Global Health & Asymmetric Rewards

A couple of weeks ago a 40yo female presented to our clinic with lower abdominal discomfort.

Physical exam was notable for abdominal distention with a palpable firmness up to her umbilicus.

Ultrasound revealed a markedly distended urinary bladder, an abnormal appearing uterus, as well as mild bilateral hydronephrosis.

Labs were notable for normal renal function and a hemoglobin of 8.2.

Putting all of the above together, initial assessment was:

1. Urinary Retention due to Bladder Outflow Obstruction

2. Pelvic Mass (appearing to originate from uterus per bedside ultrasound)

3. Mild bilateral hydronephrosis (presumably due to numbers 1&2 above) with preserved renal function.

4. Anemia, of uncertain etiology (most likely from blood loss via vaginal bleeding and/or anemia of chronic disease)

   
   
   
   

Our patient was agreeable to placement of a urinary catheter to relieve her urinary retention. Within the first few minutes of placement of urinary catheter, more than a liter of urine drained.

We did not fix all of our patient's problems. We successfully alleviated her urinary retention (providing her with significant relief...as one can imagine that having a liter+ of urine in one's bladder would be quite uncomfortable.. as well as possibly preventing more long-term kidney damage). We also armed her with valuable insight regarding her clinical condition and began the journey to more definitive care.

Ultimately, our patient will require further evaluation (with a gynecologist) and likely surgical intervention (i.e. hysterectomy) to address her underlying problem.

The following day, upon returning home from clinic, I noticed a large plastic bag full of plantains by our front door. Josefina mentioned that the plantains were a gift from a patient. I inquired as to which patient and she indicated "the first patient you saw yesterday. The lady who needed a catheter." I was surprised and humbled.

Were I to put myself in our patient's shoes, I am not certain that I would be nearly as appreciative. If someone informed me I had a mass in my pelvis and shoved a plastic tube into my urethra, I do not believe I would be in a rush to send that person gifts of gratitude.

Such asymmetric rewards are not uncommon in the field of Global Health. As compensation for visiting our center, our patient was "rewarded" with a potentially life altering diagnosis and a plastic tube in her urethra. As her healthcare provider, I was "rewarded" with a bag full of delicious plantains. Given that choice, I'll take the plantains... all day, every day... thank you very much.

Those particular plantains were initially sweet to the taste, but they did have a bitter aftertaste of injustice... the injustice of asymmetric rewards in the arena of Global Health and caring for the marginalized patient population that we have the privilege to serve.

Thank you for joining us in our relentless pursuit of a more just and loving world... one where asymmetries are rectified... a world where our collective palates are cleansed of the bitter aftertaste of injustice... and we all feast on sweet plantains.

He has shown you, O mortal, what is good.

And what does the Lord require of you?

To ACT JUSTLY and to LOVE MERCY

and to WALK HUMBLY with your God.

~Micah 6:8 (NIV)

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