My apologies to the Beach Boys for munging the title of their fine song.
This is a rather long and involved post. Summarizing, there is an article/editorial on healthcare widely circulating on the internet that is being quoted by many as fact, yet it is so egregiously false that it even fails as satire. I first became aware of this article when a dear relative quoted it in an email relating his own medical concerns. I found the editorializing in it to be a rather large horse pill to swallow, so I investigated.
As noted in my first post on my blog, a primary purpose of Harry Chickpea is to expose media untruths. I think you will find this to be an excellent example of such exposure, and a lesson on how you too can avoid being manipulated by rhetoric.
I will say at the outset, that I, among millions of others, KNOW that there are terrible things wrong in the way healthcare, medicare, and insurance are handled in the United States. I do not know all the answers, and will go so far as to state that the author of the very article I am about to dissect, draw and quarter has also written other articles that raise many valid points, making it hard for me to be critical of him.
However, writing falsehoods increases the noise level in the debate on the subject, reducing the impact of proper discussions. Nietzsche puts this point succinctly: "The most perfidious way of harming a cause consists of defending it deliberately with faulty arguments." The author is guilty of at least this, if not more. There is an honored place for creative fiction, but like cherry flavored medicine, I don't want such stuff mixed in with my daily soup.
You may read the original article here. Please go ahead and read it first, to get the original intended flavor of the editorial:
http://www.uproothealthcare.com/politics/whats missing from healthcare in rwanda
If you perform a Google search on phrases within the article, you will find how it has been copied in its entirety by various political sites.
My first inspiration was to examine the take-away line, the last line in the article, which is often a call-to-action. Examination typically provides information on at least the surface motivation of the writer, and allows me to work backwards to dissect parts of a work. I quote the article as it appeared on February 13, 2011, lest there be any question if the article is removed or changed. I quote under the "fair use" doctrine of copyright. This is that last, call-to-action line:
"If patients in Rwanda can get high quality care without regulations ‘protecting' them, why are we throwing away trillions of dollars a year on healthcare regulations and bureaucracy, money that we do not have?"
I have an inherent distrust of grandiose statements. "Patients in Rwanda can get high quality healthcare"? I had to check that out. In the days before the internet, Hearst and other opinion makers could get away with stuff like that. It is impossible to foist such lines today on anyone who has the time and inclination to verify statements.
Clearly, an independent determination of the quality of healthcare in Rwanda (post-genocide, which I imagine is much improved) was in order. Since my relative suggested that moving to Rwanda might be an alternative for him, given the state of healthcare in the United States, my first thought was "What is the opinion of our state department, in regards to U.S. tourists and workers in Rwanda?"
Since the article quoted an average income in Rwanda of $510 per year, an American with access to far greater cash reserves should be able to get excellent health care service at affordable prices in such a place. I am not unfamiliar with the concept of medical tourism, so even while dubious about visiting Rwanda, I had to entertain the idea as a real possibility, especially if I was to believe even part of the article.
My curiosity was roused even more when I considered that Hillary Clinton was Secretary of State and would undoubtedly be heaping praises on such a system that provided quality inexpensive healthcare. So I went to the website posthaste. Here is the link:
Link to state department website concerning healthcare in Rwanda
To quote:
MEDICAL FACILITIES AND HEALTH INFORMATION: There are no emergency municipal response services. Ambulances are available in Kigali through SAMU by calling 912 from any mobile phone, or through King Faisal Hospital at 078 830 9003. Ambulance service is basic and works solely as transportation, usually with no medical treatment involved. Outside of Kigali, ambulances are extremely scarce. Medical and dental facilities are limited, and some medicines are in short supply or unavailable. Travelers should carry their own supplies of prescription drugs and preventive medicines. In Kigali, King Faisal Hospital is a private facility that offers 24 hour assistance with physicians and nurses on duty in the emergency room.. There is also a missionary dental clinic and a few private dentists. U.S.-operated charitable hospitals with some surgical facilities can be found in Kibagora, in southwestern Rwanda, in Ruhengeri, near the gorilla trekking area, and in Rwinkavu, near the entrance to Akagera National Park.
