative. It took forever to get the report and I was happy and relieved at the outcome. The problem is that I do have breast cancer, after all.

It's not always easy to find the right doctor away from your own country. It's not always easy to find the right doctor within your own country. Expats have to rely on each other for recommendations and often the first instinct is to get on a plane and go back home. We want to talk about our bodies in our own language, to feel confident we understand what's going on, especially in a time of great stress.

During the endless wait for the results of the biopsy that mistakenly cleared me of disease, I spoke to friends who had had treatment for breast cancer in Italy. One went through the national health system, and was quite satisfied (not everyone is eligible), while the other used a private doctor recommended by the embassy. She was less than happy with the realization that she was being gouged financially because they assumed the US government was going to pay. Unsurprisingly, she didn't recommend her doctors, though she felt she received good medical care. A third friend told me about a female breast specialist whom she thought would be able to guide me through the process of identifying the foreign body in my breast.

I was impressed with the dottoressa's professionalism, credentials and the time she took with me. I followed her advice and had another sonogram, then another fine needle aspiration, which resulted in a definite diagnosis of breast cancer.

Italy is known for its excellent breast specialists and I believe the doctor who will treat me is one of them. I had the choice to return to the US; to go to Holland, where we have contacts in the medical community and they speak English; or to stay here in Italy. In the end, I decided to stay because of the doctor, experience of friends with similar conditions, and the fact that it would be more comfortable to be at our own house during treatment. I will have surgery in a few days.

What are the drawbacks to staying abroad for treatment for serious illness?

1- It's not always easy to find a doctor who is fluent enough in your language to discuss your medical situation with you. Even if you are fluent in the local language, you can miss the nuances and some of the important details, not to mention the different medical terminology, especially when there is stress involved. Always take someone fluent in the language with you to important medical appointments.

2- Pain management techniques don't seem to be a priority in many countries. For example, that first biopsy in Italy was horribly painful and the doctor jabbed me repeatedly as he tried to reach deep into my breast to capture the material he needed. Wouldn't he have been better able to do his job if I had been given a local anesthetic? Would the pathologist have been better able to see what was growing there if there had been more material to look at? The second biopsy was done by another doctor, who was faster and more certain, but, again, without a local anesthetic it was very painful. Why make the patient suffer unnecessarily? Recently, when I was in Ukraine, I met an American dentist who works as a volunteer in remote villages -- he says Ukrainian dentists do not even study dental anesthesia, as there are no pain meds given there at all, even during root canals.

3- The level of nursing care, staff-patient ratios, and other cultural differences (such as sharing a room with someone who has half a dozen visitors at all hours) can make hospital stays more stressful than an American, for example, might find at home. Often this depends upon the hospital itself or the city -- in Windhoek, Namibia, and in Capetown, South Africa, at some hospitals the care can be equal to or better than many places in the US or Europe. In a private clinic in Rome, the nursing care given by the Catholic nuns was so loving I almost forgot the pain. My husband, an Italian, found almost too many nurses and support staff when he had surgery in Boston, though he eventually remarked that now he understood what professional nursing was all about. I felt a lack of really proficient nurses during a hospital stay in Holland, though there were state of the art testing equipment and well-trained technicians. (I suspect this may not be the general state of nursing there, as Holland has been named the top provider of medical care in the world).

As a recently diagnosed breast cancer patient, I don't yet know what the future will bring. For now, I can recommend two excellent websites, Dr. Susan Love's http://www.dslrf.org /breastcancer/ and http://www.breastcancer.org/. Also of interest is the U.S. National Cancer Institute site at www.cancer.gov/ and the New York Times section on breast cancer http://health.nytimes.com/health/guides/disease/breast-cancer/overview.html

copyright Sharri Whiting 2008

Waiting and Waiting for September

2008-10-03T12:36:00.008+02:00

When we moved to Italy in the mid-1990s, part-time, temporary workers were not hired in Italy to replace medical workers who left on the traditional August vacation. The labor laws were changed, which was supposed to result in better medical care during August and September. My advice is not to get sick in Italy between July 31 and September 15 unless you just can't help it.

On August 4, I was told by a doctor he was ordering tests right away, which, in fact, were not even transmitted to the scheduling office until a month later; the first exam took place September 30. Stupid me, I was waiting while they were all on the beach.

Then, on a Thursday morning late in August, I went for my annual mammogram and accompanying sonogram at a big private clinic in Rome, where I've gone for such tests for five years. The sonogram showed something unidentifiable and the doctor said I would need a biopsy. I was dismayed to be told that I couldn't have the biopsy until the following Tuesday. I was scared and didn't want to wait five days for the test, but, of course, I did. I had no choice and I know that in some countries, women wait even longer.

