Bilateral Life-Changing Experiences - The Student Perspective - Kara Davis

Before I left for the rotation in Kenya I wasn’t sure what to expect. I knew that it was going to be a life changing experience. The rotation by far, has exceeded all of my expectations I have had from a rotation. This rotation has been one of the most challenging, inspirational, and influential educational experiences that I have ever witnessed throughout my entire twenty three years of life.
This rotation was challenging for me because this was the first time in my life that I have been across the country away from both my family and loved ones. There were barriers of communication which made it difficult to correspond back and forth. Nevertheless, this particular challenge began to cease after my heart went from worrying about home to caring after all of my patients and seeing the poor conditions of the hospital in which we would be practicing. I can still remember my first day at the hospital as if it were yesterday. Taking our first step into the ward, there was such a distinguishing smell that would hit you hard and make you feel sick in your stomach. It was very disheartening and one had to truly fight to not shed tears in front of the patients. I thought that it was imperative for me to maintain my poise so that the patients could uphold their dignity. I didn’t know whether or not the conditions that the patients saw themselves were even poor at all, for this is all that they know. I just kept reflecting back to the environment of our hospitals back in the States. Here in Eldoret, where there are eight beds with two patients per bed in one cube, this would have been a single or double patient room in the States. I have seen patients who are malnourished, in pain, patients who are actually dying. Come to think of it, I have never seen a patient in such conditions like this in the States. Patients with tuberculosis are spread all throughout the wards whereas in the States they would be in isolation. Worst of all, I have seen patients without life, patients who have passed away and their bodies become stiff as one tries to transport their body from the ward to what I am assuming is their mortuary. My heart goes out to all of these patients and I consider myself fortunate enough to be apart of such a collaboration between Indiana University-Purdue University and Moi Hospital, even if it is only for six weeks. Since I knew that we were going to be here for a short period of time, I aspired to put 110% effort in all of my work pertaining to Pharmacy and the hospital.
There were days where I became frustrated because patients were not receiving their medications and many drugs became out of stock. I found myself becoming more aggressive with the nurses in questioning why a certain medication wasn’t given or stressing the importance of giving medications “stat”. It was amazing because after a week or so, I saw the Kenyan interns on my team taking the same approach with the nurses, this was essential because nurses are more likely inclined to listen to them than they are to me, “the Muzungu”. Nevertheless, what I care about is the end result, patients receiving their medications, and not necessarily how we get there whether it is through me or the Kenyan medical staff. I have solely made decisions about my patient’s medications and treatment plans that I know I wouldn’t be allowed to if were practicing in the States. It may take awhile for few to realize, but here you get the sense that if you don’t take the necessary steps to optimize treatment plans, no one else will. I even shocked myself at some of the changes I recommended, or therapies I interchanged. I was faced with many days where I became saddened and had to take a moment outside to regain self-control. I’ve seen patients with lymphomas, patients with stage four heart failure, patients with all types of opportunistic infections, and patients with HIV/AIDS, etc. Back in the States, most of the patients that I have seen would be in the Intensive Care Unit (ICU), or the Progressive Care Unit (PCU), and not mixed throughout the medical ward. I know that I have seen and done things that not a lot of pharmacy students will get the opportunity to. It is wonderful seeing all of the ideals and aims of AMPATH come to life. I have had the opportunity to work in the diabetes clinic, see a satellite clinic and know there are plans on developing a future Coumadin clinic. I am excited to see where healthcare in Kenya will be within the next five to ten years.

