RK: Today we talk about the intersection of health and wealth. Many of us here, if not all of us, are people who go to work. We are trying to find some success. Trying to make it in life. The question is; at what cost are we doing this? And if we are not healthy, will we even ever accomplish the things that we set out to do? Those and more questions are what we are going to be talking about today.
We shall be joined by Patrick Ayota from NSSF.
Welcome to #360Mentor Dr. Nandi K Mutema.
NM: Thank you Robert, pleasure to be here.
RK: Nandi, a lot of people here are in a reflective mode, even those who are much younger, they are wondering; how do I invest now so that in future my life is much better?
Then you have got people like me who have started facing some tough choices. We are beginning to see the consequences of life that were never the best. Is there any intervention to make the health better?
How long have you been in the medical world?
NM: Thanks Robert. I have been a medical practitioner for over 25 years, almost 30. I grew up in the medical world, fancying it and wanting so much to be like my dad which I was glad to be able to do.
There is nothing that brings me joy like being able to take care of people. Helping them to solve their medical problems and seeing the positive outcomes at the end of the day. I have never wanted to do anything else, I am doing it. And I am glad I am doing it.
RK: And you’re enjoying it?
NM: Oh yes, I am!
RK: You know when I told people that you were going to be our guest, the praises that people were singing of you were heartwarming! I knew I had made the right choice. Congratulations on your impactful work!
NM: Wow! Thank you.
RK: You’re currently practising in Uganda, could share with us the bits and pieces of what you are doing.
NM: I opened the Clinic at the Mall in January 2015. I am a physician. I normally take care of adult patients in the US but since I came back, I have kind of been pulled into the child care arena as well more by accident than anything. But other than practising medicine and managing my clinic, I also started an NGO with my husband and David Kibuuka, an artist and a friend where we used art to raise funds to take care of medical issues like affording women mammography where they couldn’t afford it themselves. And looking into other arenas like educating people regarding cervical cancer, breast cancer, prostate cancer. Those are some of the things I do outside the box of the clinic.
RK: You’re also at the Uganda medical council, or is it?
NM: I chair the drug and therapeutics committee at the Uganda Medical Association, a position that I somehow fell into but I am a champion for change but also a champion for giving what I possibly can. I enjoy occupying that seat. The other seat I occupy is a director at Kampala Hospital, we are really looking at elevating private medical care to what it should be but isn’t yet.
RK: Let’s dive straight into the subject. Health and wealth, where is the intersection? Where do we get it wrong?
NM: To be able to accomplish everything. To be able to function at your ultimate and to be able to chase whatever it is that you would like to chase, you must be healthy and you must maintain your health. Our bodies are like machines that need to be taken care of. Serviced. And maintained to be able to be at their best. Our bodies need to be treated as such.
1. They must be given the energy they need to be able to function. Clean fuel. And that is really eating well.
2. We must exercise our bodies to be able to be in the best position we possibly can
3. You must checkin like you take your car for service. At least once a year. a complete body check. As physicians we are very inquisitive. We examine you from head to toe. We do some lab work and any other imaging that we might need to do.
That puts you in position to know that there are things you need to work on. Secondly, to edify that what you are doing is actually right. And that you are at your best and that you are at your best potential. You must be healthy to be able to achieve all these other things.
If you chase wealth. If you work so hard without giving back to your body, you will break down.
RK: Wait a minute, what do you mean by giving back to your body?
NM: Giving back to your body means eating right, exercising regularly. Making sure your mental health is at its best. Taking care of your spiritual health because it is also very important. and checking in with your doctor at least once a year. you may want to check in with a mental doctor if you are feeling under that kind of stress. Check in with your spiritual guide if things aren’t going well in that direction. No one person can make it on their own. If they think they can, somewhere along the way, there might be a breakdown that needs to be fixed.
So be real. Be true to yourself and know who you are. Figure out where you are on your health journey and then and only then are you going to perform your best and achieve your wealth that befits you.
