In Kenya, patients held hostage to medical bills

Widowed and HIV-positive, Beatrice Acheing had no money to have her baby delivered in a hospital. But she admitted herself anyway to reduce the risk of transmitting the virus during childbirth.

To her relief, the boy was born HIV-negative. But their ordeal had just begun. Hours after labor, both mother and baby were shunted into a locked, guarded room with other indigent patients. They were given one meal, sometimes two, a day, but no clothes or diapers for the infants. Nurses visited sporadically, mostly harassing them to pay their bills.

After a week in the makeshift patients’ prison, Acheing’s infant son began to shiver uncontrollably. One night, with no doctors on duty and the guard too far to hear her cries for help, he died in her arms.

The next morning a nurse took the baby away. But hospital officials detained the grieving mother for six more months, demanding $250 in fees. She escaped one morning when the guard fell asleep.

“I never found out what happened to [the body of] my baby,” said Acheing, 31.

Tragically, healthcare horror stories are common in Africa, where developing countries rarely have medical safety nets for the poor. But an increase in cases of cash-starved public hospitals and mortuaries detaining patients and even corpses over unpaid bills is spurring outrage in Kenya.

The parents of one 11-year-old girl with kidney disease issued a public appeal in April to clear a $2,000 hospital bill. The girl recovered in January but has been detained since then by the government-run Kenyatta National Hospital here in Nairobi, the capital.

The same facility was pressured this month to release 44 new mothers after a TV station used a hidden camera to prove that they were being held in a padlocked room.

“They know very well these people can never pay those bills,” said Njoroge Baiya, a Kenyan lawmaker who has raised the issue in parliament. “A more humane policy should be developed.”

Experts say government inaction makes the practice de facto policy, even though its legality has been questioned.

With such policies, it’s little wonder that poor Kenyans who are seriously ill or dying often avoid hospitals, even though they might provide treatment or dispense painkillers and help control public contagion.

Instead, many AIDS and cancer patients are pressured by their families to take public buses back to their hometowns, saving the burden of hospital bills, postmortem transportation and ensuring a decent burial. There, some face a painful, lingering death with little more than family members or traditional healers to comfort them.

In Mathare, a slum of tin shacks and open sewage streams in Nairobi, Felista Atieno, 45, is desperately trying to raise money to recover the body of her only son, Peter, who was killed in May by a hit-and-run driver.

Atieno said mortuary officials were demanding $25 -- the equivalent of a month’s earnings for most slum-dwellers -- just to view the body. A postmortem exam costs $130, and the city-owned mortuary charges $7 each day it holds the body, adding $210 to her bill over the last month, she said.

Atieno clutched a small notebook with pledges of help from friends and relatives, from 75 cents to $40. But after a month, it totals less than $100. The mortuary has threatened to dispose of the corpse in a mass grave with other unclaimed bodies.

“Under our culture, he has to be buried at his ancestral home,” she said. “If I fail, I will be banished from the family. He’s my only son. He needs to be buried next to his father.”

The mortuary director said he has no authority to waive fees based on claims of poverty.

“We can’t make a decision about whether someone has money or not,” said David Wanjohi, funeral superintendent at City Mortuary in Nairobi. “If we started doing that, no one would pay.”

He said Atieno could appeal to the Nairobi City Council, which makes case-by-case exemptions. But he noted that the city has come to rely on its mortuary as an income- generator, similar to its parking lots.

For Atieno, who is suffering from tuberculosis, the lesson is clear: “It’s too expensive to die in a hospital,” she said. “For me, I’ll go home to die rather than bring more problems to my relatives.”

Asked whether she felt anger, she shrugged.

“I can’t blame anyone,” she said. “I’m the one who doesn’t have any money.”

Detention of patients and bodies has become widespread in Kenya over the last decade, but it’s still illegal, said James Mwamu, vice chairman of the Law Society of Kenya.

“If someone owes money, there is a procedure for collecting the debt, and it’s not detaining people or bodies,” Mwamu said. “The people must sign a promise to pay, and if they don’t, the hospital must file a suit. There is no law that allows hospitals to do what they are doing.”

But, Mwamu said, Kenyan police usually treat the matter as a private dispute and victims don’t know their rights.

“Most are just at the mercy of the hospital,” he said.

Kenya’s lawmakers, often ranked among Africa’s highest-paid yet least productive, have repeatedly failed to tackle rising healthcare costs and inadequate insurance.

A spokesman for Kenyatta National Hospital said his facility was struggling to stay afloat amid government cutbacks over the last 20 years.

Kenyatta, in the heart of Nairobi, receives the bulk of the city’s poor patients, from road accident victims to abandoned babies. Whereas private hospitals can demand payment upfront, Kenyatta takes everyone.

The hospital, so crowded that some patients are forced to temporarily sleep in congested corridors, still detains nonpaying patients long after their treatment is completed, usually in dank rooms, separated from the other wards.

In the late 1980s, the government slashed funding to hospitals and implemented “cost-sharing” measures for patients who previously did not have to pay, spokesman George Ojuondo said. Since then, he said, the government has paid salaries but forced facilities to bill patients to raise money for equipment, supplies and drugs.

“The only way we can run the hospital is by charging patients,” he said. “If people walk in and don’t pay, how are we going to pay for the next patient?”

The cost of detaining patients is minimal, particularly since public hospitals typically don’t provide adequate food even for paying patients, forcing families to deliver meals to their loved ones. Meanwhile, hospitals continue to charge detained patients an average of $5 to $7 a day, so their debt continues to grow like a high-interest credit card balance.

If even a few detained patients manage to pay off the debts, the policy is profitable. And it makes people think twice about failing to pay their bills, health officials said.

Ojuondo said the hospital employs social workers to determine which patients can’t pay. But such mechanisms don’t always work.

Regina Wamza was orphaned at 10; she dropped out of school after sixth grade and ran away from her home in eastern Kenya to Nairobi, where she found herself pregnant and living in the slums. When it came time to deliver, she opted for a cheaper mid-wife, but complications landed her at the government’s Pumwani Maternity Hospital.

Unable to pay the $60 delivery fee or the $7 daily charge, she said, she was held in a room with three other mothers. She was given only a thin blanket for the baby, which served as both clothing and diaper. For four months, her baby boy did not go outdoors.

“The nurses were so hard,” said Wamza, 19. “They just accused me of taking up space. They didn’t care.”

Hospital officials did not return phone calls for comment.

In desperation, Wamza said, she caught the attention of a stranger through the window and persuaded her to help smuggle the child out. Then Wamza covered her head with a Muslim-style scarf and sneaked past the guard.

“I will never go back there,” she said. “It was like prison.”

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edmund.sanders@ latimes.com