ALEXANDRIA: Anywhere in the world, disease is a burden. It is something that is feared and dreaded, especially if you don't have insurance. It can cost you your job, your savings, your happiness and ruin your life. In developed countries, disease is a non-insured person's worst nightmare. Nobody likes to be sick. In Egypt, however, chronic debilitating diseases can be a blessing and a livelihood. For many chronically ill patients, their disease is a source of income enough for themselves and their families. This is a well-known fact for the patients at the Alexandria University Teaching Hospitals. The social backgrounds of the patients of these hospitals are more or less the same. Since treatment at the university hospitals is free, the only reason for patients to receive treatment there is their inability to afford the cost of treatment in the private sector. The men all perform some sort of manual labor for a living; farmers, fishermen, carpenters, electricians and factory workers. Many of the women work as maids or farmers. All these patients either come from the poor quarters of Alexandria or the villages of Beheira, Kafr el-Sheikh or Matrouh. Free treatment comes at a price. Many of these patients become teaching subjects. Students, interns and residents learn on these patients the various skills required of them as doctors. The patients understand this and for the most part do not seem to object. The internal medicine department is a gold mine of classical diseases as described in medical textbooks. During their stay in the hospital, endless students gather around them for a chance to see clinical manifestations they won't see elsewhere or learn how to physically examine a patient. While many patients accept this in silence until they receive treatment and are discharged, several of them have found in their illness a profitable trade. AbulYazid is a 60-year-old man with chronic heart failure, liver cirrhosis and if doctors' suspicions are confirmed, liver cancer. He hasn't worked in six years, and is on twelve different medications. His enlarged liver and spleen are excellent teaching material for 5th year students. When the teaching begins, forty students gather around his bed to watch the professor examine him. But before the professor touches AbulYazid, he reminds the students, in English: “Remember that this patient is very co-operative and has come here today specifically for your sake, so you can learn. So remember to support him financially.” This stern reminder is delivered in English to supposedly avoid humiliating the patient, but AbulYazid has been through this routine so many times he knows what the doctor is saying by heart. As students proceed to examine his liver, AbulYazid reminds them that they must pay him the price of “one Egyptian pound.” Before the session is over, AbulYazid gently nudges a student and makes a swirling motion with his hand, meaning that student has been delegated to collect one pound from each of his colleagues. When AbulYazid receives the money; he counts it to make sure it matches the number of students. He counts while they examine him. For years, this has been AbulYazid's livelihood. In sometimes comic fashion, he teaches students how to examine an enlarged liver and spleen. He's been asked the same questions by students so many times that he answers them before they ask. When the session is over, AbulYazid goes home with more money than an average Egyptian makes in a day. In a couple of days, a doctor at the hospital will telephone him and ask him to come to the hospital for teaching, once again reminding the students of their duty to “support” the patient. If on some occasion, he doesn't receive enough money, he'll refuse to come again. Hence the doctors' insistence on supporting him. At the end of the month, AbulYazid makes more money than he would at an actual job. This is his job: a patient. His case is by no means the only one. Diabetics, chronic asthmatics and heart failure patients all make a living this way. Mohamed comes from the border town of Rafah, where he has a wife and four children. His diabetes is advanced and has destroyed his peripheral nerves. This condition makes it difficult to work; which is why he's worked as a patient for several months now. The more affluent won't neglect their diabetes to reach advanced stages; so he is great educational material. Like AbulYazid, he makes a considerable sum of money from his illness. This practice regularly receives criticism from those who are not medical students. Whenever it is described to them, their faces twist in horror. “Is that how you treat a human being?” they ask. “It sounds like you're looking at an animal at the zoo, paying money to see him. You take advantage of his poverty to use him as teaching material.” It is viewed as insulting and inhumane. Medical students argue this is an oversimplification. One fifth year student gives her assessment. “They can't work in their present conditions. So the money we give them is their only means of living. You can consider it charity. Plus, the patients are pleased with the money they're making. This is the only way we can learn anything.” Not only sick adults earn their living this way, but children too. In Shatby children's hospital, Na'ma is a well-known patient to the entire hospital staff. She was born with cerebral palsy, a permanent disorder of the development of movement. It has no cure. Every week, one of the pediatricians calls Na'ma's mother and asks her to come with her daughter to the hospital, so the students can learn about cerebral palsy. Last week, Na'ma's mother collected 30 pounds, but refused to let the students continue their examination until she was given another 20. The prospect of using your child's illness to make money seems sickening to many people, but those who know Na'ma's mother and others like her argue that Na'ma will never be cured. If she doesn't make money at the hospital, she'll sit on the sidewalk and beg; a very familiar sight in Egypt, students and doctors believe. Sometimes, more sinister outcomes result from the practice of using human disease to make money. One recently graduated doctor recalls a famous patient. “We had a famous diabetic who we regularly saw in our clinical rounds and even in private lessons. In private lessons, we had to give him five pounds each, not one. Before the final exams, he stopped taking his medication so that all the clinical signs of diabetes would be apparent and easily recognized. His diabetes got out of control and he died.” Umm Israa regularly brings her 10-year-old daughter for teaching to the hospital. She was born with ventricular septal defect (VSD), a congenital heart defect where there is a hole connecting both sides of the heart. The condition could have been corrected with a free surgical operation when she was still a baby. However, her mother has been making money out of her for the past decade. Now, students gather around her to listen to the abnormal heart sounds she has developed due to neglect of the condition. With time, she may develop serious complications, including heart failure. Until these poverty stricken people find other means to make a living, chronic illness will be a blessing to them and medical students. BM