Huh? THAT doesn't sound too promising. Well, what if I just Google "Rwanda healthcare"? Surely that should turn up some info.
Right at the top of the Google list was the original New York Times article.
Link to NY Times article: Rwandas-medical-miracle
I doubted that the New York Times had enough staff to give a fair and complete assessment of healthcare in Rwanda. However, I had to read the article because of the cite in the editorial. It was typical material for the Times. I am paraphrasing what their editorial board might have thought in approving the article for publication; "We want to promote this idea (everyone in Rwanda pays $2 per year for basic health coverage), so we will show how it works, and make it easier for the readers to see how something like this could work in the U.S."
After reading the article and seeing that the Google search phrase resulted in lots of copycats and summaries, I tried a new search phrase: "Butaro Rwanda hospital" with much greater success.
Now for an interwoven critique:
February 12, 2011 What's Missing from Healthcare in Rwanda By Deane Waldman
I googled "Deane Waldman" There is a Deane Waldman MD that appears to write in the Huffington Post. He also has a blog "uproothealthcare" which appears to be the original source of the article. Much of what he writes in his blog appears to be legitimate, but I'll leave it to you how much to trust after you read my analysis of this article.
To start, that title makes little sense. What IS missing from healthcare in Rwanda? The article studiously avoids that question except on a rhetorical basis that we later find is in reference to costs, and asks instead what is wrong with healthcare in the United States. That either reflects poor writing skills, or is an intentional lead-in to get people suckered into reading the entire article. Judging from the number of articles Waldman writes, I tend to think the second is more likely. I'm not pleased, but on to the text of the piece:
A recent online article posted on NY Times Live tells a great medical success story in Rwanda. The author describes the opening of a "Harvard quality" hospital in Butaro, Rwanda where they had previously had no medical facilities at all.
There is a link to the NYT article in this first line, but that link is non-standard coloration, and almost all readers who are at all pressed for time will continue to read the article at hand rather than click on the link to the Times. This tendency is even stronger in readers who may be of a conservative bent, since the views of the Times are an anathema to them. Such writing techniques are manipulative. Continuing, I note "Harvard quality." That is an odd turn of phrase. It makes no sense as it stands, since Harvard is a school and not a hospital, like the Cleveland Clinic. In reading the background I cited above, I discovered that the hospital was in-part designed by Harvard graduate students. link to Harvard Grad students website Now THAT makes more sense. Rwanda probably doesn't have a lot of hospital designers.
The 150-bed Butaro hospital was built in only two years at a cost of R40-million. (The cost of a comparable hospital in the U.S. would be 225-300 million USD).
You could not build a hospital to those specifications in the United States. Even if you could, people would avoid it in droves. Why do I say this? Because I don't have to depend on the author's words. With the internet we all get to see photos.
For starters the author is confused on currency. The currency of Rwanda is the Rwandan Franc, abbreviated RWF or RF (we don't want to confuse it with a Ruble or Rand). 40,000,000 RWF = $66,392.93 at current exchange rates.
So, by doing some basic checking, we find that the author is claiming that a hospital that costs $67,000 USD to build in Rwanda is comparable to a hospital in the U.S. that was built for $225,000,000 USD. If that is true, we need to import some of them there Rwandans over here to do our building. In point of fact, the statement is an INTENTIONAL attempt to mislead. Fast readers will see 40 million compared to 225 million and interpret that as comparing apples to apples, and see incredible waste. That is designed to get the reader's juices flowing and rush endorphines and adrenaline into the system. "Oooh, isn't it going to be good how this article will show us how Rwanda can beat the U.S. in healthcare!!!" I could play tricks like that all day long if I wanted to. However, I try to wash such manure off my feet before addressing an audience.
The physical structure itself is designed to scrub the air twelve times per hour to reduce risk of airborne infection. Here, that requires multi-million dollar machines.