RK: Most of us, at least I was one of them, I always thought there was heroism about going to the office at 6:45am and pushing until midnight. To show that you had stmin and that you could work. The heroism was also in knowing that you could run your engine without anything. You occasionally had a cup of tea and maybe gnuts. You needed this salary so you pushed as much as you could. Are you saying that that leaves you incongruous?
NM: That leaves you running on empty. And empty of many things. empty of that which you need to sustain your own body, empty on the social aspects of your life that are extremely important. it leaves you running an empty that one needs; rest and relaxation. And you can only do that for so long.
RK: I will tell you something that I came face to face with during lockdown. And it got me thinking. Actually I changed a few things about my routine as a result of that. a lot of people my age, a lot of their parents are fairly advanced in age and that is where you see the full effect of what we are discussing. Apparently, Posta Uganda has become some kind of pharmacy, you find the whole bus is used to deliver medicines to the parents. Is that a consequence we can avoid now if we made changes?
NM: Yes, we certainly can and we must. I might sound like a broken record but we must change in terms of looking after ourselves. Nobody is going to do it for you. You must do it for yourself. And by doing a lot of those things, you are going to avoid many or some of the medical problems that some people are going through.
I will give you an example. If you are one of those people who wake up in the morning and go to the office and come back home,sit on the couch and pick up the remote. But probably, you’ve eaten wrong throughout the day. Probably you eat late at home. You keep on packing on the weight. Before you know it, you have an avoidable medical problem in terms of diabetes becusae you’ve become obese. Your blood sugars are out of control. You don’t have to get there.
RK: And you know what Nandi, what is so cruel about what you are describing is that the immediate effect of that is that you become slow at your workplace. What is even more cruel is that your employer will find a younger achiever to take your person.
NM: Robert, I often tell my patients, they come in when they are unwell. So I tell them to take days off from work. And they tell of three meetings and appointments that they have ahead of them. I ask a very bold question; what happens tomorrow when you’re dead?
RK: I will tell you what happens because I have been in the corporate world long enough to know. The person who is going to replace you will come with a wreath, will read the condolence message from your employer with a modest contribution of a million shillings and will lay the wreath, end of story. Chapter closed.
NM: True. The work. the business. The company will go on.
RK: But you will be gone because you made bad choices.
NM: Because you made choices based on “this is the way I will be valued in this space”
RK: So tell me, if we do not take care of our health in the manner that you describe, give me some health consequences that are going to afflict you. What does the countdown say on the chats?
NM: The big one is diabetes. It can be genetic. Sometimes it’s the gees that you have. And they cannot change. A lot of diabetes which is called type 2 diabetes has to do with lifestyle, obesity and therefore insulin resistance and all the way to being hungry all the time. Being thirsty all the time. And having to go to the bathroom to urinate a lot. Those are some of the manifestations for diabetes.
For those that recognise that something’s different, we are really able to manage that particular situation. A lot of the time, we put you on medication but if you take to work hard and exercise, there is always a chance that you are going to be off that medication and not be branded diabetic any more. But that’s if you made some drastic changes.
Obesity predisposes you to many other medical problems. Some cancers, the arteries. For people who have elevated cholesterol whether based on having extra curricular activities like loving meat, smoking or other fatty things, or genetics that you cannot change. Vascular diseases expose you to strokes, heart attacks, and others. But once one changes lifestyle, you can prevent yourself from getting there.
Now, sometimes, because you do not do your annual exams and therefore annual labs, you might be told that you have elevated cholesterol, it may escalate until it hammers you. But if you are in touch with your body and you have a medical home, you go for checks regularly, those are things we can tell before damage is done then you can work on a reverse.
RK: The lifestyle we described is the work lifestyle but also people who tend to do that also make the wrong (health) choices of recreation. They engage in activities that compound it. Because you are stressed at work, you will probably increase your consumption of alcohol, tobacco dependency, and bad food. Talk to us, how does that compound the situation?
