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The Student Perspective - Avery Hagedorn

2009-02-25T10:23:00.000-08:00

I honestly do not even know where to begin. Coming to Kenya, I had such a mixed set of emotions running through my mind. The anxiety was palpable in nearly everything I did the month prior to my departure for this foreign land of which I had little knowledge and knew even less of what to expect. Though we all take the elective course to “prepare” us for what each of us will do here, to be completely honest, it does not prepare us whatsoever for the experience. It is truly a life changing experience that I wish all my classmates were able to experience firsthand. Unless you have been here and seen the wards, one is likely to never understand the difference one person can make.

My first few weeks here were an adjustment period. No doubt about that. I had many days on the wards in my first weeks that were absolutely frustrating. However, as Sonak had prefaced, “if you aren’t frustrated on the wards, then you aren’t trying hard enough”, rang true for me in my first week. I have never, and doubt I ever will feel as overwhelmed as I did my first week here in Eldoret. From anger that my patients weren’t receiving their anti-TB drugs to absolute despair seeing a patient we had just rounded on 20 minutes prior pass, without anyone even so much as batting an eye, my emotions were all over the place. It is such a stark contrast to care in the States. For someone whom has never been exposed to such a system, the differences to the American healthcare system are almost too much to bear. However, I stuck it out and continued to do my best and I am proud to say that it has made me a much better practitioner.

With only two rotations left in the year, we had all been on clinical rotations back in the States. I can easily say, that in the most of resource constrained settings; I had my best clinical rotation of my experiential year. Working with such limited resources places a huge emphasis on proper patient management that is both cost effective and beneficial to patients. It is remarkable to have such freedom in the ability to practice clinical pharmacy (as a student) and manage such a large patient load. I worked tirelessly to manage my patients’ medications, help both physicians, medical students, along pharmacy students learn about the medications used for said disease states, and ensure that they received drugs vital to their care. It is amazing to me personally, to be able to say that I had my best clinical rotation in the most of constrained settings. It speaks volumes to the ability of Sonak, and the passion that most of us bring on this rotation. It is truly amazing to know that me, a single person, can have an impact on so many patients and their outcomes.

The most rewarding experience, however, was noticing my own growth from within as both a practitioner and as a person. I knew that this experience would change who I am, but I had no idea just how it would affect me. I am proud to say that I feel I have grown both my clinical knowledge and compassion, in large part because of Sonak and his wealth of knowledge and his generosity, immensely in just eight short weeks. Sonak personifies what a pharmacist is capable of, and what a pharmacist should be. He works tirelessly to change the face of the Kenyan healthcare system, and gives to patients without ever being asked to do so. He is someone for whom I have the utmost respect and someone I hope to emulate in my own practice.

Prior to this experience, I had no ambitions of ever pursuing a career in “clinical pharmacy”. I still am planning on going into community pharmacy (as many people say its not clinical, I say to them, why can’t it be!); however, I plan on brining clinical work with me, and being a catalyst for change in my own work environment. If my employer will not allow me to practice, as all pharmacists should be able, then I plan on finding an employer that will, or changing my career path. This experience has shown me what a pharmacist is capable of, and how valued we should be in any healthcare setting. I plan on carrying that on wherever my career may take me.

I also feel that I would, at a minimum, like to precept rotation students in my future endeavors. Although I only had a week to do so, I was able to teach the Kenyan pharmacy students the ropes on rounds. It was amazing to see them learning right in front of me, solely based on the knowledge that I shared with them. Giving them a short assignment and seeing them respond with research and then present the topic to me the next day on rounds was remarkable. I am grateful for the opportunity to work with them, and hopefully have taught them along the way.

Other than my time spent rounding on the wards, I truly enjoyed seeing the healthy side of AMPATH and the difference this program makes. On the wards, it is easy to forget that most patients with HIV are now able to lead a normal life, maintain their job, support their families and are such a happy people. The days I spent out at the AMPATH satellite clinics, with the Orphans and Vulnerable Children (OVC), and my day on the AMPATH farm were a welcome sight to know that we are winning the fight here in Kenya. I cannot wait to come back in a few years and see what this program has become. I know that it will be remarkable.

I’ll close on a remark from Sonak made to me on my most depressing day here, and one that I hope everyone who reads this takes to heart. “Don’t let episodes like this prevent you from always trying to do more. Every student who truly invests time into their patients will have these types of experiences. It is how you respond that really determines the type of practitioner you will turn into.” I know what type of practitioner I will be, and I hope that everyone else carries that same attitude with them throughout their time here and throughout their career.

Avery Hagedorn
PharmD Candidate, February 2009

The Student Perspective - Isabel Hagedorn

2009-02-25T10:10:00.000-08:00

My time in Kenya is nearing an end. We finished our final ward rounds on Friday with bittersweet emotions. It was a mixture of relief to not have to watch the suffering as well as an overwhelming sense of desperation to stay and help where ever I can.

In a way, my time in Kenya has come full circle. You may remember my frustration I expressed in my early days here, and as I left on my final day my frustration had returned. More so for differing reasons, but the walk home was like déjà vu of my walk home from my first solo day on the ward.