I was very fortunate to have been apart of such a great medical team. It wasn’t as if I were just some voyeur on the team observing quietly in the background. I actually had an active role in each of my patient’s treatment plans. I am very intrigued with this practice. Most importantly, I am intrigued with this rotation because it offers a bilateral exchange between both the American and Kenyans. I have to admit, before I came to Eldoret, I assumed that this rotation was going to be a unilateral exchange from the Americans to the Kenyans. But what I have found is that I have learned so much more. Yes, it is true that Kenyans have some lack of resources (i.e. certain medications, laboratory tests, space, etc.); however, my consultant and some of the interns here practice at such an impressive level of acuity for care. We all (including medical students) can learn a lot from how the Kenyans perform and diagnose varying disease states just from physical examinations. My consultant, Dr. Siika, even included me in findings of certain clinical presentations on some of my patients (i.e. hepatomegaly, hepatosplenomegaly, and ascites). I was challenged from my consultant, and even challenged back. I was given assignments from my consultant to further develop my clinical knowledge and although I may have questioned the intent in the beginning, I now truly appreciate all of the time and effort put into me because I know this will only make me an improved Pharmacist in the near future.
One of the things I truly admire about this rotation is the relationships that are developed throughout our time here. I have developed friendships with Kenyan and American medical students, medical residents and even Kenyan pharmacy students. I can’t say that I have even had a preceptor with more passion about his/her job than Sonak. One of the reasons I chose to pursue Pharmacy as a career is that I have a passion for people and take a special interest in the care and well-being of others. I am very extroverted and love developing relationships and a sense of community with my patients. It is wonderful working under someone with the same beliefs about patient care. His drive is a motivation and inspiration to work even harder and contribute to making a difference here at Moi. The “buddy system” that he developed between the American and Kenyan pharmacy students will certainly go a long way and definitely contribute to developing both professionally. This rotation was very thought provoking and intellectually stimulating. I have gained so much knowledge and I am intrigued to share my experience with colleagues, future preceptors, and loved ones upon my return.
This has truly been a humbling experience for me and I am grateful and thankful that I have been given this opportunity. It touches my heart everyday, some of the things that I have seen and some of the interactions that I have had with the people here. I have fallen in love with Africa. It is overwhelming that in a land so beautiful, so much pain is taking place. Six weeks was not enough time for me and it is my desire that I come back and help in any way possible. When I was in high school, I attained a Certified Nursing Assistant license and that experience taught me to be so much more appreciative of life. I have been faced with yet another life-changing experience that far surpasses anything I have ever dealt with and for that I will always hold dear to my heart. Words cannot describe how this rotation has made me feel. From this, I have become a better person, a better Pharmacist, a better daughter, a better sister, a better friend, etc. I have also learned to become more confident in myself. Above all else, what are most important are the patients. I truly feel in my heart, that this program exemplifies never-ending commitment to sustaining life and improving health care practice in Kenya. I know that we are only here for six weeks, but the greatest thing about this rotation is that after we leave, other Purdue Pharmacy students will arrive and carry on the continuity of care and I know that this in itself will go far.

Kara Davis, PharmD Candidate, Class of 2008

Purdue University School of Pharmacy

The Student Perspective - Colleen Drasga

A lot of times when people go to dramatically foreign places, at the end of their stay they say “Its very different, but still very much the same.” After four weeks here, I would agree with the first part. Everything here is different, the hospital, the smells, the transportation, the dancing, even the milk is different. Differences aside, my stay in Kenya has been unbelievable and I feel so blessed to have had the opportunity to come here.
The experience has been both challenging and rewarding and nothing has embodied those two feelings more than rounding at the Nyayo wards. While I sift through the charts, track down missing treatment sheets, and request labs for the third straight day I switch from feeling like I’m really making a difference in patient care and feeling like I’m watching a car wreck that I’m powerless to stop. It’s very hard to see patients suffer day after day without the ability to fix the situation. So many problems could be solved if care here paralleled care back at home. That being said, good things are going on in the hospital and focusing on these makes each day more than worth while.
Some days the most I feel I do is ensure a patient gets fluids and check that their treatment sheet is present and accounted for. Other days, I’m part of making sure that a patient receives TB medications that mysteriously disappeared from the treatment sheet, starting a patient with a CD4 count of 5 on anti-retrovirals, getting needed chemotherapy or an emergency surgery consult. Needless to say, the latter days are more rewarding. Claiming that I was responsible for all of these interventions would be both selfish and disheartening. It is selfish because I my role in many of these situations is strictly the whistle blower, and disheartening because I’m leaving in two weeks.
Luckily the people who are truly responsible for the good that goes on are not transitional. Both Americans and Kenyans involved with AMPATH are so dedicated to improving health care in Eldoret. It is such an inspiration to be working with people who are here to make forward and lasting changes in Eldoret. While my future is anything but clear, I don’t see myself returning to Eldoret. However, I know that Eldoret will stay with me. The red dirt will wash off and the memories of the smells will recede but I hope that the call to action and the inspiration to change will stay with me.
I started this entry mentioning differences. The main difference is that I have been given the opportunity to see first hand the difference one person can make in other’s lives. I hope that when I go home, I can do that as well.

