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.