Though my emotions are swirling and I’ve felt tormented at times, I wouldn’t trade a single second of my time here. This trip has helped me to define who I am as a person and as a care giver. It has also taught me who I want to become as I continue on with my education and life. I have learned a great deal about pharmacy but even more about compassion and selfless giving.

All my hours I have spent feeling helpless or useless were forgotten as I was visiting my last patient of the day Friday. He is a young man married with three children under the age of 5. As he lay in our hospital for weeks, a tumor was rapidly growing and closing his airway. Day after day we rounded on him with a casual “ENT consult” and moved on to the next patient. My anger grew until I couldn’t take it anymore. He was hardly able to breathe, eat, or talk. Within a matter of days he would be dead and I couldn’t bear to watch that happen. I found my preceptor to ask for guidance and couldn’t hold back my tears any longer. I was angry for letting myself cry, but I was so exhausted emotionally I didn’t have the strength to stop. To make a long story short, by taking matters into my own hands, I was able help get him scheduled for surgery, reviewed by oncology, and more importantly to give his wife someone to talk to for what she was going through. What felt like endless hours of work were rewarded this week when he was started on chemo and scheduled for radiation with an optimistic chance of survival. I was even able to find him a sponsor to cover the cost of his treatment. As I stopped by to see him before I left, he shook my hand while his wife hugged me and both were sobbing saying countless thank yous. Seeing their gratitude was overwhelming and it helped to confirm why I was here.

Though the culture may be different and difficult at times, the Kenyans are such a beautiful people. Working side by side with them has taught me how to adjust my work style in order to bring out the best in the team. We made some terrible mistakes as a team, but we also made some incredible saves. We will encounter many personalities and work ethics in the future and the most important thing we can do is learn to work together to provide the best care for our patients. This doesn’t mean giving up or slacking, but working longer and harder to accomplish what you are capable of. While here I have learned how to be an advocate for the patient and to not give up when you believe in something – especially when you believe in a patient.

I never knew anger could be such great fuel. When I look back on my time on the wards, the moments I’m most proud of were in response to moments that pushed me professionally and challenged me. Every effect has a cause. Why not use the cause to do great things. I don’t think I’ll soon forget what I have learned here, and I hope I never will. I believe I will be a better care giver in my career because of my experiences. My registrar, Nadia, told me repeatedly through our countless conversations to harden myself to what I was seeing around me so I can provide better care, but I think by doing that I would be letting myself slip. I enjoy the compassion I have for my patients and I intend to carry that on to the states. I think it’s especially important in America to have that drive when it’s becoming more and more about the money. I will always be grateful towards this rotation and the Kenyans for teaching me this. I can’t seem to find the right words for what I want to say, but I think one of my patients said it best when he told me, “we may be a very simple people, but God still smiles on us.”

Isabel Hagedorn, PharmD Candidate
February 2009

The Student Perspective - Lisa Zagroba

2008-11-11T07:34:00.000-08:00

Overall I really enjoyed my 8 week rotation in Kenya. This is not to say that there were not challenges along the way, but I do believe everyone that comes here makes a profound impact. It definitely took some adjusting, but after the fist few weeks I felt like I was able to contribute on rounds. We rounded with a team of physicians, nurses, and pharmacists in the Moi Teaching and Referral Hospital (MTRH) wards on a daily basis. This was a good learning environment because there are so many opportunities to use your clinical judgment to impact patient care and educate staff members. I often found myself question physicians about drug regimens, helping fellow pharmacists’ dose medications, educating patients on how to properly use inhalers, and educating nurses about various medications. I really enjoyed getting to work with the vast array of medical personnel from all over the US, Kenya, and other parts of the world. This truly was a global and very uniting experience. Sonak did a great job of helping us adjust and learn from this unique environment. I got to see many different areas including outpatient oncology, the diabetes clinic, and some of the rural clinics. In each of these very different practice settings pharmacists were making an impact.
I also really enjoyed the opportunity to do presentations and complete projects. I assisted in developing antiemetic regimens for chemotherapy treatment, helped make pediatric ARV handouts, and worked with IU medical students to complete a morning report presentation. My favorite project was a presentation about the treatment of chemotherapy induced side effects. This was a good chance for me to review the treatment options, especially since my next rotation is in oncology. This is also an area that I am considering specializing in, so it was very pertinent. It was interesting to see how their oncology program is developing, since it is still in the early stages of organization. It was frustrating, but educational at the same time. They do not even mix the chemotherapy drugs in any kind of a flow hood, just next to an open window.
I think I learned the most at our afternoon topic/ patient case discussions with Sonak and the other pharmacy students. These were great opportunities to learn from each other and better the care of our patients. Plus Sonak did a great job of asking us questions and making it a learning experience. I also enjoyed our fireside chats that related to public health topics. This was a great opportunity to lean more about the world and understand different perspectives. We discussed different topics ranging from the street kids in Eldoret to contrasting the health care systems of the US and Canada. These were good discussions because they involved people with different backgrounds and from different parts of the world.
Lastly, I enjoyed the opportunities to see some of the non-pharmacy related work that is done through AMPATH, such as the Orphans and Vulnerable Children (OVC) program, Sally Test Center, and farming. OVC was a great opportunity to see people helping each other. The stories of these families were amazing and really moved me to want to help. I met a grandmother that was caring for 11 of her grandchildren because two of her daughters had died from AIDS. The organization had helped her find a small one room home for her to live in with her grandchildren. She was incredibly grateful; the experience was very moving. The Sally Test Center was such an enjoyable environment where we could play with the children from the pediatric wards. The kids always greeted you with a smile and were ready to have some fun and forget about the hospital. I also enjoyed learning about the farming initiative, because with out food, the patients ARV regimens would useless. AMPATH tries to look at the big picture when caring for patients. Honestly, adjusting to life here was not as hard as I had expected. I had many opportunities to grow both as a pharmacy student and as an individual. I hope I was able to make as much of an impact here, as I this experience has made on me.

