Pa­tients world­wide openly held hostage in med­i­cal fa­cil­i­ties when they can’t pay bills

Daily Southtown - - OPINION - By Maria Cheng Des­mond Tiro in Nairobi and Paola Flores in La Paz, Bo­livia, con­trib­uted.

NAIROBI, Kenya — The Keny­atta Na­tional Hos­pi­tal is east Africa’s big­gest med­i­cal in­sti­tu­tion, home to more than a dozen donor-funded projects with in­ter­na­tional part­ners — a “Cen­ter of Ex­cel­lence,” says the U.S. Cen­ters for Dis­ease Con­trol and Pre­ven­tion.

The hos­pi­tal’s web­site proudly pro­claims its motto — “We Lis­ten We Care” — along with photos of smil­ing doc­tors, a vac­ci­na­tion cam­paign and staffers hold­ing aloft a gold tro­phy at an awards cer­e­mony.

But there are no pic­tures of Robert Wany­onyi, shot and par­a­lyzed in a rob­bery more than a year ago. Keny­atta will not al­low him to leave the hos­pi­tal be­cause he can­not pay his bill of nearly $40,000. He is trapped in his fourth-floor bed, un­able to go to In­dia, where he be­lieves doc­tors might help him.

No pay, you stay

At Keny­atta Na­tional Hos­pi­tal and at an as­ton­ish­ing num­ber of other hos­pi­tals around the world, if you don’t pay up, you don’t go home.

The hos­pi­tals of­ten il­le­gally de­tain pa­tients long after they should be med­i­cally dis­charged, us­ing armed guards, locked doors and even chains to hold those who have not set­tled their ac­counts. Moth­ers and ba­bies are some­times sep­a­rated. Even death does not guar­an­tee re­lease: Kenyan hos­pi­tals and morgues are hold­ing hun­dreds of bod­ies un­til fam­i­lies can pay their loved ones’ bills, govern­ment of­fi­cials say.

Dozens of doc­tors, nurses, health ex­perts, pa­tients and ad­min­is­tra­tors told the As­so­ci­ated Press of im­pris­on­ments in hos­pi­tals in at least 30 other coun­tries, in­clud­ing Nige­ria and the Congo, China and Thai­land, Lithua­nia and Bul­garia, and oth­ers in Latin Amer­ica and the Mid­dle East.

The AP in­ves­ti­ga­tion built on a re­port last year by the Bri­tish think-tank Chatham House; its ex­perts found more than 60 press re­ports of pa­tient de­ten­tion in 14 coun­tries in Asia and sub-Sa­ha­ran Africa.

“What’s strik­ing about this is­sue is that the more we look for this, the more we find it,” said Dr. Ashish Jha, di­rec­tor of the Har­vard Global Health In­sti­tute, who was not in­volved in the Bri­tish re­search. “It’s prob­a­bly hun­dreds of thou­sands if not mil­lions of peo­ple that this af­fects world­wide. It is not some­thing that is only hap­pen­ing in a small num­ber of coun­tries, but the prob­lem is that no­body is look­ing at this and it is way off the pub­lic health radar.”

Some ex­am­ples:

■ In the Philip­pines, An­na­lyn Manalo was held at Mount Carmel Dioce­san Gen­eral Hos­pi­tal in Lu­cena City for more than a month start­ing last De­cem­ber fol­low­ing treat­ment for heart prob­lems. Ad­min­is­tra­tors re­fused ini­tially to al­low her fam­ily to pay in in­stall­ments — and the cost of each ex­tra day in de­ten­tion was added to the bill.

“We were treated like crim­i­nals,” said Manalo’s hus­band, Sigfredo. “The se­cu­rity guards would come and check on us all the time.”

■ In Ban­ga­lore, In­dia, Em­manuel Malagi was de­tained in a pri­vate hos­pi­tal for three months after he was treated for a spinal tu­mor, ac­cord­ing to his brother, Chris­tanand. Pre­vented from see­ing him, his fam­ily scram­bled un­suc­cess­fully to pay his nearly $20,000 bill — and when he died, the hos­pi­tal de­manded an­other $13,700 to re­lease the body.

■ In Malaysia, a med­i­cal stu­dent from the Nether­lands on a div­ing trip got the bends. He couldn’t af­ford his de­com­pres­sion treat­ment; the hos­pi­tal locked him in a room for four days, with no food or drink, un­til he was able to get the money, ac­cord­ing to Saskia Mostert, a Dutch aca­demic who has re­searched hos­pi­tal de­ten­tions.