NM: The work stress or the stress brought on by overworking, ‘if I don’t do these things nobody else will’, and then you need to distress. Some people distress well at home which is a very good thing but others will distress out of the home. And to some, that may mean sitting around the table with drinks or food. Others may take on other extra activities which may bring unwanted consequences. You may pick up viruses like hepatitis, HIV, you have children that may add more stress to your life.
RK: Which others would you like to add on the list?
NM: Cancers. Cancers can be a product of poor lifestyle obesity. They can be a consequence of poor choices. They can also come unknowingly. We talked about sexualy transmitted diseases; those are not only infections, even cancers like cervical cancer. One can develop hepatitis B which can lead to liver cancer. Smoking too.
There are many diseases that can be caused by poor lifestyle choices.
RK: Would you say then that these then undermine our ability to be able to accomplish our assignments?
NM: Most definitely.
RK: And then also the cost of handling treatment also eats away whatever it is that we are chasing?
NM: Yes. The cost of very good care can be rather very expensive. and so one then finds themselves stuck in this rat. One thing that I find interesting having been back to Uganda and I must mention is that health insurance companies in Uganda do not generally pay for health maintenance care. And that is wrong. I don’t know how they even make those decisions. Some do but some definitely do not. Yet that could be the best way for them to be responsible. Do the annual exam, pick out the areas that are potentially ill and manage those situations when they are still cheaper to manage than waiting for somebody to be very sick and then bring insurance. Consequently, most people who have insurance will not do their annual exam, will not know where they are on their health journey but then struggle. And I have also seen that insurance here has such caps. You might exhaust it in one visit.
NM: Getting sick is very expensive.
RK: I was going to tell you, Nandi, my dad, God rest his soul. He lived all his life with schizophrenia but at some point towards the end of his life, we were spending close to UGX 800,000 a month just getting him to manage the schizophrenia but he also had diabetes. And he was out of work although he had a pension eventually, I had to pick up this and I was alone. I guess all of us here, do you want a situation later on in life where you cannot afford but also you do not have the social support mechanism to go through? You could do certain things now that could save you money when you are not earning that much for you to exist.
Patrick, from your perspective as NSSF, you help people live a better life in their senior years, what do you make of this?
PA: Dr Nandi has pointed out something that, as last week, we actually challenged insurance companies about. Why is it that you will not pick up the tab for an annual exam simply because when you find it early enough, it is going to be cheaper to treat as a backend. We should go back to our insurance providers and ask these questions. It makes sense to make the annual checkups.
The other thing is about us African men. I grew up in the old school, it was not manly to be sick. I grew up in Tororo and we had a clinic with four nurses. And each time you would cough, there was an injection. The fear of the injection just went up.
RK: By the way, Patrick, that injection was boiled on the stove.
PA: And you heard it heating up in the saucepan.
RK: You knew what was coming
PA: You know they would pick it when it was still hot and they would use it when it was still hot.
RK: There was something called PPF
PA: Exactly. It damaged me by the way. When it came to the covid vaccination, the first thing I thought about were those needles. And I postponed going for that injection for as long as I could. And I know there are other people here who are giving all forms of excuse. They just fear the needle.
NM: Patrick, that is something very important. two things;
1. One thing I have noticed in health care in Uganda self-diagnosis and self-management
2. Diagnosis by the pharmacists and management by the pharmacist
Both of those things are causing us such big trouble in this country. and we must change that. People must realise that not every cough needs an antibiotic. Not every “I feel unwell” needs a prescription.
And please for heaven’s sake, pharmacists are not medical doctors. You do not walk into a pharmacy and say I have a headache or fever and leave with medication. That’s like visiting a quack. But we do that all the time. And by the time you come to the medical doctor, you have lost time, you are really ill and they have added on to your ailment. Come-on people wake up!