The Student Perspective - Serena Harris

2008-11-11T07:32:00.000-08:00

As my first flight, of many, was about to take off I had a mixture of emotions running through my head. This would be my first experience outside of the US for longer than a week and I knew I was about to be immersed in a new culture. Everything would be different from the food and living arrangements to the lack of medical resources and healthcare facilities. I’m happy to say that although I had my worries, this experience has helped me grow both personally as well as professionally.

My experiences at the Moi Teaching and Referral Hospital were very different from any other hospital experiences thus far in my 6 months of rotations. As I walked into the hospital my first day there was a distinct, overwhelming smell that nearly took my breath away. This was only one of the many things I would become accustom to over the next 8 weeks. Multiple patients to a bed, medication not being given, unreliable lab results, and lack of resources were encountered daily. It’s indescribable the feeling you get when you know a patient will soon die because they either don’t have the money to pay for proper treatment or it simply is not yet available here. I sometimes found myself near tears during rounds and frustrated to the point of almost walking out. These were the bad days. The most rewarding experiences came when I improved quality of life for my patients and watched the transformation of the sick into the healthy. Whether it is managing glucose in a newly diagnosed diabetic or changing anticonvulsant medication to control seizures, the potential role of pharmacy in Kenya is immense.

Through my interaction with Kenyan and American physicians and medical students on rounds, it has become clear the effect we can have on patient care when working closely together. The Kenyan interns are often responsible for over 25 patients a day, a truly mind boggling thing once you understand the amount of work required in each patients care. I found my role on the team often changing from typical pharmacy related medication issues to recommending appropriate labs, calling attention to electrolyte disturbances, and addressing untreated medical problems. Purdue pharmacy students have a unique opportunity to truly make a difference in all aspect of patient care. Once you earn the trust of your team, they will look to you as the expert in all things related to medication. I not only recommended dosing, but also specific agents we should use based on patient and disease specifics.

Learning did not end with ward rounds. We had daily patient discussions with Sonak that enhanced not only our medication knowledge, but also our critical thinking skills. We used this opportunity to present difficult patient cases and determine the best management for each patient. Other unique learning opportunities came from our interaction with Kenyan pharmacy students. They made the transition from work in America to Kenya much easier. As I looked down at a treatment sheet for the first time, I had no idea what half of the medications were treating. Disease such as typhoid fever, PCP, malaria, toxoplasmosis, and tuberculosis are a common diagnosis here rather than a rarity. We were able to share our knowledge base with each other and form friendships along the way.
My eight weeks in Kenya have offered much more than just a learning experience.
The opportunity to experience a new culture and meet people from around the world has been amazing. I’ve tried new things and stepped outside my comfort zone. I clearly remember my first time walking through town. I felt like an outsider for the first time in my life. All eyes were on me as I walked through the dirt streets of Eldoret. To my surprise, I was greeted with smiles, waves, and best wishes for the duration of my stay here.

There’s a sense of camaraderie and respect for one another found here that we’re often lacking in the US. I’ve met a lot of amazing people here and I’ll never forget the kindness and generosity they’ve shown me. I’m grateful for all of my experiences in Kenya, the good with the bad. I hope that in some small way my stay in Kenya has made a difference because it sure has left a lasting impression on me!

The Student Perspective - Shauna Santare

2008-11-11T06:46:00.000-08:00

After completion of the Kenya rotation, I have been able to better evaluate the impact pharmacists can make to improve patient care. As my first experience with clinical pharmacy and also within any hospital setting, I had to quickly learn to adjust to following many patients with different disease states and following up on their care daily. I gained a lot of experience in multidisciplinary care rounds, which definitely influenced my interest in clinical pharmacy. MTRH was the first opportunity where I have had involvement in important (life or death) patient care decisions and in-depth discussions with physicians. I felt as though my opinion and knowledge were respected, and that confidence boost provided self motivation to continue my efforts.
I enjoyed this rotation for more than the obvious perks of weekend trips, new friendships, and cultural broadening. Reviewing charts may have felt tedious at times, but I learned to filter information for pertinent lab results. This skill is necessary at my new rotation site, where I am “rounding” in a different ward every day of the week and have many more patients.
I felt very intimidated in the beginning of the Kenya rotation because we were immediately thrown into the experience and had to learn to fend for ourselves. Looking back, I realize this was the only way it could be done. As for the rotation itself, I cannot recommend anything to be changed.