■ In Bo­livia, a govern­ment om­buds­man re­ported that 49 pa­tients were de­tained in hos­pi­tals or clin­ics in the last two years be­cause they couldn’t pay, de­spite a law that pro­hibits the prac­tice.

Dur­ing sev­eral Au­gust vis­its to Keny­atta Na­tional Hos­pi­tal, the AP wit­nessed armed guards in mil­i­tary fa­tigues stand­ing watch over pa­tients, and saw where de­tainees slept on bed­sheets on the floor in cor­doned-off rooms. Guards pre­vented one wor­ried fa­ther from see­ing his de­tained tod­dler. All de­spite a court rul­ing years ago that found the de­ten­tions were il­le­gal.

Health ex­perts de­cry hos­pi­tal im­pris­on­ment as a hu­man rights vi­o­la­tion. Yet the United Na­tions, U.S. and in­ter­na­tional health agen­cies, donors and char­i­ties all have re­mained silent while pump­ing bil­lions of dol­lars into these coun­tries to sup­port splin­tered health sys­tems or to fight out­breaks of dis­eases in­clud­ing AIDS and malaria.

“It’s the dirty un­der­belly of global health that no­body wants to talk about,” said So­phie Har­man, a health aca­demic at Queen Mary Uni­ver­sity of Lon­don. “They prob­a­bly think they have big­ger bat­tles in pub­lic health to fight, so they just have to let this go.”

Lit­tle ac­count­abil­ity

Hos­pi­tal de­ten­tions, some ex­perts ar­gue, can be traced to poli­cies pushed decades ago by the World Bank, the World Health Or­ga­ni­za­tion, UNICEF and oth­ers who made loans to de­vel­op­ing coun­tries on con­di­tion that they charge pa­tients fees for med­i­cal ser­vices. With­out ex­plicit pro­tec­tions in place to pro­tect the poor, they say, the poli­cies gave coun­tries the free­dom to ex­tract health care pay­ments how­ever they saw fit — in­clud­ing de­tain­ing pa­tients.

The prac­tice ap­pears to be most preva­lent in coun­tries with frag­ile, un­der­funded health sys­tems where there is lit­tle govern­ment ac­count­abil­ity. But the prob­lem has also sur­faced in wealth­ier coun­tries, with pa­tients be­ing de­tained in hos­pi­tals in coun­tries in­clud­ing In­dia, Thai­land, China and Iran.

In many coun­tries when pa­tients can­not af­ford to pay for health care, they are usu­ally sent to a pub­lic hos­pi­tal, where treat­ment is cov­ered by the state, or re­fused help al­to­gether. In some hos­pi­tals in Cameroon and else­where, for ex­am­ple, the prob­lem of pa­tient im­pris­on­ment was solved by some in­sti­tu­tions by sim­ply de­mand­ing pay­ment up­front.

Where pa­tients are im­pris­oned, hos­pi­tals ac­knowl­edge it is not nec­es­sar­ily prof­itable. But many say it of­ten leads at least to par­tial pay­ment and serves as a de­ter­rent.

Un­like many hos­pi­tals in de­vel­oped coun­tries, African hos­pi­tals don’t al­ways pro­vide food, cloth­ing or bed­ding for pa­tients, so hold­ing onto them does not nec­es­sar­ily in­cur a sig­nif­i­cant cost. De­tained pa­tients typ­i­cally rely on rel­a­tives to bring them food while those with­out oblig­ing fam­ily mem­bers re­sort to beg­ging for help from staff or other pa­tients.

Dr. Fes­tus Nju­guna, a pe­di­atric on­col­o­gist at the Moi Teach­ing and Re­fer­ral Hos­pi­tal in El­doret, about 185 miles north­west of Nairobi, said the in­sti­tu­tion reg­u­larly holds chil­dren with can­cer who have fin­ished their treat­ment, but whose par­ents can­not pay. The chil­dren are typ­i­cally left on the wards for weeks and months at a time, long after their treat­ment has ended.

“It’s not a very good feel­ing for the doc­tors and nurses who have treated these pa­tients to see them kept like this,” Nju­guna said.

Still, some of­fi­cials openly de­fend the prac­tice.

“We can’t just let peo­ple leave if they don’t pay,” said Leedy Nyembo-Mu­galu, ad­min­is­tra­tor of Congo’s Katuba Ref­er­ence Hos­pi­tal. He said hold­ing pa­tients wasn’t an is­sue of hu­man rights, but sim­ply a way to con­duct busi­ness: “No one ever comes back to pay their bill a month or two later.”

