Featured Articles

The Challenges and Opportunities in Managing a Health Condition Abroad: Part I

It can be extremely stressful when we or someone we love becomes ill abroad. As well as the (very normal) physical and mental turmoil of illness, we often find ourselves dealing with additional challenges that are unique to international life.

At the 2018 Families in Global Transition (FIGT) conference in March, I got together with psychologist Vivian Chiona of Expat Nest for a “Kitchen Table Conversation” (KTC) on exactly this topic.

Participants included missionaries, financial planners, educators, researchers, writers, coaches, and others within the international community. They ranged from parents of children with serious medical conditions, to partners of seriously ill adults, to expat physicians, to former and current patients. It became clear that all sectors of the international community share common challenges when facing a medical condition abroad.

Below are eight common concerns that emerged from this fascinating discussion with expert expats and expat experts alike!  In Part II of this article, we offer 16 sound, supportive strategies to help you get through or avoid these potential roadblocks.


The Three I's

Participant Michael Watkins, an expat who bounces between three countries on a regular basis and who experienced a life-threatening medical crisis while traveling in Switzerland, outlined these first three major challenges faced by expats and travelers.

1. Ignorance

blindfold.jpg

In the true sense of the word, many expats and travelers, have little, if any, knowledge or information about the local healthcare system until they are faced with a crisis. The process, coverage, and payment protocols differ greatly from country-to-country, but we often make assumptions that our healthcare experiences will be similar to those in our native country (or our last country of residence).  Regardless of the outcome, assumption and lack of knowledge add undue stress to an already stressful situation.

An American mother described a scenario where she made daily trips to the ATM machine in the hospital where her preschooler was admitted.  Every day, she'd withdraw the maximum, thinking she would have to pay thousands for her child's five day hospital stay. Her husband was out of town. The one friend she had in the city was on vacation and the one she thought she could count on didn't come through. She'd been studying the language, but it wasn't enough to understand the process.

In the end, she was charged only 10 euros per day for the meals she consumed while accompanying her child. Though this was a welcome and pleasant surprise, those five days not knowing what would happen, both medically and financially, were especially heavy.

2. Insurance

The wrong insurance (or no insurance) can lead to a personal financial crisis. Those who have been through a medical crisis abroad, stress the importance of understanding the host country's local medical coverage and how it interacts with private insurance carriers, including medevac coverage and pre-existing conditions

One American couple traveled all over Europe believing they were covered by Medicare. After one sustained a serious bicycle accident, broken bones, head injury, and week-long hospitalization in Italy, they learned that Medicare did not cover them outside the United States.  While they were not denied care, the stress of trying to navigate how they would pay these international bills while also figuring out how to transport her seriously injured husband home for surgery (where it was surely covered) was overwhelmingly stressful.

Another traveler described the financial barrier he and his wife faced in Spain when "the hospital demanded upfront payment for most of the cost" of a surgery and hospitalization after he sustained a fall. In this case, they were covered by insurance, but were forced to use credit cards at admission and would not be reimbursed for some time, causing a period of financial hardship.  Additional room and board costs were not covered.

Sometimes you get lucky like Watkins who explained how he learned, after the fact, that his private insurance covered not only his private room, but higher quality medical equipment, medicines, and food during his lengthy hospitalization in Switzerland.  This detail varies from country-to-country as well.

3. Isolation

daan-stevens-282446-unsplash.jpg

Almost everyone described the sense of isolation and lack of support they felt being far from a personal and professional support system. Whether alone for weeks in a stark hospital room, recuperating at home as a single, without the support of close friends or family, or posted in a remote area, far from quality facilities, isolation can be a major obstacle to recovery. 

Lack of emotional and logistical support (e.g. like someone to collect kids from school, run household errands, or cook) contributes to this sense of isolation. Without a close support network, individuals and families dealing with a medical crisis abroad can feel unmanageable stress and fatigue, decreasing their ability to cope, make decisions, or maintain a positive outlook.