The Student Perspective - Tobie Rogers

2008-11-11T06:42:00.000-08:00

Before arriving in Kenya, I was very apprehensive about the experiences that I would have. I had heard horror stories about the sights and smells in the hospital. I was also still slightly nervous about the environment that I would be living in, especially after the post-election violence. However, I knew that Purdue would not let us go if we were not going to be safe. The first week or so of rounds, I was very overwhelmed. I was fortunate enough to have rounded on a medical team before; however, I had never covered a patient load of this magnitude. The charting and lab reporting system is very different from what I am accustomed to and made thumbing through the charts somewhat challenging at times. I was also not used to being a member of such a large team, which reached over 20 people occasionally. Fortunately, the sights and smells were not nearly as horrible as I had envisioned them in my head. Eventually, I was able to somewhat adjust to their system and become more at ease with my role. Looking back on the experience, I was able to identify some of the challenges and benefits associated with it.
In the beginning, rounds were very trying for me, in that I often felt useless and unhelpful in many ways. One major barrier was actually hearing the Kenyan medical students and doctors as they tend to be very soft-spoken. This coupled with the fact that I was at the very back of the pack of students made deciphering what was going on very challenging. However, as I began making pharmacological recommendations to the team, I began to earn their respect and a spot nearer to the front. As time passed, I found that the interns would seek me out while they were admitting for recommendations. At the end of my time with my team, I felt I was a very vital member of the team.
Another major frustration stemmed from not knowing which medications were carried by the hospital and the lack of medications available for use. We were given a ‘formulary’ at first, but it was never updated over the course of the rotation. It may be beneficial to actually develop a formulary and printout a list of stock outs either daily or weekly for the entire medical staff including pharmacy, nursing, and medical students and interns. Another alternative for the pharmacy students is to hold a brief meeting every morning to give updates on current medications that are not available. I found often that I was halfway through rounds before it was brought to my attention that a medication was out of stock, which required me to go back through all the treatment sheets to change those medications on the patients that had already been seen.
Finally, the nursing staff is overworked in that there are not enough nurses scheduled to work for the number of patients that are in the hospital on any given day. This leads to less than exceptional care for the patients; which means that medications are often not given appropriately. I feel that it may be beneficial for the pharmacy students to present brief in-services to the nursing staff on a weekly or bi-weekly basis. It is important to discuss the treatment of infections and disease and emphasize the importance of compliance and receiving the medications at the time they are ordered.
Although the rotation was challenging at times, there were positives as well. First, the pharmacy students from Nairobi are a great addition to the medical teams. Their knowledge of the name brand medications and standards of care in Kenya are invaluable to the team. Also, their ability to speak Kiswahili is an added benefit. Communication with patients would have been much more challenging without them. I feel that we learn just as much from them as they learn from us.
This experience also exposes us to various disease states and infections that are not often seen in the United States, offering a great learning experience. I felt that I learned a great deal of information that will help me as I pursue a career in clinical pharmacy. A large amount of information that we were exposed to is applicable while practicing in the United States, while the rest is merely a great learning experience. I also enjoyed venturing to the clinics to work in the pharmacy. It was great to interact with the patients and practice speaking Swahili.
I have been home for a week now and looking back this experience was more than I ever thought that it would be. Although it was frustrating at times, it was also very rewarding. My most memorable experience at the hospital was with an HIV+ woman who was experiencing symptoms associated with zidovudine-induced anemia. I went to the AMPATH pharmacy and switched her zidovudine for stavudine and took it back to her. A few days later, I was standing at the nurse’s station reading charts and she came up to me to tell me that she was feeling better and that she would be going home. She said thank you, shook my hand, and walked away. A week or so later as I was walking through the hallway in the AMPATH clinic, someone grabbed my arm. When I looked down, it was the same woman. She told me that she was there for her follow up and thanked me again for helping her. I felt amazing knowing that I helped someone and made a difference in their life, even if it was only that one person.
I learned a great amount of medical and pharmacy information in the time I was in Kenyathat will help me professionally. However, I also was able to learn a lot about the people of Kenya and its culture through talking to the Kenyans that live and work at IU House and to the pharmacy students from Nairobi. It was definitely an experience that I will not soon forget. My hope is that after graduation, I will be able to go back to work at Moi and visit with the friends that I have made. Who knows, maybe one day I will be the first psychiatric pharmacist in Kenya!! I am quite certain Sonak is counting down the days until my joyous return!!!