Written by Colleen Drasga,
PharmD candidate 2008
Purdue University School of Pharmacy

Adherence Counseling and the Buddy System

Today, we spent the afternoon at the Imani Workshop. The Imani Workshop is one of the many unique programs offered by the comprehensive HIV care approach utilized by AMPATH. The Imani Workshop provides income security to the HIV positive patients receiving care through AMPATH by employing them to make a wide variety of crafts that are sold all over the world. The pictures in this blog are of the actual warehouse where many of these products are made. Today, the pharmacy students and I went to the workshop to provide these patients with counseling and various teaching points about their medications and disease. As you can see the pharmacy students were quickly integrated into the group of patients as the patients/employees were all very eager to take advantage of this opportunity to ask our students about the intricacies of their medications. One of the other things the pictures illustrate is our Kenyan buddy system. To further enhance the collaboration that is present at every level of AMPATH, the Purdue pharmacy students have been paired up with Kenyan counterparts from the University of Nairobi, School of Pharmacy. This collaboration has allowed us to improve care for patients by combining the advanced knowledge of the Purdue pharmacy students and the hands on Kenyan experience of their counterparts from Nairobi. At the same time, the Purdue and Kenyan students are able to engage in a bilateral exchange of information as they attempt to address many of the patient issues they face on a daily basis. They currently collaborate on rounds, counseling, and topic discussion. One of the common themes throughout all of these blogs is that this is just the beginning and I fully expect that many great things will come from these simple collaborative partnerships. I look forward to seeing the impact the next generation of Purdue and Kenyan pharmacy students will have on patient care.

Julie Everett Nyongesa Pharmacy

On November 8, 2007 we celebrated the renaming of the Purdue Pharmacy to the Julie Everett Nyongesa Pharmacy. As you can see from the pictures, we celebrated this joyous occasion from the balcony of the AMPATH center with over 70 close colleagues and friends from AMPATH. The greatest part of this celebration for me was the speeches of Beatrice Jakait (AMPATH Pharmacy Department Head) and Joe Mamlin (AMPATH Co-Field Director). While I’ve always heard all about the great things Julie has done and all her contributions to the program, it was great to finally have the next generation of AMPATH members (including myself) take a moment to really reflect on how far this program has come because of her.
As we continue to watch the program grow from its humble roots, we will now have a constant reminder of where we came from whenever we look at the Julie Everett Nyongesa Pharmacy. The celebration was capitulated by the announcement from Joe that PEPFAR has decided that they will award us the $60 million grant that will allow AMPATH to continue to grow and serve patients. While I never met Julie and only exchanged one email with her, from all I’ve heard about her, I have a feeling there are very few things that would have made her happier than knowing the work she started will continue for many years to come through this $60 million grant.

My favorite picture, however, is of the new generation of the AMPATH Pharmacy staff happily filling the tackleboxes (started by Julie) under her smiling picture.

The Student Perspective by Jeremy Rife

Written words simply cannot describe my experience in Kenya to the fullest. However, they are a start. My most rewarding experiences in Kenya were not necessarily the rounding that took place at the hospital. This is not to say they were not important and learning did not take pace, but only to say that even better things transpired. There are three things that I will always, always remember about Kenya and hope to relish all of them in the near future: the IU (or I should say Purdue) Kenyans, the Sally Test Centre and Children, and Moses.