PA: I was talking about the fear that we men rarely want to accept. We are scared of going to the doctor just in case they tell us something is wrong with us. And that is the attitude I had. But luckily I was in the US for about 20 years and going for medical checkups became routine. I would like to ask Dr Nandi, for us men, for prostate cancer, they would use blood work to try to determine whether or not what you have may be cancerous. We know that the procedure they are using has got issues. In the US, they used to do the physical exam, they would stick the finger in there and you would feel it. here the doctors don’t do it. I appeal to our doctors here to find better ways of doing some of these things.
But I would like to tell the men and women on this platform, we need to be frank and discuss our health. There are so many of us in our families with mental issues and it’s okay. It’s like having a headache. Let’s not be scared of it and ask for help.
At NSSF, we now have a wellness program where our staff can call in confidentially and the number of people that called in was amazing.
NM: Patrick, you bring out two important lessons again. Gentlemen, just like the ladies, do a thorough exam and go for a pap smear when they are of age of 21 and are sexually active. There are parts of the medical exam that may not be the most pleasant, but they have to be done. Patrick talked about sticking the finger, yes we do the digital erectoral exam for all the gentlemen above 40. It helps me to know whether the prostate has enlarged. It allows me to feel the texture to know whether there is a nodule on one side and not on the other. It is important to do both.
There are other complaints that guys come with e.g. when I go to the bathroom, I don’t feel like I have emptied and I need to go back a few minutes later. Again, it’s a prostate size issue that must be evaluated thoroughly. It’s a few seconds of discomfort but it won’t kill you. Patrick, the digital erectoral exam is available at the clinic for anyone above 40.
I usually say, you won’t die on the table and you will smile when I am done. And it usually happens.
The issue of mental health is very important. We tend to put a stigma to it. We shy away from it. Even when a medical doctor says we’ve looked at your symptoms, there isn’t really any pathological reason for fear and we must explore something called a psychosomatic side to this, you look at a patient wandering, ‘are you saying I am crazy?’.
It’s not that you are crazy. It’s just that our minds, at times, are just so unsettled and we literally have physical symptoms. That’s when they open up on what they have been dealing with. That’s when you introduce them to a chemical psychologist to arm them with tools on how to deal with the situation. And most times, we don’t need to use medication. But we are able to identify that we have a mental health problem and that we can manage it and solve it.
RK: I want to bring this on the table now between you and Patrick. Patrick , you once told me that we need to keep liquid assets. As we progress in age, the need for liquid assets to finance medical bills becomes more important. You can’t liquidate a house to go for treatment in India. What can people do, in terms of financial planning, to be able to meet those bills when they arise without selling off investments.
PA: One of the things I know is that simply because you exhibit symptoms for example, for us men, if you go to the bathroom and you feel you have finished, or what we usually call ‘one for the road’, does not mean what you have is cancerous.
About resources, the older you grow, you want to have as many assets in cash. The reason is when you are going to invest, you have to invest in something that is not going to tie a lot of your capital in liquid assets. For example you could have 10 acres of land but need 1 million to go to Mulago for treatment but you find you cannot raise that amount at that time. That’s where the idea of near- cash assets comes in to address all these emergencies that may come through.
You find a man in the 70s still buying land, it is good but it is not good for you in an emergency.
RK: Nandi, from the medical side as someone who looks at the bills, what would be telling somebody like me, how do they prepare for the financial aspects of the problems they are likely to face, apart from the lifestyle changes?
NM: I am not really familiar with the investment vehicles here but there are several options one could be willing to look into. if one has a life insurance policy that has an arm that you can actually borrow from. It might be important to get that early because it will cost you less when you are younger. But if it is able to mature like an asset, that you can actually borrow money from, by the time you get to a point where health is becoming more expensive, that can be something that can be available to you. That is something I know that is available in the US but I am not sure if the insurance companies have something like this.
Here, life insurance is not common, but it is an asset that would be good to have. in as much as they don’t pay for annual exams, depending on how much cap you have, there will be some money to have there, however, you might have needed to join it when you were young to be able to benefit from it after the age of 65. Usually you cannot get a new policy after the age of 65.
