Monday, April 21, 2014

Camille Writes About the Hospital

(Or, you can scroll to the bottom for some Easter pictures of Eric.) 

The male ward
Naivasha District Hospital, a level IV government hospital, has about 200 beds.  There are 10 or so medical officers (doctors that have completed a general internship and are working as general practitioners, “paying back” the government for their medical education), 30 clinical officers (the equivalent of physician assistants in the US, who, along with the nurses, handle nearly all of the outpatient care), 20 clinical officer interns, and 14 medical officer interns.  We have four “consultant” doctors who oversee all of the medical officers and interns (one surgeon, one obstetrician, one pediatrician and one internist).  We have nutritionists, physical therapists, and a psychiatry nurse.  We have two sets of operating rooms, a pharmacy, outpatient clinics, a lab, a public health office, a physical rehabilitation center, and 4 wards:  male, female, pediatrics and maternity, which includes a unit for newborns who need special care.

We have one oxygen concentrator and one nebulizer per ward, an x-ray machine, and two ultrasounds.  We have most of the medications on the WHO essential medicines list.   We have ventilators for surgery only.  We have two ambulances, which are primarily for transferring patients to and from other facilities. 
Patient meals

Each ward has about 30 beds, and is staffed by 2-4 nurses.  When the census is high, as it frequently is, patients are two or three to a bed.  Medications are theoretically handed out three times a day, but with so many patients to care for, it often ends up happening twice, or maybe even once.  Interns do their own blood draws that must be brought to the lab by noon.  Results are generally not reported until the next morning.  We can get a CBC, some electrolytes, blood cultures, basic urine tests, HIV tests, tests for Cryptococcus, and blood cultures.  Last month we got a GeneXpert machine from the government, which lets us test for TB more accurately.
We treat many of the same diseases here that are common in the US, and some that are not:  Heart failure, hypertension, diabetes, pneumonia, cancer, major trauma, strokes, sepsis, GI bleeds, psychosis, gallstones, gastroenteritis, appendicitis, pancreatitis, alcoholism, TB of every variety, typhoid, malaria, rickets, malnutrition, hippo attacks.

Things break and run out a lot.  The oxygen concentrators frequently don’t work.  We run out of jelly for the ultrasound machine, reagent for labs, gas for the ambulance, money for the power bill. 
The residents who come here from the US are usually prepared for a lack of resources.  They expect limited laboratory capacity, a basic formulary, and no high-tech imaging.  They are prepared to use limited means to diagnose and treat very sick patients.  But they are frequently unprepared for overworked, underpaid, and deeply demoralized hospital staff; nurses, interns, doctors who seem like they don’t care.  Why did a septic patient not get fluids for three days?  Why hasn’t a blood pressure been checked in a week?  Why were no meds given over the weekend? 
During ward rounds one day, the consultant (or in-charge) physician turned to the team of medical and clinical officer interns he rounds with once a week.  “What is the most deadly disease in the world?” he asked.  Everyone was silent.  “HIV?” someone answered.  “Cancer?”  “Poverty!” he said, and turned to the next patient. 

Patient chart
He was verbalizing the feelings of many of the doctors and nurses:  that we don’t really have a chance, that we’re defeated before we start.  And in many situations, he’s right.  But this implicit acceptance of the inevitability of poor outcomes for our patients is troubling.  You are poor, therefore you are in a poor hospital, and nothing we can do will change your ultimate fate of ill health, suffering, and early death. 

Although the diseases and patients are different, Kenya does not differ all that much from the US in this defeatism.  Health care in the US is also rationed on ability to pay.  In the private hospitals in Nairobi, just as in private hospitals in the US, no one goes without oxygen. There are enough nurses for every patient, there are MRI scans, chemotherapy, dialysis, stat labs, and even, occasionally, organ transplants.   

EKG machine
Global health work is, at its best, a quest for equality.  What frustrates the residents is not just the glaring inequality they confront, but the demoralization and perceived complacency of those who deal with it everyday.  And yet the same complacency is endemic in our own country.  Here in Kenya, perhaps, it is a little more blatantly, painfully in our faces.  But in both countries, the poor get worse care.  They suffer more and die younger. 

Drug cabinet
Everyone has a right to be healthy.  When we get sick or hurt, we should receive medicines or procedures that will restore (or at least improve) our health.  Health care works best when we are all on the same team, when we’re all part of a system that’s population-driven and evidence-based.  This is not to say that customized or personalized care is wrong or inappropriate—the best health care is both custom and personal.  But market-driven care is not good care, nor is it cheap care.  As demonstrated every day in both Seattle and Naivasha, tiered health care is expensive financially and, more importantly, morally.  Here in Naivasha, the human cost is unavoidable.  What kills our patients isn’t scarcity, but inequality.

That was heavy.  Your Eric fix for the week:  Easter!

We went to play with our neighbor's baby bunnies.
Bunny is soft.
Easter egg hunting with Geoffrey and Matilda

Should I put them in my mouth one at a time or simultaneously?  


  1. My Daughter in law Doc.--I truly hope that you and Dan speak to the Berkshire School community next year, and that you drive home the message you so vividly displayed in this blog entry. Our kids need to hear this and you are the person that can best communicate it. Danny, Eric, and Camille were right to travel to Kenya and give up a year of saving $ to learn about and therefore help save the poorest of people. I could not be prouder of three people than I am of you guys. Thanks for being who you are.
    Bill Gulotta (Dad-In -Law -- or DIL from short.

  2. Shared this with some of the hospitalists and nurses at our hospital - wow! Puts a whole new perspective on the quality of health care in the US and the expectations that come with this - also the frequent sense of entitlement. Dad and I are so proud of the good work you and Dan are doing and the experience you are living to the fullest. Looking forward to hearing about Dan's adventure climbing Mt. Kenya! Love all of the Eric pics (of course) - can't wait to hug him again. Love, MOM

  3. My class liked your blogs guys