Purdue Kenyans

I met more great, close friends during my experience in Kenya than I ever imagined. Mwangi, Kelvin, Ken, Dennis, Calvin, Benson, Francis, Javan, and taxi Peter were a huge part of the reason I never got homesick during my two month stay (as well as my fellow Purdue colleagues) and also the reason I am now "Kenya" sick. The generosity and kindness they showed towards me (and everyone) was unforgettable. Each and every one of them would drop anything they were doing in order to assist anyone who asked a favor of them. Talking about them could reach novel-length, so I will end by saying a huge thank you from all the Purdue kids. You will continually be missed, and I can say with the utmost of certainty that I will be back to see you all again.

Sally Test Centre and Children

This place was what I looked forward to most at the end of rounds. Even if I could only stop in a visit for a short 20 minutes, it made the day so much better. The operation is smoothly run by a great staff and volunteers. Just a small amount of one-on-one attention with any of the children at the centre also made their day even better. Whether it was holding them, playing a game of Memory, singing with them, or even just receiving a hug around the legs from them could turn a poor day into a great day. Putting a smile on their face put a smile on my face. Saying goodbye to them was difficult and rewarding all in one.

Moses

Moses is a 10-year old child who I met many weeks ago in front of the Nakumatt store. He is a street child. I do not know what it was about him that triggered such an intense response, but I immediately wanted to make his life better. His story is heartbreaking. His mother and father have both passed away, and he lives (when he's home) with his grandparents and aunts along with 10 or more other children. His relatives also beat him. It's very easy to see street children and assume that living on the street and sniffing glue was their poor decision. However, after hearing the stories of a few of them, the lives they are running away from are far, far worse than what the street offers them. Along with the help of Mwangi, Kelvin, and Francis, we are in the process of removing him from the streets and getting him into a good school. Francis and his wife have generously offered to adopt him as their child. I will provide for him financially. Although he is currently still on the streets, I have complete faith that by January semester, he will be back in school. I wish I could help more of them, but I simply cannot. The financial portion is nothing compared with what Francis, his wife, Mwangi, and Kelvin have done and are doing.

A story I heard from one of my fellow colleagues comes to mind:Once a man was walking along a beach. The sun was shining and it was a beautiful day. Off in the distance he could see a person going back and forth between the surf's edge and and the beach. Back and forth this person went. As the man approached he could see that there were hundreds of starfish stranded on the sand as the result of the natural action of the tide.The man was stuck by the the apparent futility of the task. There were far too many starfish. Many of them were sure to perish. As he approached the person continued the task of picking up starfish one by one and throwing them into the surf.As he came up to the person he said, "You must be crazy. There are thousands of miles of beach covered with starfish. You can't possibly make a difference." The person looked at the man. He then stooped down and pick up one more starfish and threw it back into the ocean. He turned back to the man and said, "It sure made a difference to that one!"

Written by Jeremy Rife, PharmD Candidate 2008, Purdue University School of Pharmacy