The point that Patrick brings out where one needs to have ready cash is very important. My mother used to say, ‘insurance yobukadde be baana”. A lot of time, it is the children that pay for their parent’s health care. As much as that is good, at some point the change needs to happen.
RK: Nandi, someone has said to me that our parents are the last generation to whom that will happen. our kids will not want to know.
NM: I don’t want to totally agree with that but potentially, it could happen given the way they are being raised at the moment. But as a society, things need to change.
RK: Patrick, if I can demonstrate to you as NSSF that I go for my annual check ups, and that I do my exercise, I have proof of that, would you give me an incentive and give me a return for doing that, can have that to motivate a healthier living among your savers?
PA: By the way, it’s already here. There are two insurance companies UAP and Jubilee. We have group insurance with them. Last year after the lockdown, we embarked on a wellness program where we encouraged every staff member to exercise. We had challenges. What we found out at the end of the year was that their health insurance was less than what we had previously paid as a group.
This year, they gave us a discount on our premiums. They have increased coverage. So we can do this in companies and this is working for us. Because they can see that people are not getting sicker or better based on how much they are paying on medical costs.
Should NSSF give you a better return? The thing is that your lifespan is no longer 45, it is not 63 for an average Ugandan. This means if you have your money at 55, you are still within the average lifespan.
In the new amendments, we are negotiating with insurance companies to see that as a group, they offer insurance cover to our members over the age of 55. That’s something we are working on.
RK: Now, you’re talking.
Nandi, do you think incentives like that would encourage better living?
NM: Theoretically, it would. And it should. But I think it is important to have measurable parameters. Tangible parameters. Patrick, that the staff did not use more of the insurance might have mre to do with access, that they were unable to get to the places where they could access the health care. We’ve had lots of people who could not come to the clinic. Others feared to come.
The other discussion we need to have is with insurance, what are they doing racing to the bottom of reimbursement. You find that medical practitioners are told they have to charge less and see more and more which means less time for each patient which makes it unnecessary. Yes, insurance is good but at the same time, it needs to be reasonable. It needs to know what the medical practitioner iis doing and pay for it.
RK: Nandi, could you have a direct message to young people in their 20 and 30s. there is a lot of binging in terms of a lot of alcohol, fast foods, lack of rest, can you talk about the future life they are creating and the pressure it is going to put on their medical capacity to deal with those situations and their ability to remain in the workplace.
NM: One of the ways I would like to approach that topic, first of all, is to encourage everybody to have a medical home.
RK: Please explain.
NM: It ties into what you are asking. When you have a medical home, it is a space where you are one on one with your medical provider. And like I said, we are very inquisitive, we ask a lot of questions, but at the end of your visit we are able to say,
1. You are not sleeping enough
2. You’re drinking too much
3. You’re not exercising as you should
4. You’re not spending enough social (positive) time.
These are things that could speak of your evaluation and you need. You cannot be working from 4am because you got up so early to finish up an assignment and late in the night because you came back tired. You cannot say you work Monday to Saturday but then go back to the office on Sunday.
RK: Others are getting intO recreation for 24 hours.
NM: Failing to recreate affects your results at work. Sometimes it’s not a generalisation of don’t party so hard, don’t drink so hard, don’t smoke so hard… it’s more of finding that space where you are known inside out. When you walk in, the nurse is able to know where to start from. You need to have a place where you are validated, where people are concerned about your health. Where someone will tell you to cut back on the drinking and you don’t take it bad. People who will hold you accountable.
A medical home is extremely important for everybody. It’s a concept that is not known here. Here we jump from medical practitioner to another. Find a medical home where you are known inside out. where you can be aligned on a healthier and strigher journey. Where you can be cautioned when you are doing something that’s good for your health. Where they know everything about you.