Five More Hurdles in Healthcare

In addition to the challenges born out of Ignorance, Insurance, and Isolation, issues related to Trust, Communication, Overwhelm, Parenting, and Pain also came up in our KTC.  While several of these may be true for anyone facing a health crisis, the interplay between them amplifies the overall challenge, creating a unique experience for expats in this arena.

1. Communication

Or rather, miscommunication, or misunderstandings with healthcare providers due to a language barrier or cultural differences in communication styles and expectations is a real roadblock.  Even routine check-ups and screenings can be put off or missed altogether.

For some, these misunderstandings lead to a general mistrust of the medical system, itself. Once this has happened, it can be hard to reconcile, to return to the same system when a need arises again.

2. Trust

Trust can be difficult to cultivate when communication is a struggle, but when a patient's symptoms are not believed or validated, or where a misdiagnosis occurs, a patient is left to suffer both physically and psychologically, as described by more than one participant.

When a patient is empowered and knows themselves well, not being believed, heard or helped when they are suffering is even more maddening. There could be a cultural or individual bias at play and the solution may be as easy as switching primary care physicians or specialists, but overcoming mistrust of an entire medical culture is a heavy burden for those who must continue to engage with the system.

3. Overwhelm and Indecision

Some described a sense of paralyzing overwhelm when they received news of a new diagnosis; a long list of tasks to complete within a limited time-frame, under stress, not knowing how or where to begin.  This feeling can lead to indecision or the "Freeze" stress response in which no action is taken whatsoever. 

Another version of overwhelm is "analysis paralysis" where the person who must make the medical decision becomes overwhelmed by all the information and possible pathways, becoming stuck and unable to move forward.

4. Parenting 

There are a myriad of scenarios that make parenting more challenging when there is a health crisis in a family. If one parent must split time between hospital visits and home routines, but they are lacking social-emotional support themselves, stress levels rise even higher. Finding time to recharge seems nearly impossible.

If it is a parent who is injured or ill, children may also need extra emotional support at a time when the parents’ emotional reserves are low.  It may be overwhelming to think about how to talk to the children about what's happening or to know how much to share.

mother and child.jpg

If the child is the patient, there are often social-emotional and scholastic implications that arise, in addition to the physical issues. Depending upon where the family is based, there may not be access to necessary medical care or support services. A career may be cut short, siblings lives up-heaved.

A couple of parents described hasty departures and medevac rides, uprooting in search of a posting that could support their child's well-being.

 

5. Pain and Discomfort (both physical and emotional)

Anyone who has experienced acute or chronic pain, understands how it can dominate everything else listed here. Aside from learning how to survive and thrive physically, patients and their loved ones reported feelings of guilt, self-blame, doubt, sense of loss, grief, anxiety/depression, hopelessness, helplessness, and fear.

fabian-moller-401625.jpg

How human pain (both physical and psychological) is interpreted and treated varies widely between cultures. Some cultures medicate for every ache, while others hold off on pharmaceuticals.  Some systems provide substantial patient support services, while others provide only essential medical care. Non-pharmaceutical pain management options may be suggested, but no coaching provided on how to implement them.

Finally, mental health is not always covered by the local system and if it is, it may be difficult to find a therapist in one's native language.  Culturally, the role of a psychiatrist may be primarily to prescribe medications without therapy and monitoring, so those seeking both may feel like they're falling through the cracks.


What would you add to this list? What insights do you have for those facing illness abroad? Let’s share our tips and support each other!

If you are experiencing some of the challenges above, please know our thoughts are with you and we are sending you great love and strength.  Part II of this article discusses strategies, solutions, and suggestions for smoother sailing.

If you are considering seeking professional support, working with a professional coach or psychologist creates a safe place to express your thoughts and feelings, find solutions, and feel more satisfaction, peace, joy, and vitality in your life. A Certified Child Life Specialist can support you and your children through a medical event by helping you facilitate opportunities for self-expression, preparation, education and effective coping. 

If you found this article useful, please share it, so others can join the discussion. Perhaps, these words will give insight and comfort in helping someone to know they are not alone.