My leg goes to the doctor

This is an update on my leg, and a response to some questions posted by a reader about the medical system in Argentina.


First things first: the cause of the problem seems to be not my leg, but my spine. A couple of X-rays of my lower back shows that one tip of my last lumbar vertebra (L5) is too close to the top of the sacrum (S1), "pinching" the L5–S1 space (I don't know what this is called in English; it's a pinzamiento in Spanish). The numbness in my right leg and my other symptoms seem to correspond to a sciatica, possibly caused by compression of the nerve that comes down from the spine and goes into the leg. In order to confirm that, the doctor told me to get an electromyography. That'll be next Tuesday.

Besides this, and quite possibly because of it, I've developed a slight functional scoliosis, which means my spine is curved a bit laterally, with a convexity to the right. That may be the cause of a small but persistent pain I'd been feeling in the right side of my middle back. In addition, the vertebrae of my lower back are aligned horizontally, while above them, the upper lumbar and dorsal vertebrae are going up in a straight line. That is, when you see my spine from one side, instead of the proper elongated, smoothly curved S-shape, what you see in the bottom half is a horizontally-flipped "Z". Neither of these abnormalities are permanent. The scoliosis will be corrected once the leg is fine again; the other problem is most likely the fruit of a sedentary life and can be fixed by strengthening my lower back and abdominal muscles.

Regarding local medicine, here are the questions:

1. "How was your visit to your local medical center?" — I actually went three times: first to see the doctor (it's a first come, first served system), next day to have the X-rays, and next day to see the doctor again. The doctor should've arrived at 5 PM but both times he came at around 5:20... The first time I was the second patient; the other time I was #5 and had to wait for more than an hour. My mistake for not being there before. The X-ray was very quick. The X-ray machine was made in Britain and must have been 25 years old, but it worked fine. The radiographer kept the films, and the radiologist had the report ready the next day when I fetched them before seeing the traumatologist. Apart from the waiting, everything went OK. The waiting room and the doctor's room were a bit cramped, but clean and comfortable. The doctor was nice and the clinical exam was thorough enough.
2. The question you didn't ask: how much? Well, I had to pay a fee (AR$8) each time I saw the doctor, and I had to pay AR$26 for the X-rays. In a public hospital or another common healthcare center I'd probably get both things cheaper. This is at the neighbourhood's medical center, so it's like an association or club and you have to pay to stay in — only AR$13/month, per family. Not all neighbourhoods have such association, and most don't have such facilities, but mine is an old-time poor-but-hard-working-class barrio of 80,000 residents, give or take.
3. "When you go to a public facility, are the doctors you see all internists? What happens if you need to see a specialist?" — It depends. At the most basic, a public primary healthcare center has an internist and maybe an emergency doctor all the time. The specialists don't work full time in a single place; they come at certain times and certain days of the week, see the patients and leave (for example, the doctor I'm seeing comes Monday, Wednesday and Friday at 5 PM, and leaves at 7 PM). In a public hospital you typically have an office where you can schedule an appointment with the specialist, as in private facilities.
   
4. "How readily available are diagnostic tools such as MRIs and ultrasounds in public healthcare?" — Ultrasound is widely available, even in primary care centers, since public health serves predominantly poor patients, and those include many pregnant women. CT and MRI are available as well, in hospitals, at least in the developed areas (such as Rosario). I'm not sure about the municipal hospitals here, but of the 3 large provincial ones in the metro area, two have CT, one of those has MRI, and the third has a gamma camera. The cost varies according to the economic possibilities of the patient — the full price is significantly less than the one you must pay in a private hospital, and if you can't pay it, you can state your problem and the hospital's auditing office will decide what to do.
5. "If you need extensive treatment in a public facility, does the government (city, provincal etc.) pay for everything? How would you imagine that the cost may influence how good the treatment is in such a situation." — In certain cases (patients that clearly cannot pay) the government will pay for everything, though it might take long, humiliating days or weeks for the patient to go past the bureaucratic barriers. Based on my inside experience, however, the quality of the treatment doesn't suffer. The bureaucracy separates the physicians from the monetary issues. The medical staff may come and do their job without even knowing whether the patient has paid for the treatment. At least in Santa Fe, you can get dialysis, cancer drugs and chemo, HIV drugs, insuline and diabetes medication for free and forever, though there are occasional delays in the provision of drugs.
   
6. "If you have an medical emergency, can you go to the ER of any hospital and get treatment?" — Yes. This is common even for patients with private health insurance or with union-based healthcare systems. In theory, when you go to a public hospital the administrative staff takes care of checking whether you have insurance, so as to send them the bill later. In practice, many small emergencies are taken care of and the patient goes without anybody paying for anything.
   

I hope this answers your questions!