The Student Perspective - Alex Fohl

2008-07-28T00:28:00.000-07:00

Practicing pharmacy at Moi Teaching and Referral Hospital in Eldoret, Kenya revealed a health system highly influenced by pharmacists and demonstrated effective management of patients in a resource-constrained setting. The past two months have re-enforced the difference a pharmacist can make in patient care. MTRH has made a permanent impression on how I will practice pharmacy in America and has demonstrated the positive impact pharmacy can have on patient care regardless of the setting.
Moi Teaching and Referral Hospital currently has a number of outpatient clinics (cardiology, diabetes and oncology) to accommodate the follow-up of patients. Doctors are involved in the clinics, but the pharmacists take significant responsibility in ensuring patients understand their medication regimen and monitor their own therapy. The pharmacists act as the first line in the clinics, and they defer complicated patients to the doctors and ensure the doctors agree with the assessments of routine patients.
During our rotation, we assessed the need of an anticoagulation clinic in Eldoret based on a chart review of cardiology clinic patients. Currently, patients are being anticoagulated in the hospital and either sent home on a dose which will hopefully maintain a therapeutic INR or they are sent home without any anticoagulation at all. Most patients are sent home without any anticoagulation because there is no means to reliably monitor the patient’s INR due to the lack of resources and funds. Kenyan patients also lack a regular diet which may result in alterations in their INR. The anticoagulation clinic we are setting up will help to manage patients on their anticoagulation medications and may eventually yield an opportunity to establish a valve replacement clinic within the hospital.
Something that really surprised me during this rotation was the condition of the wards. Upon walking into the hospital the smell nearly takes your breath away and no one breaths through their nose for the rest of the day. Proceeding down to the Nyayo wards, the men’s ward is to the left and the women’s ward is to the right. Each ward is divided into six cubes with each cube holding eight beds. Normally there are two patients to a bed with their heads facing in opposite directions. There is no identification for these patients, and I do not know how the nurses ensure that the correct patient receives the correct medication. There are times when I am not sure we are talking about the correct patient when we are holding the patient’s files during rounds. The condition of the wards really surprised me, but patients do receive their medications and improve.
AMPATH is very impressive and it is hard to imagine that it started in 2003. Currently, it is an integrated and established department for Moi Teaching and Referral Hospital. AMPATH has helped so many patients and doctors in the hospital refer patients regularly to AMPATH. This is an excellent example of the influence pharmacists can have in the practice of medicine with some determination and effort. I know there were a lot of people that told professor Mamlin this would be too daunting of a task, but his confidence in his abilities remained strong and currently AMPATH is a reality.
The experience I will remember most regarding my clinical experiences in Kenya revolve around a little girl who presented with an exacerbation of sickle cell anemia. She may have been eight years of age, but weighed only 25 kg. She was in so much pain she winced every time we touched her stomach or moved her. She refused to talk to us or even smile. Her father, a man suffering from the effects of polio since birth, remained at his daughter’s side day and night. Family remaining at the patient’s bedside for the duration of their stay is a common occurrence in Kenya. Although there are visiting hours, patients are permitted to have one family member present at all times. This often proves useful during rounds because the patient’s representative is able to update us on the patient’s status over the night better than the nurses. The patient’s representatives act as the patient’s primary caretakers while they are in the hospital. After a couple days in the hospital, we realized that our patient with sickle cell disease was not receiving the medications we were requesting. After talking to the nurses and the pharmacy multiple times, we were able to get our patient the care she required. After a couple of days, she made a full recovery and became a very happy young lady once again. Her father was so thankful her daughter was back in good health again, he shook my hand every time he saw me in the streets. Seeing our patient smile as she walked out of the wards has left a permanent impression on my patient care.
The practice of pharmacy in Kenya demonstrated the importance of pharmacists taking an active role in the care of patients. Pharmacists have established multiple clinics to patients’ needs and work directly with patients during follow-up visits once they are discharged from the hospital. From this experience, I have a thorough understanding of the common tropical diseases present in Kenya (ISS, malaria, tuberculosis, PCP, cryptococcal meningitis and toxoplasmosis), but I also understand the importance of pharmacists establishing themselves as active participants in patient care both in the hospital and in the community. If patients can be effectively managed in the resource-constrained society of Eldoret, Kenya, patients can be effectively managed anywhere in America, but pharmacists have to become essential to the practice of medicine.