Lilly Lazarus Effect

For anybody who has worked with AMPATH or HIV patients, they know exactly what I am referring to when I speak of the Lazarus Effect. Everybody who works in this setting has had the opportunity to witness first-hand how antiretroviral medications for HIV have brought back patients literally from the dead. We often call this revitalization the Lazarus effect as patients who were previously wasted and preparing for their funeral return to living normal lives just months after starting life-saving HIV medications which can now be purchased for less than $300/year. Personally being a part of this on a daily basis is still one of the most gratifying experiences I’ve had in my career and after seeing Joe Mamlin’s (70+ year old program director from Indiana Univ) continued enthusiasm it doesn't seem like this ever gets old.
With all the attention that has been given to the HIV epidemic, it sometimes becomes difficult to address the needs of patients who aren’t suffering from HIV. This “stovepiping” of healthcare resources sometimes prevents us from addressing the whole host of healthcare issues patients from resource poor settings face. It is through the infrastructure AMPATH has created that we hope to begin to start creating a more comprehensive approach to addressing the entire healthcare system and not just HIV.
In typical AMPATH fashion, everything starts with one patient. I’d like to recount the story of one of the patients I’ve been caring for since the first day I arrived at Moi Teaching and Referral Hospital. This one particular patient was situated in the middle of ward and his chart label read “Unknown African Male”. Day in and day out we would pass over this patient as he was in a completely catatonic state and did not respond to any stimuli or have the ability to communicate with us. He was suffering from catatonic schizophrenia and would essentially remain stuck in whatever position we placed him in. He was essentially stuck in a freeze frame for the first two weeks he was in the hospital. The only reason he even made it to the hospital was through the kindness of passersby who saw a motionless young boy staring off into space on the side of the road.
About a week into his hospitalization we were finally able to acquire Zyprexa (olanzapine), an atypical antipsychotic agent which had previously not been available in Kenya. The only reason we had this medication was through the generosity of an Eli Lilly donation program where they provide us with certain Lilly medications free of charge. This medication was added to his regimen of electroconvulsive shock therapy and we had not noticed any signs of improvement in his status and we were starting to lose hope as he continued to lie motionless in his bed.
I returned to rounds on Monday morning, as usual, and our team went through our usual habit of going over the care of all of our patients. We passed by his bed once again and noticed that he wasn’t here. The rest of the team and I immediately assumed that he must have passed away. As we proceeded to the next bed, we noticed an excited young boy sitting with another patient. This boy was writing papers and telling stories in perfect English to the other patients in the ward. We slowly began to recognize that this was the very patient we had virtually lost all hope for. The therapeutic benefits of Zyprexa had finally kicked in and the patient had returned to his normal state. He was also able to uncover the mystery of his identity and narrate his whole life story. Like so many other abandoned children in Kenya, both of his parents had passed away and this 15 year old boy was struggling to go to school and help raise the his orphaned brothers and sisters. He was on his way to school when he was frozen in this catatonic state waiting for the bus. I can’t even begin to accurately recount the impact this one boy had on our entire team. Our entire team was reinvigorated with hope as our efforts in conjunction with the generosity of Eli Lilly had saved this child and given him the opportunity to potentially live a normal life. I’ve never seen an entire team of practitioners smile for an entire rounding session. The more we talked to him, the more we realized how special he was. One of his first questions to us was when he could go back to school. His love of education was evident as he was by far one of the most well educated 15 year olds I had ever encounered. This is one patient I will never forget and it is a patient I will always remind myself of when the frustrations of practicing in a resource poor setting start to get to me. He will serve as a constant reminder to me of what is possible through collaboration and the linking of first world wealth and resource poor hope. Let his picture at the beginning of this blog serve as proof of the truly immense power of collaboration.

The Joys of Precepting

One of the best parts of my day is coming back home to dinner and hearing all the great things that the pharmacy students have done for patients on the wards. All the work and effort the pharmacy students have been putting in has clearly been paying off for patients. The great part is that this is just the beginning. Despite all the great things I have been hearing, the pharmacy students still insist that they feel like are struggling on rounds and not able to do all the things they want to. I look forward to seeing all the things Purdue’s involvement in this program will do for patients.

This Friday, the students had the day off to go on a safari. As I was looking over the medications for all the patients on all the wards, the difference in the level of prescribing was clear as the errors I noticed on a daily basis just several weeks ago were now a thing of the past. I feel confident that we've only begun to scratch the surface of our potential.

Moving Forward

In only one week of working, the students have quickly realized the many areas of improvement which make the delivery of healthcare inefficient here in Kenya. We are currently formulating a wide variety of research projects which will hopefully bolster the delivery of care in a variety of ways. Through the generosity of Eli Lilly, we have received thousands of dollars worth of free medication including psychiatric drugs, insulin, and chemotherapeutics. However, we have never really checked to see the impact of these medications which were previously unavailable in Kenya. We are currently developing proposals to help retrospectively capture the impact these medications have had on patient care and also to help bolster our ability to acquire future donations to manage not only HIV but the whole constellation of maladies patients face. The Kenyan staff has been incredibly helpful in this process and the pace at which we are able to gather this information is truly remarkable. We are also beginning to consider ideas to optimize the way we manage patients with chronic diseases. For true long-term development we must use the increased funding opportunities for resource poor settings because of the HIV epidemic as a catapult to improve all aspects of healthcare management from chronic diseases to life threatening acute illnesses.