Healthcare this way

My right leg has been behaving strangely as of late, which I blame on my new jogging habit, though I knew there was something wrong with it before. My knee feels a bit hurt all the time, and a kind of weakness propagates upward from there. I let it pass for a while since it looked like a simple adjustment from sedentarism to a regime of consistent exercise, although weirdly it didn't bother me at all while jogging. But now it's bothering me even as I stand or walk. I can give up jogging, but I go everywhere on foot.

Given that, I need to go to a doctor, and I thought it'd be interesting to speak of medicine in Argentina. I've read a lot of reports of foreign visitors and expats marvelling about the quality and price of health care here, and especially the existence of universal socialized medicine. The latter is not something you usually hear much about, since people with $$$ don't really need to go there. The most expensive quality medical treatment you can find in Argentina is still a bargain compared to the costs of medicine in the United States or Europe.

If you have a good salary, you can pay for a private health insurance plan. They're not cheap, and they've become extremely restricted — you can get away with emergency service and basic treatment, but not surgery or other complicated procedures, for which you have to pay additional money. Alternatively, if you're working en blanco (formally registered), you may have a health plan associated with your union. It won't get you everything you need for free, but you can get away with simple medical matters for a few pesos.

However, if you don't have money or a job, or you don't have a unionized healthcare plan, or your plan is insufficient, you'll have to brace yourself and go look for attention in the public health system. There's a provincial system, with hospitals in large towns and cities, smaller health centers in small towns, and little primary care centers everywhere, covering the entire area of Santa Fe. Overlaid with it there are local (municipal) health centers, which are usually coordinated with the provincial system. Rosario, being much larger than any other city, is a special case, and even more so because of the constant competition and bickering between the provincial and the municipal governments. The municipality manages several major hospitals on its own, including one for emergencies and one for children, and a multitude of primary centers.

The provincial health system is divided for administration into several Health Zones, each divided in turn into Programmatic Areas, each one having one base hospital and several primary care centers. The main difference regarding patient attention is that the provincial centers accept people from anywhere in Santa Fe (and even outside), while Rosario's municipal centers tend to send non-rosarinos elsewhere. I worked in one of the three largest provincial hospitals in Argentina and I can tell you that the quality of medical attention can range from very good to atrocious, depending on luck and on the good will of the doctors and employees; I don't know about the municipal hospitals. There's an unspoken assumption (acknowledged by the provincial officials) that Rosario's public health is better managed, though I couldn't tell for sure; conversely, the handling of internal jurisdictions, finance and large amounts of patients in the provincial system's hospitals is completely chaotic, in part because the hospitals were left to their own devices during the Reutemann administration.

Picture this: a large organization, self-ruled, with huge expenses, led by an unelected political official appointed by a faraway authority and with lesser authorities partly elected by votes of its employees (usually bought or pressured by a politically-connected union, if not entirely forged), which receives money from its higher authority but must not answer for it, and needs to gather extra money to work but cannot formally ask the patients for that money since in theory the public health system is free and the government is proud of that. This mess could be maybe corrected by re-centralization and enforced by tight controls, but that would make the central Health Ministry accountable for each little fault. With formally autonomous, self-managed hospitals, that responsibility is diluted.

Anyway, tens of thousands of people seek public health care in Rosario every day, and they get it, maybe after long waits or in less-than-optimal conditions, but usually from decently good professionals. If you want to become a doctor, you need to do your residence in a public hospital, and everybody knows that those young, eager residents are the ones that really do the grunt work in hospitals. Moreover, it's still a source of status for a doctor to serve in a public hospital, if only for short periods, even while he or she has a private practice; and hospitals are also schools, so residents always receive advice from qualified specialists. It's possible to give birth to a child, to have a serious fracture mended, or to get years of treatment for cancer in a public hospital for nothing, or at the very least for a fraction of the cost of private medicine, in any major public hospital in Santa Fe.

This is sadly not true of all of Argentina. Many patients in the interior of the country don't have a half-decent coverage, and need to travel long distances to their provincial capitals or even to other provinces. Some end up here in Rosario, others go to Buenos Aires. (I remember once a patient from Paraguay got a mammography in my hospital. She travelled once a year to Argentina to visit her extended family, and it was cheaper for her to pay a few pesos and get a decent study while she was staying here.) Some complex and expensive treatments, such as the ones surrounding pediatric bone marrow transplants, are only available in Buenos Aires. All in all, this makes it more attractive to live in a big city... and it's one of the reasons why poor small-town and countryside residents migrate here. The only way to fix that is simply to take good health care closer to them.

In the meantime, I'm going to take care of myself... My leg's going to see a doctor in the neighbourhood's community center, four blocks away — the 'hood is poor but the community center has at least a few specialists and, importantly, an X-ray machine!