Alex Fohl
PharmD Candidate, May 2009

The Student Perspective - Maria Thompson

2008-07-28T00:25:00.001-07:00

The Kenya rotation is unique since we are able to learn and grow in many facets of life, not just in pharmacy knowledge. In addition to pharmacy knowledge, I have gained cultural experiences, inter-professional experience, and the opportunity to assist with improving the system through individual projects.
The pharmacy knowledge gained is phenomenal. As students, we are able to round on teams with doctors nearly everyday. Also, the opportunity to use your clinical knowledge on the patient’s treatment is a great experience to build confidence but can also be challenging. This was my first rotation so I felt a bit overwhelmed in the beginning but patient discussions assisted me with thinking through regimens.
This rotation is also unique in the diverse areas of pharmacy it exposes to the students. I rounded in both the women and men wards. The medical issues dealt in both wards were different which exposed me to many disease states. I was also given the opportunity to round on the pediatrics ward. I really enjoyed seeing the children even though it is tough to see them suffering. Pediatrics is interesting because your patients have a greater chance of recovering than geriatric patients but if they do not recover it is so much more devastating. In addition to rounding on patients, I attended the oncology and diabetes clinics. The diabetes clinic showed me an ambulatory setting for a pharmacist. Additionally, we traveled to regional AMPATH clinics to assist in dispensing medication.
The impact we are able to make as pharmacy students is enormous in this setting. I am currently preparing a spreadsheet of oncology regimens which I will calculate the cost. The information will assist the oncology clinic at MTRH in creating updated oncology protocols. This project will affect each cancer patient in Eldoret and will maximize the use of resources.
This experience has taught me the difference in American and Kenyan cultures. I found American lifestyle to be more fast-paced and very systematic. Kenyan lifestyle is more slow-moving and runs on organized chaos. However, being in Kenya humbled me more than anything. In general, Kenyans cherish family and relationships more than material items. Learning the differences has taught me to have patience in a new setting and to become flexible in new systems.
The two months in Kenya are spent living with many people from different backgrounds but all with the purpose of enriching themselves in a new culture. I was able to live and travel with medical students and physicians from America and Canada. Many friendships were created in Kenya with a variety of people from all over the world. Also, I was able to learn how physicians make decisions and see their thought process. The inter-professional exposure was exceptional since it gave me experience working with a team of doctors, medical students, nurses and clinical officers.
The Kenya rotation was a once in a lifetime pharmacy and cultural experience. Interacting with people from a different culture taught me more about myself than I could ever imagine. Most importantly, I learned this experience is more about a bilateral exchange of ideas and not the Americans coming over to change everything.
Maria Thompson
PharmD Candidate, May 2009

The Student Perspective - Lauren Hull

2008-07-28T00:20:00.000-07:00

After looking back on the last eight weeks, I am very glad that I had the opportunity to live and work in Eldoret. Before coming, I really had no idea what to expect. I knew that I would see multiple patients per bed, many medications would be out of stock, and I would encounter many HIV positive patients. Outside of these things, I was clueless to what I would experience and see. Throughout my time in Kenya, I have learned so much. Kenya has given me much more than I could give back. I have learned to be flexible, to try new things, meet new people, and step out of my comfort box.
Rounding on the wards was a completely new experience for me. Initially, I was very nervous and unsure of myself. I was afraid of touching anything and being touched by anyone. As time went on, I got much more comfortable and was able to turn rounds into a learning experience. I really enjoyed having patient presentations in the afternoon because it provided an opportunity for me to have an impact on rounds and to increase my clinical knowledge. I really liked the opportunity to learn by taking care of the patients we were seeing everyday. It is very rewarding to know that the interventions we are making will better someone else’s life.
I am also glad that we had so many presentations and projects. The best way to learn is by doing, and we were able to learn a lot through our presentations. It is also encouraging to know that our work is not without purpose. It is encouraging to know that our projects are going to last long after we leave. The HIV adherence project is going to have a lasting impact on patient care in Kenya and other parts of the world. I am so thankful that we are able to look back on our time in Kenya and know that we are making an impact on patient’s lives while we are here and it will continue when we leave.
The best learning experience for me were the people I had the opportunity to meet and get to know. My favorite parts of my time spent in Kenya are the times spent in the car with a Kenyan or working alongside a Kenyan and getting to know their stories. Many Kenyans have a much different outlook on life than the typical American, and it is a refreshing view. I was talking to an AMPATH driver who was a victim of the post-election violence. In telling me his story, he told me that he and his family were very, very fortunate, all they lost in the violence was their property, and his mother’s home was burned. He went on to tell me that God was so good to his family and they were so blessed. I was very surprised by his views, if the same situation happened in America, many people would say “we lost everything, our home is gone, our property, everything”. It showed me that many Kenyans have much different values and priorities than a stereotypical American. I was also surprised by the hospitality and generosity of the Kenyan people. Many Kenyans were so welcoming of us and what we are doing. I was pleasantly surprised by the hospitality and friendship we were shown by the Kenyans.
During these past eight weeks, there have been some really good times and some really frustrating times. Overall, I would highly recommend this rotation and experience to anyone. It is definitely not a glamorous job and you may not have a phenomenal, life-altering experience; but it is definitely worth the time and effort to be here. It is an experience that will change you, maybe in huge ways or maybe little seemingly insignificant ways, but it is a wonderful experience.