At many Kenyan hos­pi­tals, in­clud­ing Keny­atta, of­fi­cials armed with ri­fles pa­trol the hall­ways and guard the hos­pi­tal’s gates. Pa­tients must show hos­pi­tal guards a dis­charge form to prove they’re al­lowed to leave and even vis­i­tors must some­times sur­ren­der their iden­ti­fi­ca­tion cards be­fore see­ing pa­tients.

In its 2016 fi­nan­cial re­port, Keny­atta’s au­di­tor-gen­eral said the hos­pi­tal lost more than $470,000 in fees from pa­tients who “ab­sconded” with­out pay­ing. That year, the hos­pi­tal re­ported to­tal rev­enue of more than $115 mil­lion.

Kenya’s min­istry of health and Keny­atta can­celed sev­eral sched­uled in­ter­views with the AP and de­clined to re­spond to re­peated re­quests for com­ment.

After she was elected to Kenya’s Par­lia­ment, Es­ther Pas­saris vis­ited Keny­atta last De­cem­ber to check on sup­port­ers who were in­jured in elec­tion vi­o­lence. She was stunned to find that pa­tients were in­car­cer­ated.

“There was one lady I met in the cor­ri­dor and she was cry­ing, ‘Please let me go home,’ ” Pas­saris said. The woman had hurt her back and hip. She had been med­i­cally cleared to leave but wasn’t al­lowed to go home be­cause she hadn’t paid her bill. “I just thought, ‘Oh my good­ness, it’s al­most Christ­mas, how can these peo­ple not go back to their fam­i­lies?’ ”

Pas­saris started an on­line cam­paign to have the pa­tients re­leased. Just be­fore the hol­i­days, Keny­atta let more than 450 leave — a vic­tory, Pas­saris says, though the prob­lem re­mains.

Stay­ing mum

For­eign agen­cies and com­pa­nies that op­er­ate where pa­tients are held hostage typ­i­cally have lit­tle to say about it. Some ex­perts said the in­ter­na­tional health com­mu­nity’s fail­ure to ad­dress the is­sue has un­der­mined its own goals.

“Aid money be­comes in­ef­fec­tive and use­less in an en­vi­ron­ment where peo­ple are ter­ri­fied they’re go­ing to be locked up,” said Robert Yates, a health pol­icy ex­pert at Chatham House, the Bri­tish think tank that re­ported on im­pris­oned pa­tients. “It’s very em­bar­rass­ing for the global health com­mu­nity that these de­ten­tions have be­come so em­bed­ded into coun­tries that they seem nor­mal, and so the whis­tle needs blow­ing on all of us.”

Said Har­vard’s Jha: “There are ba­sic hu­man rights abuses that we can­not ig­nore in the 21st cen­tury. It is not too much to ask that when pri­vate com­pa­nies like phar­ma­ceu­ti­cals or fed­eral agen­cies like the CDC be­come aware that their part­ners en­gage in such a fun­da­men­tal vi­o­la­tion of hu­man rights, that they hold them ac­count­able and work to end these prac­tices.”

The CDC pro­vides about $1.5 mil­lion every year to Keny­atta and Pumwani Ma­ter­nity Hos­pi­tal, via fund­ing from the Pres­i­dent’s Emer­gency Plan for AIDS Relief, or PEPFAR.

At Keny­atta, the CDC cov­ers treat­ment costs for pa­tients with HIV and tu­ber­cu­lo­sis, trains health work­ers and helps with HIV test­ing, among other pro­grams. The agency de­clined to com­ment on whether it was aware that pa­tients were reg­u­larly de­tained at Keny­atta and Pumwani or if the agency con­dones the prac­tice.

Among its other part­ner­ships, Keny­atta has been work­ing with the Uni­ver­sity of Wash­ing­ton for more than 30 years.

Dr. Carey Farquhar, di­rec­tor of the uni­ver­sity’s Kenya Re­search and Train­ing Cen­ter, said she didn’t re­call see­ing any de­tained pa­tients at Keny­atta, though she was not sur­prised that it hap­pened — she knew of no hos­pi­tals there that did not de­tain pa­tients.

“It does make me un­com­fort­able,” she said.

Farquhar said the is­sue “doesn’t cross our radar as much” since her uni­ver­sity is fo­cused on med­i­cal re­search, rather than pa­tient care. She added that she might raise the is­sue with her col­leagues at Keny­atta but that “the solution has to come from within.”