The outrage and rhetoric is getting TOOOO funny!!! Check out http://inhabitat.com. It shows a wonderful diagram of the 1970s style passive ventilation system of the hospital, where fresh air enters lower windows and is exhausted through a clerestory set of windows. I saw the same idea in an old "Mother Earth News" back around 1972, and it was old then. "Scrub the air twelve times per hour" is a total fabrication! It takes in the air from outside, along with small insects, airborne bacteria, pollen, and all, and shoves it inside, with an air exchange rate of twelve times per hour (more when the wind is blowing). Around here we call that a screen porch. ...and this author practices medicine??? I imagine if he thinks a screen porch is a multi-million dollar machine, he must charge a high fee for "oto-lyringial inspection protocol and use of point source high lumen facilitating apparatus and prophylactic shield." (Looking at your tonsils while using a condom-covered flashlight.)
The Butaro hospital has advanced laboratory facilities, telemedicine capability, and a fully functional, user-friendly electronic records system.
OMG, I am rolling on the floor. Take a LOOK at the pictures at. http://www.peacecorpsjournals.com to see why. In particular, click on the photos under "Late updates from 2010 Dec", to enlarge them. The Peace Corps volunteer also notes some info about the equipment.
In a country where the annual per capita income was $510 in 2009, patients get as high quality medical care as we get here in the richest nation on earth.
This guy just set my BS meter spinning. Did you look at the photo of the operating suite equipment? And how about that massive open ward with NO privacy, and beds that look about as comfortable as a yoga mat on a camp cot? "high quality medical care as we get"? Has someone snuck into the pharmacy before writing their editorial?
But wait - their care is better! Why? Because it cost a tiny fraction of what health care costs us here.
Hee Hee. The RONCO TV offer come-on. Maybe we could all chip in together and send this guy to Rwanda for a personal on-site report? I think we could get Pollyanna to go with him on a date. Authors like this, who intentionally deceive to make thief points, need to be hoisted by their own rhetoric.
What is missing from the new hospital in Butaro?
Ohhh, a loaded rhetorical question! What is missing? Gee, how about... semi-private rooms, air conditioning, a few dozen toilets and sinks, bedside tables, and it looks like sheets and blankets might be in short supply as well.
Answer: things that waste money, such as unnecessary duplication and the #1 dollar waster in U.S. healthcare: a massively bloated bureaucracy needed to support a costly and harmful regulatory machine.
Uhh, Buppy, there is nothing there to regulate. Their imaginary CT scanner doesn't need to be checked for imaginary electrical faults. I find humor when authors become so overwhelmed by their own emotions that they burst into nonsense neologisms and dangling comparisons of apples and oranges.
Before 2010, the U.S. healthcare bureaucracy consumed almost 40% of healthcare expenditures. That is right: 40% of all U.S. healthcare dollars never touch a patient. With passage of PPAHCA (disingenuously named Patient Protection and Affordable Health Care Act), that number could approach 50%. Even Everett Dirksen would consider throwing away one trillion dollars a year wasting "real money."
And this has WHAT? to do with Rwanda??? As long as you are wandering off the purported subject of your article, how about a nice little side-rant on the evils of bedbugs, and how those spartan beds in Rwanda have 99.9% fewer bedbug infestations? The comparison would probably be a lot more accurate and more useful. At this point, it is becoming obvious that the author is using and abusing the hospital in Rwanda as his soapbox for complaints about the state of affairs in the United States.
You really need to experience healthcare from the inside to appreciate fully how and how much the U.S. healthcare ‘system' wastes dollars and frustrates providers. Most of that daily waste is missing from Rwanda.
"Most of that daily waste is missing from Rwanda. "...as is medicine (bring your own, according to our state department). For what it is worth, doctors might be missing too. One of the sites I researched mentioned that there are a total of 3 doctors trained in cardiology in the entire country.
Doctors in Rwanda can communicate with each other without fear that HIPAA looking over their shoulders hoping to find them "out of compliance" and pull their licenses.
Well that would be logical, since in that spanking new R40,000,000 hospital every blessed patient in a ward could overhear what a doctor was saying. Again, the author is stamping on his soapbox platform with manure-covered shoes.