RK: Talk to us as the parents. Some of us are modelling the behaviour that is being picked up by the young ones yet we know where it is leading.
NM: Right. Children are very impressionable. They see more than you think they see. They hear more than you think they hear. And they have that inherent desire to model mum or dad. And so when we aren’t at our best, when we don’t take care of ourselves, they are seeing. They are vulnerable. When we snap because we are tired and stressed, it hurts them. When they don’t spend the time that they should have. that they desire, they suffer.
To treat ourselves well, to do everything well is to the benefit of our children. Yes, we leave them with workers but that worker did not bear your child.
RK: That’s correct.
NM: That worker is not responsible for instilling everything responsible for that child. We need to be role models for those children. We need to positively teach them but also whatever we do, to make sure that whatever they see must be good for them.
Comrade Otoa: There is a question about blood types and the food you are supposed to eat?
Mary Apolot; Does your clinic have an insurance plan that can help patients to do an annual check-up?
NM: We are always open to ideas that might be able to help us to take care of more people. We have not looked at an insurance scheme at all. It’s something that has been on the table but we would like to have more people. For now we have UAP. But should we get a new way to help more people, we would be very glad.
Susan: Healthcare is very expensive, as a society, time has come to approach healthcare as a major concern. We can have schemes where we can start to put away money for the rainy day to pay for medical bills. Do you think that can be feasible?
NM: I don’t know whether that is a concept here but the idea of saving for the future would be very important. It would work even better for people who are already using insurance but would still cover a small segment of society. But still I would like to see how that is adapted in Uganda.
Albert: On adhoc medicine where you don’t have a family doctor, people need to be advised to have that one stop centre. People need to stop jumping from one clinic to another.
NM: I am glad you talked about this. This is not something that the government is going to create for you, it is you deciding to do for yourself.
Nshakira: on processed foods, what does Dr Nandi have to say about these improvements since most of them have additional nutrients?
NM: One of my professors used to say, eating as close to the ground as possible. It’s a phrase I use with my patients a lot because it’s something you can always fall back on. Eat maize on the cob as opposed to posho, meat in its natural form as opposed to processed. Eat your vegetables. Eat as close to the ground as you can, you will be a lot healthier.
Rwakatungu: We are spending so much time on screens, how is that affecting our health?
NM: Screen time takes away from physical interaction. The love. care. It may cause damage to your eyes. A headache maybe, does it take away from your sleep time? most definitely. Does it take away from keeping your brain involved in a positive way? Possibly.
But I feel the most important part it takes away is preventing meaningful interactions that were normal in yesteryear that are not not normal anymore.
PA: I would like to make a comment on insurance. Both Susan and Nandi touched on insurance practice in the US. Having lived there, I audited a lot of hospitals. In a country like Uganda where 80-85% of the population are in the rural areas, and live below the poverty lines, what it means is that insurance companies are businesses first and foremost. That explains why when COVID hiit, most insurance companies ran to quickly label covid as a pandemic and they didn’t cover pandemics or otherwise, they would be wiped out. and the reason is healthcare is a social good. My headache when I have one million shillings is the same as my mother’s with one thousand. The way insurance works is that few can cover up for the many. It’s a total fallacy.
In Uganda, we need to have a hybrid where the casic insurance is more like public cover and those who can add on can continue to have an additional cover. But we should not assume that insurance is willing to cover basic illnesses in a country as poor as ours.
RK: Wow! Talking to both of you, my takeaway is that the responsibility for your health lies with you. And only and only when you are healthy will you be able to;
1. To accomplish your dreams
2. To create the wealth that you so desperately want and enjoy it.
If you don’t take care of your health you will be out of here before you realise your dreams or enjoy your wealth.
I want to say thank you to Patrick Ayota, the Deputy Managing Director NSSF and Dr Nandi Mutema of the Clinic at the Mall for such a wonderful evening.
NM: Thank you for having us in this space, I wish everyone good health.
PA: Thank you Robert.