The Dry Season
ENCOUNTERING LIMITATIONS AND PROGRESS AT A KENYAN HOSPITAL.The New Physician
As we made the four-hour ride northwest from Nairobi to Eldoret, I was shocked to see zebra grazing along the road. Suddenly, I realized I was in Africa.
I was a bit jet-lagged from the 20-plus-hour flight, so as my driver dodged all the potholes, I was more fascinated by the roadside stands than our many close calls with oncoming traffic. These stands didn’t seem to have anyone running them, but if you looked carefully, you could find the vendors hidden in the shade of a nearby tree.
It was late March, and the Rift Valley in western Kenya awaited the beginning of the rainy season. A part of the world made famous as the birthplace of humanity, the valley is an agricultural area today. While some farmers tended to their livestock, many others simply waited around for the rains to come.
I was traveling to Moi University Faculty Health Services in Eldoret, where I would spend three months studying at the Moi University Teaching and Referral Hospital. Moi, like other medical facilities in Kenya, is lacking in basic services; however, it is also a teaching facility that graduates 40 badly needed physicians each year.
The lack of medical services makes spraying for mosquitos necessary. Endemic malaria poses a constant threat to the area, especially with the approaching rainy season. Some people, including two of the medical students with whom I was staying, had malaria so many times that they reacted to it just as they would with a cold. I, on the other hand, was terrified of it, and I took my weekly mefloquine religiously.
The frustrating part of malaria is that it would not be such a major killer in Africa if people could simply afford the medicine, but that is one of the many barriers to health care on this continent.
Since there is no such thing as health insurance in Kenya, and the government does not provide extensive health services, the treatment that a patient receives is entirely dependent on what he or she can afford. In determining treatment, Moi clinicians would ask patients what they could afford. Starting with the optimal treatment, clinicians would work their way down the list until they found something that the patient could pay for. Because of this, many basic drugs like fluconazole could only be given to the wealthiest patients. It may seem cruel, but Kenyans believe a bankrupt hospital can treat no one, so they struggle on despite a host of limitations.
For example, bed space is limited, and sometimes two people shared a bed. There is a tuberculosis (TB) isolation ward, but the number of positive cases almost always exceeds its capacity, so the overflow is put in with the rest of the ward.
The high incidence of TB is due to the high incidence of immunosuppression, primarily caused by HIV. There is still such a stigma associated with the disease that HIV-positive individuals are referred to as “seropositive” or “ELISA-positive.” One fifth-year medical student came down with TB last year and suddenly became ostracized by his classmates—even with the medical profession, the stigma persists.
Diabetes is common there, too. In the medicine ward, the stories were all similar. Either the patient couldn’t afford to buy the insulin or was unable to refrigerate it properly. Common blood sugar levels for admitted diabetic patients ranged around the 300s, assuming that sugar strips could be found to get a reading, which never could be done on weekends for some reason or another. Even after their blood sugars were normalized, many patients hung around while they tried to figure out a way to pay their hospital bills, for they could not leave until they did. One man in his early 20s, standing at least six-and-a-half feet tall sat around several weeks in his pink, breast cancer awareness shirt. He occasionally went to the snack stand outside to buy a Coke, apparently unaware of his dietary restrictions.
Many patients waited for care. A man with pneumothorax sat in agony for days as we tried to convince him we needed to put in a chest tube. On the morning that we were going to finally put one in, I saw hospital staff rolling out his corpse before rounds. No one would know exactly what he died from; autopsies cost money.
The medicine practiced at Moi is with minimal equipment. X-rays could be done, which are usually only posterior–anterior and not lateral, but there are no view boxes, and films must be read with natural light. The CT-scanner worked fine, but very few people could afford to have it done. Lab tests were sometimes inaccurate, and on some days either everybody or nobody had malaria-positive blood smears. To get the more sophisticated tests, a patient would be sent to the Nairobi Hospital Lab.
The operating room had its troubles as well. A large, benign jaw tumor in one man was inoperable, because the plastic surgeon needed to resect it wouldn’t be in town until November.
In the outpatient clinics, there was an emphasis on immunization. During one afternoon, 95 doses of meningitis vaccination had been acquired to give to the hospital workers on a “first-come, first-served” basis. Within an hour, the vaccines were gone, but the people kept coming.
The clinics did more than just immunize, though. They provided counselors as well. Because of the emphasis in rural Kenyan communities on having large families, many women came to the clinic seeking contraceptive counseling, and most did so without their husbands knowing. The method of choice among them was an undetectable, injectable Depo-Provera shot.
Despite the difficult circumstances under which medicine is practiced in Kenya, things are taking a turn for the better. When four faculty members at Indiana University were interested in beginning an extensive collaboration with a foreign medical school, they were drawn to the new program at Moi, which, since its inception 11 years ago, has established an internationally reputable medical school that produces quality physicians adept at practicing medicine in the constrained environment of a developing nation.
In 1989, Moi and Indiana teamed up to begin a cooperative program. Over the past 11 years, they established the first long-term collaboration between an American and a sub-Saharan university. Due to the resounding success of the agreement, the schools renewed the 10-year contract last year, and they hope future efforts establish other cooperative programs in the region.
Other progress is also evident. Four additional operating rooms have been recently built at Moi to meet the high surgical demand. And collaborations with international medical programs like the one at Moi assure that the faculty and students are exposed to the latest advances in medical technology, even if the accessibility of such technology for this patient population is several years away.
Dan Handel is a third-year student at Northwestern University Medical School in Chicago.