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.