Tuesday came and I had the biopsy. The doctor said he would "rush" the results to me in 4-5 days. I took that to mean probably Friday or Saturday morning. I went home and got excessively busy -- writing, housework, laundry, talking on the phone to supportive friends, searching the Internet for information about benign and malignant tumors. At about four o'clock every afternoon, a sense of dread would sweep over me as I realized that the phone might not ring that day with a call from the doctor. A call to the clinic late Friday afternoon was fruitless -- no results possible before Monday.

I called my mother, a retired nursing professor in Virginia, who stayed calm and professional, at least on the surface. She told me that she was surprised there was such a delay, and why wasn't a frozen section done for a tentative yay or nay. My questions exactly.

An Irish friend found a lump a few weeks ago while visiting Rome. She had a mammogram quickly and easily in Italy (in August) and flew immediately with the films to London, where she had a biopsy and received a diagnosis within minutes. Her doctor back in Ireland assembled her "treatment team" within a few days and she is now recovering well from a lumpectomy. The whole process was done and over with in less time than it was taking me to get an answer.

Dr. Louis Timmer, the former director of a large medical center in the Netherlands, told me that at his hospital in Holland, patients must be told the results of biopsies within 48 hours of the test and any necessary surgery done within 7 days of diagnosis. I started thinking about flying to Amsterdam.

Another friend, an American who lives in Rabat, Morocco, has had biopsies in Indonesia and Japan and received the "all clear" almost immediately.

Why, I wondered, during the long dark nights, was it taking eons to look at a slide under a microscope? How many other women in Italy were lying sleepless because the medical community doesn't feel speed in this situation is important? As the days passed, I went from terrified to numb. We had a houseful of guests for a big family wedding, which made the eternal wait even more frustrating. Finally, while we were standing in a store late on Wednesday afternoon, the fourteenth day, the phone rang. I don't have cancer, thank heaven.

Maybe the doctors felt the situation was low risk and failed to transmit that to me. Maybe I over-reacted because I share every woman's fear of breast cancer. Or, maybe it was simply August.

copyright Sharri Whiting 2008

Preventive Medicine for Travelers

2008-02-22T14:34:00.014+01:00

Sometimes the best medical experiences abroad are the ones that never happened -- the result of preventive medicine for travelers. Dr. Louis Timmer who spent years as a tropical doctor in a government hospital in Biharamul, Tanzania, and recently retired after two decades as CEO of the Westfries Gasthuis Hospital in the Netherlands, is a big believer in being prepared.

Traveling can a risky business these days, according to Dr. Timmer. Frequent complaints include diarrhoea and fever, variously called Montezuma’s revenge, King Tut’s revenge, or La Vendetta dell Faraone, with at least 15% of travelers remaining ill after returning home. Cruise ships have found these kinds of illnesses spread rapidly in enclosed environments and have worked hard to eradicate the bugs onboard. Airplane air is the carrier of more colds and flu than a kindergarten.

Dr. Timmer says that fewer than 50% of travelers take preventive measures for either tourist diarrhoea (among the remedies sworn by among frequent travelers is chewing a Pepto Bismo tablet before breakfast and after dinner every day of the trip) or malaria, which can be deadly. Though preventive measures are known for various illnesses picked up by travelers -- vaccination, chemo prophylactic medicine and preventive behavior – Dr. Timmer recalls the results of a study that showed less than 50% took them. He maintains that the current system of providing medical advice for health and prevention for travelers is vastly insufficient.

The most devastating problem is malaria. Every year there are 300 to 500 million new cases of malaria in the world; at least a million people die, most of them African children under five-years old. Every thirty seconds, a child dies of malaria. While malaria is not a big problem for tourists, it is not something to be ignored, especially by those expats, tourists and international students studying in malaria areas.

Dr. Timmer notes, “As the resistance of the malaria parasite to anti-malarial drugs continues to increase, the efficacy of efforts to control malaria in many tropical countries is diminishing. In a terrible irony, in regions of high endemicity the use of insecticides and drugs leads also to an increase in incidence due to enhanced resistance development.”

Fausto Coppi, the greatest cycler in the world in the 1940s and 50s, was a hero to Italians and bicycling enthusiasts around the world. He was the ultimate champion, winning every race: five Giro d’Italia, two Tour de France, one world championship, and for many years held the record for cycling speed and endurance. Coppi accepted an invitation to go hunting in Africa during the off season; after he came back to Italy, he contracted what he and his doctors thought was the flu. In just a few days, Fausto Coppi, the paragon of health and fitness, had died of malaria.

