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.

Alternative Gifts

During this holiday season, and as 2015 comes to a close, many are searching for meaningful “alternative” gifts to give. While my expertise is in healthcare, let me suggest a few reputable organizations that are doing good in my hometown and around the world.

Austin

Hope Medical Clinic offers healthcare to political refugees settled in Austin through the United Nations’ resettlement program. Unfortunately, their initial health coverage in the form of Medicaid lasts only eight months. Then, most of these refugees from Bhutan, Nepal, and Iraq are left uninsured, yet needing the same preventive, chronic, women’s, physical therapy, and dental care that we all need. Hope runs purely on volunteer support and is a way to help refugees here in our own backyard.

The Austin PrEP Access Project evaluates patients for Truvada, to be taken as Pre-Exposure Prophylaxis against HIV. High-risk patients are evaluated by volunteer medical providers and monitored through regular blood draws funded by private donors. PrEP has proven wildly successfulin lowering HIV incidence in San Francisco, saving lives and saving costs for the local community.

Global

Samaritan’s Purse through its World Medical Mission funds short-term medical missionaries in settings requesting assistance around the world. This faith-based organization places physicians, dentists, and other personnel and supplies into resource-poor settings. I will be teaching as volunteer faculty at PCEA Chogoria Hospital’s new Family Medicine residency program through Kabarak University from February through June 2016. Samaritan’s Purse’s World Medical Mission is assisting in coordinating my documentation, travel, and funding. Follow this link, search for my name, and be assured your tax-deductible funds will go to essentials such as travel, food, visas, and my Kenyan medical license.

Medic to Medic funds education for physicians in low-income areas. The US has 2.5 physicians per 1,000 people; Malawi has less than 0.1 physicians per 1,000. This is a sustainable way to fund the education of health workers where they are needed most. You could fund a medical student’s tuition and all supplies for just $750 per year. A close UK-based physician friend of mine is an organizational leader.

SEED Global Health is a public-private partnership with the US Peace Corps designed to place American physicians and nurses in medical/nursing school and residency training settings as faculty to assist in educating physicians, nurses, and clinical officers in low-income countries. Being a uniquely American NGO, this organization funds some educational debt repayment for each year of service. I will be teaching with SEED from July 2016 through June 2017.

In my opinion, these three global options all represent sustainable steps towards universal health coverage in some of the poorest areas on the globe. Please join me in supporting these servant organizations. Have a wonderful holiday season and a Happy New Year!

A World of Difference

“You should try the cheese and chocolate,” she said. “Cheese and chocolate?!” A confused facial expression accompanied my response. The local Stone Town woman smiled warmly under her ornate hijab and instilled confidence in this Zanzibar pizza chef – she was a regular. I couldn’t decide between the savory tomato, meat, and cheese or the sweet nutella, chocolate, and banana. She’d made my decision for me. “Don’t worry,” she said as she walked off with her pizza in hand, “you’ll try it anyway - this one’s on me.”

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The first few times I traveled in sub-Saharan Africa, it was only natural to be confronted with how different this was from my world. There were people living in conditions like I’d never seen, receiving healthcare in clinics and hospitals considered substandard in Texas, and those with cultural practices and beliefs that seemed so odd. I was confronted with these differences each day, smelling the air, hearing the sounds, feeling the heat, stomaching the tastes. But following a more prolonged stay, becoming more comfortable with the setting, and after wading past the differences, I’ve started to appreciate all of the similarities. Why is the focus so frequently on our differences?

In American politics, we focus on what distinguishes one candidate from another, bringing us to the polarized place in which we find ourselves. In religion, one hears the call to prayer and sees the dress and thinks about the divergence of Muslims from Christians. In healthcare, physicians are trained to observe or judge patients based on differences in culture, gender, generation, or sexual preferences. And in current events, the media highlights the many challenges our dissimilarities have brought us. Perhaps if our global village started to focus on our similarities, our mutual reliance on a healthy economy and environment, and our collective desire for basic necessities, we would avoid much of the needless conflict we see ourselves in today.

When Ebola first set foot in the U.S., we were already 8 months and about 4,000 cases into the current epidemic. It was already 10 times larger than any prior Ebola outbreak. And then the West took notice. We were different from Liberians, until we were in the same boat. Ebola was a world away, until prevalent international travel put us on the same globe. Then we started a furious search for a drug or a vaccine. Lower resource countries don’t have the market power to create the demand to inspire solutions to many tropical diseases. Instead we wait for vocal advocates such as Bill Gates, Bill Clinton, or Margaret Chan to push donors into these arenas to find an answer.

The silver lining of this experience with Ebola ought to be a resurgence of civil debate on how we spend our abundant resources, with renewed focus on the societal good.

The last two weeks I spent learning predominantly about Palliative Care and HIV/AIDS care in Uganda. Our week at Hospice Africa Uganda involved learning about the expansion of oral liquid morphine access for pain control in terminally ill patients, followed by home visits to those receiving home hospice services. Our home visits involved two women dying of cervical cancer, dealing with pelvic pain and urinary incontinence. They simply wanted pain relief and urinary care to die with dignity and in peace. Much like patients in the U.S. 

These patients many times get confused by difficult drug regimens, despite only having ibuprofen and morphine for pain control. Primary care doctors, nurses, and clinical officers at times are not trained to refer to Palliative Care at the appropriate time. There is also a shortage in these providers to competently prescribe this powerful drug, which lowers the amount of patients who can benefit from it. And Hospice Africa Uganda is on the brink of a severe funding shortage, with 70% of their funding coming from external donors, much of that being cut in the near future, leaving inadequate funding from the government to keep the service up and running as it is now. They are the only producer of oral liquid morphine for all of Uganda. All of this – poor funding, health worker shortages, patient education challenges – we deal with in the U.S.

The HIV/AIDS epidemic is showing signs of improvement. The number of new cases each year is dipping, but due to a lack of functioning health facilities and a severe shortage of health workers, many are still diagnosed late, dying of largely preventable causes. Mulago Hospital, the national referral hospital for Uganda is overcrowded and under-staffed, but still the best place to handle complex cases. There, we rounded on patients with advanced lymphoma, visceral leishmaniasis, advanced lung cancer, and toxoplasmosis. The chemotherapy or proper treatment is largely unavailable or too expensive, and thus these patients rely on family to take them home and care for them, without the help of the public health system. Despite seeing this for a couple months now, it doesn’t make it easier. In the U.S., we too still have many without basic health insurance and poor access to primary care services, thus they present late in their disease, which can lead to worse morbidity or even mortality, and is more costly on society.

When I return home from traveling and studying this time, I’m sure I’ll be asked about the differences. But in addition to telling of these, I plan to speak of the many similarities, and how we are in this together. Whether we plan to bring the current Ebola outbreak to an end, or to control tropical ailments with basic public health efforts, or plan to alleviate poverty in any setting, it may just be in our interest to focus on how similar we are, rather than taking the easier route of considering us all so different.

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My cheese and chocolate pizza was ready around the time my friends caught up to me circulating the nighttime food market on the water’s edge. We each tried a bite and she was right - it was a hit. So we ordered three more to finish off our dinner.

Morning

Morning view for coffee and Al Jazeera, WSJ, and Health Affairs reading.