Personal views: When is medical evacuation justified?
Authors: Andrew R Potter
Journal: BMJ (1998)

Illness is a pain in the neck. Its arrival is always unwelcome, unsolicited, and an intrusion on the more pressing urgency of living. Only the most perverse individual could relish the experience. All the more inconvenient then when you are far from home. 

“Not much of you, is there?” joked the avuncular physician as he cast an eye over my unclothed form on the examination couch. I had flown into London that morning, evacuated from west Africa, for investigations into marked loss of weight and a sky high sedimentation rate. The dark spectre of tuberculosis, AIDS, or metastatic malignancy loomed and I saw it reflected in the worried facial expressions of those about me. I, too, was naturally scared, for it could mark the end not only of my chosen career in the tropics but of my very life, neither of which I cared to countenance. 

True, I had not been well for the previous three months and, although I had continued with a very full schedule of work, I had stopped running and swimming, two of my favourite pastimes. The doctor I consulted, being a good general practitioner, listened, looked, and advised “waiting and seeing.” I waited and saw that nothing improved. By now I had pain in my throat, a small swelling in the front of my neck, a racing heart, and a skeleton that seemed to be pushing through my shrinking skin. My legs trembled as I walked and even I was aghast when looking in a mirror. A month on and I encountered my doctor at a social gathering. He took one glance at me and declared, “You must go home for tests.” 

Expatriate doctors who work in poor tropical countries get used to treating the local population with their often gross and advanced pathology. They quickly lose confidence, however, caring for other expatriates. This does not imply that after some months or years in the tropics these doctors become incompetent or lose touch with modern medicine. Rather it is because the support services available at home—biochemistry, histology, radiology, and scans—are not usually available in tropical countries. So the normally robust clinician, who from necessity has developed a sixth sense in diagnosis without modern technology, becomes nervous. Worse when you are confronted with a colleague. “Come up to the house. I’ll see you there away from the bustle of outpatients.” That is the first mistake. And patients expectations’ differ. Some expatriates demand to be sent home at the first hint of malaria or dysentery. Others, perhaps like myself, are more stoical, playing down their symptoms in order to keep going. 

But the question is pertinent. At what point is a medical evacuation justified? Some insurance companies will reimburse the cost of the air ticket only if the patient is a stretcher case, which is illogical, for it is better to come home upright and pay for one aircraft seat than to be horizontal and pay for six seats. Airlines, too, vary in their reaction to carrying sick passengers, so much so that it may well be in the patient’s interest to keep quiet and travel as an ordinary tourist rather than undergo the rigours of a medical cross examination in a foreign airport. 


There is no doubt, however, that once back home whether choosing the private or public health sectors all the stops are quickly pulled out. No one wants to miss a case of open tuberculosis or a tropical haemorrhagic fever. Many who work overseas carry private health insurance and in the space of a week after my arrival I had been examined by two physicians, had many blood tests, electrocardiography, x rays, isotope scan, and needle biopsy under ultrasound control. 


“I was impressed with the efficiency of it all, but horrified by the cost”



I was impressed by the efficiency of it all, but horrified by the cost. A 10 minute consultation with the consultant physician, who summarised my results, declared the diagnosis and wrote a prescription, cost more than I pay my cook cum house servant for a month—and he has a wife and six children to support—or nearly double what my best hospital nurse receives in Benin. 

If it had been possible to stay overseas for these investigations a lot of money would have been saved. My medical evacuation cost well over £2000. But apart from these substantial costs there are other factors. What message is conveyed to my African friends? When they get sick they are treated locally with the facilities and drugs at our disposal. They recover or not as the case may be. When I, as a foreigner, get sick I am whisked off to England at great expense. I am almost ashamed by this. 

So at what point is a medical evacuation justified? Should a system exist that allows me to go but denies an equally or more sick national colleague that chance? Should those of us who choose to work in remote, underprivileged areas accept that if we get sick we will be treated only as far as local facilities and skills allow? How can I expect to be considered as an equal when I have so many extra privileges? 

And my diagnosis? De Quervain’s thyroiditis with thyrotoxicosis. As I said—a pain in the neck.