Diagnosing malaria has not improved dramatically in the last fifty years, when patients get sick far away from known malaria areas. Dr. Timmer warns that there are cases of people who contract malaria tropica though they have never been in the tropics – for example, in the summer of 2006 malaria-carrying mosquitoes were imported into chilly Holland by people who disembarked planes from malaria areas. This kind of situation may be one of the dire consequences of a world that is getting ever smaller, while it simultaneously experiencing climate change.

The Dutch government has alerted all the doctors in the Netherlands to this danger and has suggested they reread the old books on tropical medicine. The diagnosis is easy, Dr. Timmer says, provided the physician considers malaria even with patients who have never been in the tropics. Geography is no longer a guarantee of not contracting malaria.

Prevention: What can You Do to Avoid Malaria?
Good prevention is not only for tourists, but is also necessary even for expats who live for long periods in the tropics, especially since immunization is impossible at this point in time.

Chloroquine, mefloquine, proguanil and doxycycline can assist in avoiding the contraction of malaria, but they are no guarantee. Though proguanil is effective and easy (you can stop taking it seven days after leaving the malaria environment), it is also a great threat, because malaria mosquitoes are beginning to resist its effects. A potential alternative to historic drugs is artemisinine (derived from a Chinese plant, artemisa annua) is being studied by the Royal Tropical Institute in Amsterdam, among others. Used in combination with other anti-malarial drugs, it may prove to be the most effective therapy in the future, but is more costly to obtain and deliver.

General preventive measurements are better for travelers and more effective in the long run:
1) Insecticidal spray (DEET = diethyltoluamide). Put it on everyday you are in a malaria area.
2) Wear long-sleeved shirts and long pants.
3) Use mosquito netting for sleeping, preferably nets which have been sprayed with insecticide.

Dr. Timmer observes that “Everybody knows, but not everybody does.” Travelers who pay attention to these three malaria prevention techniques are not only taking responsibility for themselves, but they are lessening the dangers of malaria epidemics and the increased resistance of the illness to prophylactic medications.

For more information on malaria and the fight to prevent it, go to the Louis Pasteur Institute, The Global Fund, World Health Organization and Malaria News.
copyright Sharri Whiting 2008

Snake Bit

2008-02-05T18:21:00.003+01:00

My friend Amy was asleep in her bed on a Sunday morning in Windhoek, Namibia, when she was bitten by a zebra cobra that crawled into her bedroom through the open French doors to the terrace. She is only one of almost a million people in Africa bitten by snakes every year, many of them children. This one was a Western Barred Spitting Cobra, Naja nigricollis nigricincta, called by locals a zebra snake; it occurs from Namibia northwards into Angola, not in South Africa. The bites cause a lot of damage on legs and arms and the bites are sometimes fatal.

Fortunately for Amy, a wildlife photographer and writer, she was near a first class hospital, where a well known poisonous snake expert happened to be working on this quiet Sunday morning; she didn't become one of the 20,000 Africans who will die of snakebite this year. Ironically, Amy had recently written an article about zebra cobras, so she knew there was no anti-venom for its bite -- how terrifying to remember this salient fact as she lay waiting for her son to take her to the hospital.

According to the World Health Organization, about five million snake bites and scorpion stings occur every year, most of them in Asia, and over 80,000 people die, the majority agricultural workers and children. Many who live have horrible scars where the poison resulted in necrosis.

As our lust for adventure travel continues unabated, these numbers may start to reflect not only poor farmers and small kids who have little access to medical care, but the people who have flown to remote areas with first class tickets and brand new khakis. It's easy to forget that poisonous snakes, scorpions and spiders are part of nature when you live and work in hermetically sealed houses and office buildings; those of us who crave the scent of Africa or Asia, the wide open spaces, that amazing light, must also pay attention to the dangers that indigenous populations face everyday.

WHO has recognized that, while snake and scorpion bites are on the increase, anti-venom supplies have been on the decrease, and they began a five year program to address this problem in 2007. Hopefully, their efforts will result in the lessening of both deaths and disfigurements.

