The Chogoria Pattern

“We are out of vitamin K?...and streptomycin?” “Yes, but her family can go try to find it at a pharmacy in Nairobi.” The Intern called Mugao, our team’s nucleus, explained the stock-out. “You know, they say that in places without many facilities, God works harder.”

It is amazing how quickly life circumstances can change in two weeks. I was dropped at my flat on the PCEA Chogoria Hospital grounds just 12 days ago. It was mid-afternoon and I needed to plan for dinner. That requires cooking. Which requires utensils. And a stove. And food. All of which require shopping. You get the point.

Meticulous planning simply cannot prepare you for some things. Fortunately, my transition into life in Chogoria has been eased by the guidance and generosity of many key people. Leonard, the hospital staffer who does the work of three people, along with his staff that look after housing, helped fix leaks and ensure my kitchen was equipped with essentials like plates, bowls, and a coffee cup. The Webbers, a long-term missionary family with three of the cutest kids under the age of five, recently in from Uganda, welcomed me with dinner last weekend and a tense game of Ticket to Ride. The three international NGO staff have helped with critical local intel and sorting out a water filter. After multiple failed shopping attempts in Nairobi by others, Dr. Yulu (one of the residents) returned from Meru a hero yesterday with a modem to get me online at my flat! And finally, Mrs. Ritchie, our program director’s wife, the physical therapist, homeschool teacher, and mother of six, greeted me within an hour of arrival and helped me with everything from my first two dinners to a coffee pot to key introductions around town to a block of cheddar cheese.

My flat was renovated and painted in anticipation of my arrival. I am getting into the routine of buying fresh vegetables and fruits in the markets, finding zucchini, green peppers, tomatoes, mango, and apples, and cooking in the evenings. My new housekeeper came Friday and worked especially hard on the first deep clean. She is also helping me with washing and chopping vegetables in addition to laundry. She laughed at my lack of cleaning supplies, but is helping me provision to this end.

News of the drug stock-out came during rounds in the adult female medical ward. The day starts with breakfast and coffee on my back porch, enhanced by the daily sounds of over a hundred serenading secondary school girl voices coming from their four-story complex just over the hedge at 7:30 a.m.  Then, lecture at 8 a.m. with all Interns, clinical officers (CO), residents, and consultants. After my introduction on Day 1, we hit rounds. There are usually roughly 50 adult inpatients on the medicine service, and thus they have split into two teams, each led by a Medical Officer (MO) Intern. One team has a Physician Assistant from the States, Derek (father Webber), and Dr. Ikunda the CMO of the hospital. My team has the Burundian Dr. Boaz, one of the two Family Medicine residents, and me as the consultant (attending). Rounding on roughly 25 patients can take until 12:30 or 1 p.m., but rounding on the entire 56-patient service, as my team did last Saturday, can take longer despite the earlier start. Supposedly our service is a bit busier this week thanks to transfers from the public hospital down the road in Chuka where the nurses have been on strike since Monday.

Our service has patients with pulmonary tuberculosis (TB), AIDS, cryptococcal meningitis, extrapulmonary TB including meningitis and pericarditis, uncontrolled diabetes or hypertension, congestive heart failure, rheumatic heart disease, nephrotic syndrome, and substance abuse including a suicide attempt with pesticide. It feels like our team averages one or two deaths per day. This occurs without the flurry of a Code Blue, without commotion. The patient is physically gone from their bed the following morning.

Depending on the source you read, faith-based health providers (FBHPs) provide anywhere from 20% - 50% of healthcare in sub-Saharan Africa. PCEA Chogoria Hospital is a 300-bed hospital founded in 1922 founded by Scottish missionaries. It is a faith-based health facility which accepts the Kenyan National Health Insurance Fund (NHIF) for both in- and out-patient care, although the newly implemented outpatient coverage of $1 per month per patient does not even cover the costs of a chest X-ray ($5). The insurance fund pays roughly $22 per night in the hospital, but the patients pay out of pocket for specialized imaging like ultrasounds ($12), CT scans ($80 - $100) or medications not found in our pharmacy. Of course, the hospital accepts cash as well, and the very basic inpatient costs start at about $5 to cover linens and food, which is usually porridge. If the patient cannot pay their bill on discharge, they are kept in-house until they can, increasing their debt to the hospital.

The afternoons are usually devoted to clinic time or reserved for teaching sessions with the residents. More time will be spent in the outpatient setting in the coming weeks, now that we have a rhythm with the inpatient service. Traditionally though, these MOs on the inpatient medicine service only see their consultant roughly weekly, so they are used to the autonomy. Our Intern has been here at the hospital for almost a year and is strong, but we will exchange his class of interns for a new one in the next couple months, depending on government postings.  

The evening ends with cooking dinner, reading, and usually more nighttime singing coming from the secondary school.

Early in the week, one of our 60 year-old patients on the female ward began complaining of bilateral leg numbness and weakness just as her discharge was imminent. She was closest to the entrance and near the middle of the 32-bed female ward. The curtains to separate patients are typically not drawn. Dr. Boaz asked in Kiswahili if she had been up walking around at all and she said indeed she had. Her two neighbors on her row laughed out loud! The patient smiled. “Really, how far did you walk?,” he asked. Our patient, busted, pointed to the other side of the small ward. The other patients and our team all laughed along.

In medicine, we are taught to recognize patterns. And just as you get used to hearing all the stories that neatly fit into a particular diagnosis, someone says something that just does not sound right. Alarm bells are raised and the search for disease begins. After two weeks in Chogoria, my daily home and work routines, and the pattern of seeing incredibly ill patients, has all started to feel familiar. But one thing that is hard to simply accept is the vast difference between the pharmaceutical, imaging, funding, and health worker resources available here and those found in higher income countries needed to protect privacy and afford this community sufficient health care to thrive. For now, we will welcome the distraction of mid-rounds laughter along with the patient innocently lying about her walking effort.