Lauren Hull,
PharmD Candidate, May 2009

The Student Perspective - Anthony Gentene

2008-07-28T00:09:00.000-07:00

I am very glad I made the decision to come to Kenya and thankful I had the means to come as well. There is quite a bit to say about spending 8 weeks in Kenya. There are many aspects of the trip from experiencing and learning the culture, time spent in the hospital, relationships built with Kenyans, getting to know my current friends better, weekend trips, improving pharmacy practice skills, and meeting many unique people at the IU house.
I was very surprised by how friendly most of the Kenyans were. They were really quick to make friends with us. The first Friday we were here they made sure to include us in experiencing the social life of Eldoret. My first week of rounds, the resident of my team took another American medical student and me out to lunch one afternoon. Multiple families invited large groups of us into their homes for dinner and tea. So many of the people we would meet at the hospital or the IU house were quick to welcome us to Eldoret. Others invited us to church and made sure we felt welcome there. I hope to remember how friendly the Kenyans were to us so when I go back the US I can return the warm welcome to visitors.
It is important to remember the obvious poverty and comparative wealth we have in the US and incredible opportunities we have. I feel like it is difficult to even write about this topic because the differences can be so drastic. It is essential we don’t forget this lesson when we go back to the US. It is easy to slip into our own thoughts and situation when life is busy, but it is important to remember past experiences and what we’ve seen. Not only to help us appreciate what we have, but to do something about helping others and allow them to experience at least a part of what we have been blessed.
I was able to further my pharmacy knowledge and skills during this time as well. We had many opportunities to discuss patients, ask questions, present on a variety of topics, and interact with other healthcare professionals from a variety of regions within the US and Kenya. During my time spent in the hospital wards on rounds I had the opportunity to work alongside Kenyan medical students, nurses, interns, and residents, American medical students, an American oncologist as well as regular interaction with fellow pharmacy students and our preceptor. It was a unique experience to work with such a variety of people. I was able to learn from them as well as pass on knowledge from a pharmacist prospective and hopefully advance others’ opinions of pharmacy practice through these interactions. I had two unique opportunities to participate and develop projects that would extend beyond my time Kenya. Our group was able to gather patient information that is going to be used to assess the need of and hopefully begin an anticoagulation clinic. The clinic will enhance patient care in Eldoret and will extend many patients’ lives. Another student and I were able to develop a tool to aid HIV medication adherence counselors. The tool provides information for the patient when they meet with the counselors and also guides the information the counselors will discuss with the patients. The project has potential to be utilized for over 70,000 AMPATH patients.
Two specific interactions in my time at MTRH have had a significant impact on me while I was here. There was an HIV patient who was on my ward who was admitted for oral thrush and cryptococcal meningitis. He happened to speak English so I was able to talk to him everyday and see how he was feeling over the three weeks he was in MTRH. He was finally discharged after improving with amphotericin B then switching to fluconazole due to nephrotoxicity. One week after discharge he came back on his own when our team was rounding to say thank you for helping get better. I never expected this patient to return to thank me. I was able to see him once more when he was meeting with an HIV medication adherence counselor and talk to him one last time.
For about three weeks our rounding team had an American oncologist from Brown University who visiting MTRH. During the three weeks I was able to learn much from her about the care of patients medically. At the same time I was able to observe her interactions with patients making sure she provided individual attention to each one, and despite the fact that most could not speak English, she was able to hold a patient’s hand or lay her own hand on their shoulder to communicate her care to each one. Towards the end of her time in Kenya we were having a large group discussion one evening conversing, in part, about the current and future role of pharmacists. She made a statement that as a result of her experience on rounds in Kenya, when she rounds in the US she wants a pharmacy student each time on her team. This was very encouraging and motivating to me knowing that I was on her team in Kenya and was able to have a positive influence on and receive a compliment from an established practicing oncologist that I grew to respect much.
My time in Kenya has been a unique experience that will continue to affect my life both personally and professionally. I have had many opportunities others will never have. One of the most unique aspects is that I have had the opportunity to influence and affect lives in Kenya while experiences and others in Kenya have been able to influence me. My hope is to continue to help patients in Kenya, despite being in the US, by updating and furthering our projects completed here. I don’t know where this will lead or when it will end, but I desire is for these experiences to continue with me and shape my practice of pharmacy, care of patients, and overall values and character as a person.

Tony Gentene
PharmD candidate, May 2009

The Student Perspective - Kathryn Ringenberg

2008-07-27T23:58:00.000-07:00

My time in Kenya has been awesome. I would even go so far as to say it has been a life changing experience. Being immersed in a new culture for two months tends to have that effect on a person. I have grown in so many ways, both inside and outside of the realm of pharmacy. That is what is so great about this rotation. Your knowledge base and clinical skills are challenged and expanded through the direction of a preceptor who expects excellence. At the same time you are experiencing so much in addition to just pharmacy. The people, the culture, the food, the music…it is a refreshing experience.

Throughout this rotation the pharmacy students have had many different opportunities in many different settings. Our primary responsibility is patient care at Moi Teaching and Referral Hospital medical wards. This is an experience that takes some getting used to. The wards are like nothing you would ever see in the United States. The physical conditions of the facility take adjustment in and of themselves. Other challenges faced daily include out of stock medications, more than one patient per bed, no isolation for high risk patients (those with TB for example) and a nonsensical payment structure. These remained reasons for frustration, to say the least, throughout the duration of my stay here, but by the end we were able to adapt and really begin to make a difference. I saw how valuable pharmacists are to the medical team, especially during rounds. Not a day went by while working at MTRH that Purdue pharmacy students did not make an intervention on a patient’s behalf. More than once these interventions were significant enough to be life saving. Beyond this, during rounds my colleagues and I made friends with many Kenyan medical and pharmacy students. It took time to gain trust but I really feel these friendships will last beyond my two month stay in this country.