In the meantime, adventure travelers should pay attention to these suggestions offered by David Worrell, a researcher at Oxford University. A known expert on poisonous bites, Worrell suggested these steps to avoid snakebite in a presentation for WHO:

don't wear sandals when traversing bush or rocky areas; wear boots and long pants
avoid sleeping on the ground if possible (many adventure travelers sleep on platforms atop their vehicles)
know the local snakes and what they look like before you travel
use a flashlight (torch) when walking at night
if you see a snake, don't go for a closer look
dead snakes can still bite reflexively; don't touch them
remember that snakes like termite mounds, open-eaved thatched roofs, rubbish piles

For the full report, including some attention-grabbing photos, to go
www.who.int/entity/bloodproducts/animal_sera/D.Warrell-WHOSettingthescene-final.pdf

Lastly, don't think there aren't poisonous reptiles in the United States and Western Europe, as well as Asia, Africa, Middle East, South America and the Far East -- take a look at the site maintained by the University of Adelaide, Australia, to identify poisonous snakes, spiders and scorpions around the world.

copyright Sharri Whiting 2008

Take two aspirin and call me in the morning

2008-01-27T17:06:00.002+01:00

One of the most important things you can do to ensure you receive proper medical care when traveling or living abroad is know what medications you are taking. Make a list of both the brand names and the main ingredients and take it with you wherever you go; in addition, if you have life-threatening drug allergies, add them to the list of your medications, clearly marked with the word "NO!" in capital letters. If you go to a doctor or hospital, take the actual medications with you. Some hospitals will allow you to take your own pills, rather than requiring you take meds provided by the hospital.

According to the Joint Commission International, which accredits hospitals worldwide and works closely with the World Health Organization, "medication errors harm an estimated 1.5 million people and kill several thousand each year in the United States of America, costing the nation at least $3.5 billion USD annually. . . .

"In some countries, up to 67% of patients’ prescription medication histories have one or more errors, and up to 46% of medication errors occur when new orders are written at patient
admission or discharge."

If that doesn't get your attention, check out the Institute for Safe Medications Practices' list of often confused medicines. The Mayo Clinic also offers suggestions, including taking along an extra supply of your current medications. (This isn't always easy, as sometime pharmacies are only allowed to provide a thirty day supply due to doctor's orders or insurance requirements). Check the USFDA link on this site for a list of drugs often confused because their names are similar or they are called different things in different countries.

PulseAmerica, a non-profit organization dedicated to patient safety, offers these tips regarding your prescriptions:
Make sure that all of your doctors know about all medications you are taking including prescription, over-the-counter medicines, and dietary supplements such as vitamins and herbs. Before leaving your pharmacy, open the bag and check for your name and the name of the medication. Be sure you understand the instructions. Ask if there may be any interactions with other medications you are taking.

Expats, study abroad students, and international travelers have the added challenge of obtaining medical care and prescriptions in languages they may not speak. Do not hesitate to ask that the prescription be copied for you in writing you can read, and reconfirm with the pharmacist that the medication is indeed for your condition and that it does not conflict with other medications you take. Be aware that in some countries the doctor has written the instructions on the prescription, but you will not see it on the drug label, or you will be given the drug in the manufacturer's packaging and not a special bottle.
Be sure you know how much and how often to take the medication

Regarding prices: prices for prescription medications differ from country to country -- in the USA, the cost to fill a prescription without insurance can be well over $100 USD, while in Europe the same thing can be under 20 Euros. Over the counter products, such as cold medicines, aspirin and vitamins are often much cheaper in the United States than they are elsewhere.

copyright Sharri Whiting 2009

Diagnosis in Italy

2008-01-25T15:51:00.001+01:00

Marlene Fine, a professor at Simmons College in Boston, who teaches in Rome a few weeks every summer shared her experience with the public health care system in Italy in June 2007:

My right arm and shoulder started throbbing late on Sunday night after I had dragged my 50 lb. suitcase (lost at the airport for a week) from Fiumicino by train to Termini, then to Trastevere by bus and tram, and then three long blocks by foot to my apartment. By Wednesday, I could no longer move my arm in any direction and the pain had kept me awake all night. Not knowing what to do, I decided to go to the emergency room at the nearest hospital.

I walked in, waited while an extended family in front of me argued for what seemed liked an hour with the receptionist. They were finally allowed to accompany their elderly mother/grandmother into the hospital and the receptionist beckoned me forward. I explained my problem and she stared at me blankly. "Italiano?" she said. "No, Inglese," I said. She left and returned with a young man who could speak a little English. I explained my problem again. She asked for my passport. In my pain addled state, it never occurred to me to bring it with me. I said I didn't have it with me. She said okay and told me to wait. A few minutes later, I was escorted into an interior waiting room.

About half an hour later, I was sent in to see a doctor. He had visited the United States many years before and knew a little English. I described my problem. He sent me for x-rays. Three people took the x-rays, positioning and re-positioning me, while a group of students watched and animatedly commented throughout the procedure. I then returned to the waiting room and waited another half hour or so to see the doctor again. He told me I had injured my rotator cuff and had a frozen shoulder, and that I should see a doctor in the US as soon as I returned.

