A painful price

Bilharzia, diabetes, hypertension -- Egypt is riddled with these afflictions and they all add up to one looming threat: chronic renal failure. But as Dalia Dabbous reports, diagnosis is often only the beginning of a long nightmare
photo: Sherif Sonbol
photo: Fathi Hussein Hospital scenes: Doctors, nurses and patients struggle against a less than perfect system
Samira Omar stares silently as the huge machine next to her bed sucks blood out of her veins through long tubes, passes it through a filter and returns it once again to her frail body. She is undergoing haemodialysis, a four-hour procedure that is trying to do what her kidneys have ceased to do properly: clean her blood. She is used to it by now; she goes through the process three times a week and will continue to do so for the rest of her life. Although she is only 53 years old, Omar's tired face, withdrawn eyes and mostly white hair reflect a woman late into her sixties. In this drab, dimly lit room, where she spends so significant a portion of her days, Omar tells us she is not in pain. She is, however, depressed and tired.
The onset of renal failure, also called kidney failure, is both emotionally and psychologically distressing, but perhaps more importantly, it is a major financial strain. For the many thousands of Egyptians suffering from this potentially fatal condition, the mounting costs of treatment are often beyond their means. The Ministry of Health (MOH) is often their only resort (although select cases of non-governmental assistance do exist), but despite efforts to provide financial support, it is never enough.
Not only are the frequent haemodialysis treatments costly, but patients are prone to complications, such as anaemia. Injections treating anaemia cost another LE300, and many patients need up to two to three per week. Many of the people who develop kidney failure are victims of poor living conditions such as unsanitary environments and unclean water and are obviously incapable of financing expensive medical treatments.
According to Ministry of Health records for the year 2000, 21,000 Egyptians, mostly men, were found suffering from chronic renal failure -- an estimated 10 to 15 per cent increase from the previous year. This makes Egypt one of the worst-stricken countries with regard to kidney failure and constitutes a true health crisis. The Ministry of Health preaches preventative measures, like the proper treatment of afflictions that are the most common causes of renal failure, but many people do not grasp the necessity of regular check-ups, even when their environment makes them prone to infection.
MOH spokesman Mahmoud Qasim admits that for many people, the cost of treatment for kidney failure can be prohibitive, noting that the ministry allots an enormous sum out of its budget for financing this. "The ministry pays all medical expenses for chronic renal failure patients who seek its help, whether they are rich or poor, because we understand that it is a costly process for everyone," Qasim told Al-Ahram Weekly. The figures Qasim cites are indeed hefty. He notes that every renal failure patient is allocated LE14,460 annually by the ministry for treatment. This includes LE85 for three dialysis sessions per week and a monthly stipend of LE100 for life. But for the average patient, this is far from sufficient, as it fails to cover the many side-effects of treatment -- one salient example being the expensive anaemia shots -- and makes patients dependent on government clinics.
And, of course, people suffering from renal failure are usually too weak to work, meaning that they are without a steady income. Kamal Abu Shirea, an elderly man suffering from hypertension, was diagnosed with kidney failure only a few months ago. He chokes back tears as he explains the financial troubles his illness has caused. He is too sick to work and none of his sons can find work. His pension is not enough to cover their expenses, much less his treatment, and he has been reduced to borrowing money in an attempt to make ends meet.
But even when the money becomes available, the treatment in itself can be fatal, especially when patients are forced to accept whatever low-cost options are available. Returning to the problem of anaemia, dialysis patients are often forced to submit to blood transfusions -- a "cheaper" treatment than the weekly shots. Patients need roughly two bags of blood a month, and at LE120 per bag, this option is more financially viable. But the measures for screening blood donations are dubious and most blood banks depend on donors who sell their blood for money. The risks involved in regular blood transfusions were tragically highlighted last year with the case of a renal failure patient who received AIDS-infected blood.
AIDS is not the only cause for concern. A specialist at the renal unit at Helwan Hospital, speaking to the Weekly on condition of anonymity, said that of the 80 dialysis patients received by the unit, at least 70 have Hepatitis C as a direct result of blood transfusions. Hepatitis B can also be transmitted through the blood. On the issue of blood infection, the MOH's Qasim admits that dialysis machine filters, which cost LE35, can themselves be carriers of disease when they are not disposed of immediately after the dialysis session. "Some centres, for their own personal gain, re-use the filters for different patients," he said.
Iman Anwar El-Azb, a lecturer on internal medicine and nephrology at Ain Shams University, says she advises her patients to try and undergo a kidney transplant, "because I see it as less stressful, psychologically and emotionally, and in the long run, a transplant is cheaper than dialysis." But opting for a transplant has its own attendant concerns (see related article below) and according to MOH figures, only one per cent of renal failure patients chose to have a kidney transplant in the year 2000. One obvious inhibiting factor is the cost: a transplant can cost up to LE30,000, excluding the costs of post-operative drugs. The government allocates LE5,500 for the operation and an annual stipend of LE17,000 the first year only. The second year it is LE10,000, and LE8,500 thereafter.
There does exist one other option: peritoneal dialysis, a procedure that can be performed at home by the patient. But the treatment is particularly cumbersome and Dr Adel Afifi, president of the Egyptian National Kidney Foundation, points out that most patients prefer dialysis. The patient is connected to a two-litre solution-filled bag through a tube in their stomach, but this option requires constant proximity to a "mobile" kidney unit and a nurse on hand.
So haemodialysis it is, for most patients, in spite of the risks and time-intensive procedure. Patients are sent to one of the 243 governmental renal units, home to the government's 2,488 dialysis machines, or go to one of the 370 private kidney centres. If they have insurance, they may be sent to renal units in health insurance hospitals. Some hospitals are run in conjunction with mosques, such as the Fateh Islamic Hospital, where Samira Omar receives her dialyses.
At 8.00am, the renal unit at the Helwan Hospital begins to receive 80 men and women, who line up in the dreary halls to await treatment. Work at the unit will continue until 8.00pm. A board on one of the paint-cracked walls lists their names in the order they will receive treatment from one of the hospital's 19 machines. Although the renal unit at Helwan Hospital boasts that maintenance of their dialysis machines is exceptional, one patient broke into an angry fit when her machine broke down "yet again." "My machine is always breaking down. It is so old," she fumed. "Why can't they change it?" A resident at the unit explained that although 10 of their machines have gotten old to the point of expiry, the hospital continues to use them because of the large number of patients.
Non-profit organisations, like the Egyptian National Kidney Foundation, aim to develop programmes that foster awareness of preventive treatment, targeting both medical personnel and the public. According to Afifi, "Early detection and management of renal diseases that may be complicated by renal failure is a first step to preventing this disease." But then, it is not all about awareness. People in low-income areas have no choice but to drink the water they get, even if it contains high levels of metal deposits from rusty pipes or contaminant from nearby factories -- both sources of kidney infections. As is so often the case, the poor are sometimes punished for being poor.
Recommend this page
© Copyright Al-Ahram Weekly. All rights reserved
Send a letter to the Editor