Dr. Agnes Sou­cat of WHO said the U.N. agency was aware of hos­pi­tal de­ten­tions and con­firmed they hap­pened “quite fre­quently.”

“We do not sup­port this in any way, but the prob­lem has been doc­u­ment­ing where it hap­pens,” said Sou­cat, di­rec­tor of WHO’s depart­ment of health sys­tems, fi­nanc­ing and gov­er­nance. To date, WHO has made no at­tempt to col­lect data on hos­pi­tal de­ten­tions and says such in­for­ma­tion is hard to find. The AP ob­tained pa­tient lists, records and bills from about a dozen hos­pi­tals in Congo de­tail­ing im­pris­on­ment prac­tices.

And though WHO has is­sued hun­dreds of health rec­om­men­da­tions — from treat­ing AIDS to Zika — the agency has never pub­lished any guid­ance ad­vis­ing coun­tries not to im­prison peo­ple in their hos­pi­tals.

Sou­cat said WHO of­fi­cials in more than a dozen coun­tries had ex­pressed their con­cerns about de­tained pa­tients to min­is­ters of health, but that those dis­cus­sions were pri­vate.

Some jus­tice

One in­ter­na­tional or­ga­ni­za­tion did fight pub­licly for de­tained pa­tients.

Re­searchers for the Cen­ter for Re­pro­duc­tive Rights, which acts to sup­port women’s health around the world, were con­duct­ing a study of ma­ter­nal health care in Kenya in early 2012 when they learned of the cases of Maimuna Awuor Omuya and Mar­garet Oliele.

Un­able to pay her bill at Pumwani Ma­ter­nity Hos­pi­tal after the de­liv­ery of her sixth child, Omuya and her baby were im­pris­oned along with more than 60 other women in a damp ward, in Septem­ber 2010. She of­ten slept on the wet ground next to a flooded toi­let. Mother and child were re­leased after nearly a month, but only when one of Omuya’s friends ap­pealed to the mayor to in­ter­vene.

Two months later, Oliele ar­rived at Pumwani. Dur­ing a botched ce­sarean sec­tion, doc­tors left a pair of sur­gi­cal scis­sors in­side Oliele’s stom­ach; a sec­ond surgery was needed to re­move the scis­sors and she later suf­fered a rup­tured blad­der and a blood in­fec­tion. When she couldn’t pay her hos­pi­tal fees, Oliele was taken to a de­ten­tion ward.

“I tried to es­cape, but when I got to the main gate, I was taken by the se­cu­rity guards,” Oliele said. “I had no clothes on and still had the catheter in my stom­ach. The guards then force­fully took me back to the hos­pi­tal where they hand­cuffed me to a bed, while claim­ing that I had gone mad.” She was held for six days. Cen­ter for Re­pro­duc­tive Rights lawyers re­solved to take up the cause of de­tained pa­tients, bring­ing suit on be­half of Omuya and Oliele.

“These were two very ap­palling cases and their treat­ment was very de­grad­ing,” said Eve­lyne Opondo, a se­nior re­gional di­rec­tor at the cen­ter who over­saw the case.

They won. In Septem­ber 2015, Kenya’s High Court ruled the women’s de­ten­tion vi­o­lated numer­ous hu­man rights en­shrined in the con­sti­tu­tion and was there­fore il­le­gal. The High Court de­scribed the women’s de­ten­tion as “cruel, in­hu­man and de­grad­ing.”

The court fur­ther or­dered the Kenyan govern­ment to “take the nec­es­sary steps to pro­tect all pa­tients from ar­bi­trary de­ten­tion.”

But three years later, it ap­pears lit­tle has changed.

“Peo­ple are still be­ing de­tained,” Oliele said. “They should stop treat­ing peo­ple like an­i­mals and treat them as fel­low hu­man be­ings.”

Nei­ther Omuya nor Oliele have been paid the dam­ages awarded to them by the court: Omuya was to re­ceive $14,842 from the hos­pi­tal while Oliele was to re­ceive $4,948.


Ado Ntanga and her son have been de­tained, un­able to pay $850 for the boy’s sickle cell ane­mia treat­ment.


Ki­menua Ngoie, who lost her baby at birth, has been un­able to pay the $360 cost of her op­er­a­tion.


A par­a­lyzed Robert Wany­onyi is un­able to go to In­dia, where he be­lieves doc­tors might help him.


A clean­ing woman oc­ca­sion­ally brings Gabriel Mu­tamba food but oth­er­wise he has few vis­i­tors.

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