He was very reassuring, telling me that he thought physical therapy would solve the problem rather than surgery. He prescribed two medications for me and told me where to go to purchase a sling for my arm. When I left, no one asked me for any payment. I stopped at a pharmacy on the way home and filled both prescriptions and purchased my sling. Total cost: $72.

The medication stopped the pain within hours and by the next day I could gingerly move my arm. My diagnosis when I returned home: injured rotator cuff. Three months of physical therapy strengthened my shoulder sufficiently for me to regain normal use of my arm. Imagine if my injury had occurred in the US and I was a foreign national without health insurance (or even a U.S. citizen without insurance). $72 for x-rays, diagnosis, and treatment? Doubtful. In fact, some hospitals might have simply turned me away.

It can be daunting to go into a crowded emergency room when you don't speak the language and are in pain. When possible, take someone with you to translate or simply give moral support.

Comments about personal experiences with medical issues while living or traveling abroad are welcomed. Statements must be based on your own personal experience or that of a close family member.

copyright Sharri Whiting 2008

Don't be Modest

2008-01-15T14:48:00.001+01:00

At age nine I shared a log cabin at Girl Scout camp in the US with seven other girls. When it came time to go for a swim in the lake, we tore off our sweaty shorts, pulled on our bathing suits and raced out the door. All of us, except for one. This was the girl who stood behind the chest of drawers, hiding from the others as she tried to wriggle into her swimsuit. I hope she's never had to go to the doctor in western Europe.

Seasoned travelers are well aware that in some countries restroom facilities will be unisex -- they've gotten used to washing their hands next to someone of the opposite sex. Yet they are shocked when the doctor expects them to undress right there in the office. I will never forget going to an internist in Amsterdam for the first time. We talked a bit, seated at his desk; then he asked me to take off my clothes for a stress test.

I went into a cubicle and stripped down to my pantyhose and bra, expecting to find some kind of hospital gown before going any further. There was nothing. I stuck my head out between the curtains and asked the doctor, who was doing paperwork, "Is there something for me to put on?" "Not necessary," he responded, "just come out in your underwear and get on the bike." I sidled out and climbed on the machine, mortified. The doctor flipped the switch and went back to his paperwork, leaving the office door wide open. I felt the gaze of every single person who passed by and saw me huffing and puffing on the stationery bike, my stockinged feet slipping off the pedals. It was the longest five minutes of my life; he probably never noticed anything except the data on the EKG tape.

I've learned since then that in some countries modesty and medical care are mutually exclusive. Some doctors offer more privacy than others, its' true, but, the upside is that I rarely feel anyone is in a hurry to get me out the door so they can see another twenty patients that day. I value the presence of the doctor in the room with me for my mammogram in Italy more than I hate having to undress in front of him. Mamma mia, he cares not a whit about my less than perky bosoms; he prefers to look at the pictures.
Copyright Sharri Whiting 2008

Who's to Say?

2008-01-14T12:04:00.001+01:00

Who's to say that medical care is perfect in one place and terrible in another? Not me. I'm not a medical person, although I am the daughter of a surgeon and a professor of nursing. As those who share that dubious distinction, the best we can recall is that our parents usually told us we weren't that sick and to get over it. Miraculous cures occurred when my father began rummaging in his black medical bag, looking for long cotton swabs and mercurochrome to go after my sore throats. Needles? Don't even go there. Medical or nursing school? Fuggedabudit.

Then why this blog? Because we, those of us who spend time away from home in countries not our own, sometimes need help navigating medical care which may be, not worse, just different than what we're used to. Sharing that information in one place can be helpful to us all.

When you live or travel abroad, you need to keep a handle on your own medical condition, with a list of medications you take, not only by marketing name, but by ingredient name, as well. Keep that list on your person in case of accident. Bring the actual bottles with you in your suitcase, along with printouts of the drug specifications. Don't put your pills in one of those multi-pill containers unless each section is carefully identified.

Put aside pre-conceived notions of how medical exams take place in your home country or how nursing care is organized. Don't think you can depend on your embassy or consulate to take charge of your medical care beyond the initial emergency assistance. Be sure your health and travel insurance covers the essentials, including repatriation, if necessary. If you suffer from a chronic condition, take along enough meds to keep you going for while.

Remember, you chose to be an international, an expat, a world traveler. In a perfect world, that means never getting sick away from home; but, in the real world, it requires being prepared in case you do.