Student Arrival

The students have finally arrived and to start the rotation we thought it would be a great idea to start with a topic discussion on research ethics at the Great Rift River Valley where it is postulated that civilization began. The students will begin rotating throughout Moi Teaching and Referral next week and I will be back to rounding on the wards. The excitement of the students has definitely been contagious as the Kenyan pharmacy staff now seem just as excited as the students are about working together. I look forward to seeing the results of this amazing collaborative effort.

Perpetuating Stigma

While the training session this week was great, I was struck by one of the instructors who still seemed to hold on to many of the old notions about HIV which perpetuated the stigma patients faced on a daily basis. I must also admit that I am too young to really remember, beyond what I’ve read, the era when HIV-infected patients were shunned from society. In his lecture on epidemiology he spent 5-10 minutes discussing the potential for transmission through swimming pools and oral to oral contact. I was completely shocked to hear any educated provider profess such a ridiculous notion. While HIV can be found in the saliva, the risk of transmission through that method is so miniscule that I would challenge him to find me even one case of transmission in that method. In terms of his comments about swimming pool transmission, I think one of our IU physicians said it best, “you would need to swim in a pool of saliva and swallow a lot of water to have the potential to contract the virus in that fashion.” My bigger problem with this statement was that it took away from the focus on the risk of transmission through sexual contact.
This will probably be one of my last independent blog posts as I expect to see the incoming students carry on the torch and narrate their experiences.

The Contrast Between American healthcare and AMPATH

This week I spent most of my time attending the AMPATH clinician training session. The remarkable feature of this training session was that they were effectively able to provide 60 clinicians with all the tools and knowledge they needed to effectively manage the majority of issues HIV infected patients seen in Kenya will face. It made me think about training sessions I had attended in America. So many of these sessions were focused on highly theoretical, complicated topics which rarely were encountered in clinical practice. Most training sessions sponsored by the pharmaceutical industry are often focused on educating providers about the latest drug on the market rather than describing the proper us of the simplest drugs which are most commonly prescribed. I admittedly am guilty of this as well. In presentations I’ve had to give, it was always more interesting for me to discuss the novelty of an innovative new drug rather than concentrate on the nuances of using our time-tested drugs which would have a much greater impact on the treatment of many more patients. I started thinking about what the goal of my previous presentations were. I came to the conclusion that it had very little to do with improving patient care and a lot to do with impressing the people I was presenting for by teaching them random facts about a new drug or idea that they will rarely if ever use. I think this example is a microcosm for how the US healthcare system operates. So much of our time is focused on thinking about the things that we can do with our skills to get reimbursed. The unique feature about the AMPATH approach is that they look to see what patients need and find the people to make those things happen. This may seem to be a subtle point but I think it is the keystone to the success of AMPATH. After living in Boston for a year in the Longwood Medical Area I was reminded of this phenomenon on a daily basis. This area has the highest concentration of hospitals in a one mile radius in the world. These are by far some of the best hospitals in the world with Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Mass General Hospital, Dana Farber Cancer Institute, and the Joslin Diabetes Center to name a few examples. Was this massive concentration of hospitals a result of patient need or the desire to be associated with and tap into the wealth of resources housed within the Harvard Medical School and Harvard community? Keep in mind that this is one of the more affluent areas in the country and the most impoverished areas are typically the ones with the greatest healthcare needs. In contrast, AMPATH has built satellite clinics throughout Western Kenya to make care accessible for patients who previously had to walk >10 miles just to make their monthly appointments. As you look around at the US healthcare system, you will see countless examples of this. This is to be one of the expected consequences whenever you make healthcare a market based commodity.