Hospitals in Rwanda do not waste time and money preparing for a Review by the Joint Commission (JC). They do not have to hide their doorstops on take down the books on top shelves. If the JC reviewers find doorstops or anything within 18 inches on the ceiling tiles in doctors' offices, they can close the hospital because those infractions will place them "out of compliance."
Someone has not only lost perspective and not done their basic homework, but gone into the deep end of the pool without the knowledge of how to swim (or write coherently).
Nurses in Rwanda can spend time with patients, time that American nurses must waste in repeated annual training modules about security upgrades, ethics infractions, theoretical biohazards, and the next set of regulations that must be followed to the letter.
Don't worry about that biohazard problem. Put one patient with Ebola into that "Harvard quality" hospital in Rwanda and every single nurse and patient will have it within a day. Biohazard training for nurses would be simple. "RUN AWAY! RUN AWAY!"
Nurses in Rwanda can use the infection prevention checklist without filing a research protocol with the FDA.
True, they just need to make sure the patient in one bed isn't close enough to the next bed to bleed on another patient.
In Rwanda, restocking hospital supplies does not require multiple committee meetings, forms in quadruplicate, and pre-approval by legal counsel.
Because they DON'T HAVE supplies, Buppy. Donations are cheerfully accepted, in case you care.
In Rwanda, research to find better ways to treat patients does not require 87 different steps*, each involving multiple committee meetings, thousands of man-hours and billions of red tape dollars.
No, all they have to do is look at other countries, since that research already exists. When you don't know how to perform an appendectomy, the research on how to hold a scalpel is pretty easy.
The number 87 was not picked at random. Dr. David Dilts at Vanderbilt reported in a 2006 article that number of different steps are mandated when going from an idea to actually starting a clinical research project.
And I am by now expected to take this at face value and become upset? Buppy, you lost your cred back in the first paragraph. Here is a clue. This hospital in Rwanda is closer to being a triage center than a research hospital. They won't be doing any major research projects in the foreseeable future.
One more thing that is missing in Rwanda: Federal organizational charts. Go online and look at the organizational charts for the NIH or the FDA. Then recognize that every box represents a whole agency with its own organizational chart, and each box in a box represents hundreds of bureaucrats, thousands of regulations to oversee, billions of dollars to consume, and thousands of providers to hound right out of health care.
By now, if a kid out of grade school came up to me and started reciting factoids, I'd listen to him before Mr. Waldman. This entire article has been favorably comparing the equivalent of an empty mom-n-pop grocery store warehouse to a Wal-Mart distribution center for the entire southeast. Even though a basic look at a couple of photos will show that, this author continues to beat the dead donkey of his assinine comparison.
To your right is displayed an organizational chart for the Healthcare ‘Reform' Act (PPAHCA). Are you surprised that it will cost only a trillion or so dollars? This too is missing from Rwandan healthcare.
For some inexplicable reason, the U.S. Public thinks that healthcare regulations are free or at least that they do not have to pay for them. In fact, the Federal healthcare bureaucracy is the leading cause of dollar wastage in the U.S. Those are dollars they do not need to waste in Rwanda.
If patients in Rwanda can get high quality care without regulations ‘protecting' them, why are we throwing away trillions of dollars a year on healthcare regulations and bureaucracy, money that we do not have?
The "high quality" care in Rwanda is undoubtedly better than the "high quality" writing of your screed, Mr. Waldman. What I find absolutely hilarious though, is that in doing a tiny bit of basic research, I discovered that the hospital being lauded by some very conservative websites was built in partnership between, not private industry, but such leftist-leaning and charitable organizations as:
Partners In Health
The Peace Corps
A grant from Bill and Melinda Gates
the graduate students of Harvard University
and...
wait for it...
Bill Clinton.
You can even see the pictures of him there at the dedication ceremony.
Heres Billy
I would suggest that readers think twice before believing that Rwandan medical care is on a par with medical care in the United States, even though Deane Waldman seems to think it superior in some ways.
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