The Potential of Clinical Pharmacy in Kenya

After spending a week on the clinical wards rounding with the medical team, I was first struck by the stark difference in the lack of availability of many of the resources and medications I took for granted in my former practice setting in the US. Even something as simple as ordering oral potassium for electrolyte replacement was not possible as this medication was not stocked and potassium is rarely replaced here. However, as I got over the shock of not having many of these simple treatment modalities, I started to notice that the lack of resources wasn’t the main barrier preventing the delivery of appropriate care to patients. The lack of coordination and accountability in the healthcare system was the true culprit behind many of the misadventures patients experienced here. One particularly telling example of this was one of the patients I saw on the first day of my work on the wards. We were rounding on a 35 year old female patient who been diagnosed with cerebral toxoplasmosis which her immune system was unable to fight off because of the toll AIDS had taken on her over the years. This was her third week in the hospital and she was beginning to rapidly decline and based on her current progress was expected to end up in a coma within a couple days. As I was reviewing the medical chart and treatment sheet for the first time, I noticed that all of the prescribed medications were exactly as I would have recommended for HIV patients I would have seen in America. I noticed how every medication on her profile had been checked off and documented as being given except for one medication. To my shock and dismay, this was the one medication which could treat the potentially fatal infection she was currently dying of. I had assured myself that it could not be possible that she had not been receiving this life-saving medication for the past weeks as I assumed there must have been some part of the medication distribution system I did not understand. However, I decided to confirm with the med student just to make sure. She did not understand why the medication wasn’t checked off and why there was only the notation o/s in the first day of treatment either so we decided to ask the nurse caring for this patient. Upon questioning the nurse, she calmly and matter of factly told me that the pharmacy had been out of stock of this medication for the past two months so she was unable to give this to any patients. I could feel my rage growing with the lack of concern this nurse expressed for her patient who was on death’s doorstep. Seeing that this was my first day, I tempered my rage and calmly walked away and over to the pharmacy. I was given the same story once again, the pharmacy simply notates o/s (out of stock) on the treatment sheet when medications aren’t available. I was appalled at this system which perpetually transferred accountability without considering the ramifications of their oversights. This whole incident bothered me as it seemed many employees were complacent with the inefficiencies and consequences of a system which functions this poorly. It was almost as if they were inured to the notion of needless death and morbidity. This is clearly a direct consequence of the toll HIV/AIDS has had on this society as the overall life expectancy in Kenya has been cut by 20 years predominantly due to the pandemic. I can’t even begin to imagine the psychological toll of seeing countless patients and family members die of a disease which the Western world has been able to control with medicines that cost less than <$1/day. While I was troubled by this experience, I also saw the amazing potential clinical pharmacy and the incoming pharmacy students could have in closing up many of these gaps in care. I was also invigorated by the enthusiasm of the Kenyan staff to start improving and fixing these problems if given the right guidance.

In this situation, I tried to explain the importance of this medication to the patient and the pharmacy staff started to see how important their role could be in patient care. After making one phone call to the pharmacy manager, I was able to get a stat bottle of the medication within one hour. I immediately delivered this to the patient and made sure she not only took the pills but was able to swallow them without aspirating them in her current deteriorating condition.
The true happy ending was in seeing the patient two days later sitting up in bed and looking out the window. I still can’t believe that by Thursday we were talking about discharging this patient and starting her on life saving antiretrovirals through AMPATH’s diverse network of satellite clinics. With all the stuff I’ve seen in the past two weeks in Kenya , I feel like I’ve been here for months rather than weeks.

Re-establishing the Collaboration

Throughout my first week at the Moi Teaching and Referral Hospital, I've been amazed at how excited and welcoming my Kenyan counterparts have been with my arrival. More than anything, it is a testament to the tireless work of Purdue University staff who have come before me to build this solid collegial relationship. I would also like to relay the empathy many of my Kenyan colleagues have expressed for Julie Everett's family. Julie clearly touched the lives of everybody who had the good fortune to work with her. Without her, the program would not be the success it is today.

For my first week, I've been touring and working in the 7 satellite pharmacies dispersed throughout the Moi Teaching and Referral Hospital and AMPATH pharmacy. I can't wait to see the incoming Purdue students function in these settings and be immersed in the hands on practice of pharmacy in a completely different environment. The greatest joy of my week in Kenya has been interacting with the many characters and personalities which have allowed the pharmacy to function despite a complete paucity of resources. Our mutual curiousiy in each other's culture and practice setting has led to numerous interesting discussions which I anticipate Purdue students will soon enjoy and relish in.

I will begin rounding on the wards next week and look forward to the opportunity to directly interact with patients and help improve pharmacotherapeutic management of disease states we rarely see in America.