Outside of the hospital we spent time at various sites including AMPATH clinics. This was a great experience. Students worked with Kenyan pharmacists at these sites to dispense antiretroviral medications to HIV positive patients. It was during my experiences at the AMPATH clinics that I was offered a glimpse into the severity and extent of this epidemic disease. I looked into the eyes of 2 and 3 year old children infected by mother to child transmission at birth. They were destined to a life on complicated and not-so-benign medications by no fault of their own. It was heartbreaking but also rewarding to know that a difference was being made, and I was witnessing and even perhaps contributing to a small part of that. Without my time spent in these clinics I would still have no appreciating for the burden of this disease in sub-Saharan Africa.

Just being on the content of Africa and interacting with the people has made me fall in love with this place. I have learned that it is a place of much need but also great hope. This rotation allows you the flexibility and great opportunity to interact with students living at the IU compound from many different universities in the AMPATH consortium. One student in particular had an impact on me. He was here on a return trip doing work with street children, or children who live on the street at least part of the day in hopes of making money and surviving under the oppression of poverty. I was deeply impacted by watching him work with these children and gained insight into the complex social implications of this problem. I say this to emphasize that although I came to Kenya intending to learn mostly about tropical medicine as it relates to pharmacy, I left with so much more than that. This place gets in your blood, at least it did mine. The opportunities are so vast. It is wonderful to come here as a student under the direction of a preceptor, together identify needs, and then have the freedom to implement programs or research initiatives to make a difference. That type of flexibility is unique to a setting like this. The needs are great but so are the opportunities. The more you put in to this rotation, the more you will get out.

It is also great to be in a setting with other pharmacy and med students all working together. Learning and working together as students is an avenue to doing the same as professionals. I was amazed to watch as barriers were broken down between the two fields and students came to realize how complementary the knowledge base is between pharmacy and medicine. It was energizing to me to be on a rotation where everyone was working hard and we learned together.

It is probably obvious, but I really have loved my time here. If you are thinking about coming to Kenya please view this opportunity as a privilege. It is not a vacation. You will work hard, which is ultimately for your benefit and the benefit of all your future patients. There will be plenty of time to travel and experience Kenya as a whole, but I challenge future students to take the work they do here seriously. The Kenyans have come to depend on us, and we have the ability to make a huge difference. With a proper attitude this rotation is an absolutely incredible and life changing experience. I am so thankful I have had the opportunity to experience this place. I’ll be back. You can count on it.

Katie Ringenberg
PharmD Candidate, May 2009

The Kenya Rotation after the Post-Election Crisis-Jessica Reiter

2008-04-11T09:17:00.000-07:00

As I’m sitting down to write this blog, I can’t believe I’m actually in Kenya. A few months ago, I didn’t think I was going to be able to come at all. I had even donated all of the clothes I had saved up to the Salvation Army. But once the peace agreement was signed and Purdue gave us the ok, I jumped at the chance. This wasn’t an opportunity I wanted to miss, and in the short time I’ve been here, Kenya has been every bit of the experience I thought it would be.
I have only been here for two weeks and I know that I am a different person today than I was when I arrived and I won’t be the same when I leave as I am today. I may not be learning as much about clinical medicine as the other groups have been, but I am learning so much about people and culture. Granted, it is a pharmacy rotation, so I am learning about HIV/AIDS and opportunistic infections, but being out in the clinics and experiencing the people of Kenya is what is making this experience so memorable.
Our main project during our 4 weeks in Kenya is to help implement a computer data base system at the AMPATH pharmacies. This is quite interesting as most people have never even seen a computer before, let alone ever used one. Everybody is very excited to have a computer and very eager to learn. Well, they are eager to learn how to use the computer, implementing it into everyday prescription processing is another story. Just seeing the excitement on somebody’s face about something we use on a daily basis, makes you stop and think about how much we take for granted.

We, in America, have things so much easier and have so many more opportunities but aren’t as happy as a culture. No matter where I go in Kenya, everybody is eager to shake my hand, welcome me to the country, serve me tea and mandazis (Kenyan donughts) and make sure I have a place to sit. The Kenyans will stand just to make sure I have somewhere to sit. I don’t think I have met a rude or unfriendly Kenyan yet. And, they are very patient. I have not seen anybody get upset about waiting – and I mean waiting. When we all went to the clinic in Kitale to bring them their computer and set up the data base, we took over the pharmacy for a good 2 to 3 hours where no one could get their prescription filled, and I didn’t hear one complaint. That would never happen in an American pharmacy, people get upset if they have to wait 5 minutes. Most of the Kenyans aren’t the richest people financially, but they are some of the richest people in heart I have ever met. They would drop what they were doing the second you asked for anything. I hope to bring back to America a portion of the kindness, patience, friendliness, and thankfulness that I have seen in every Kenyan I have met so far.

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

2007-12-20T12:30:00.000-08:00

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

2007-11-26T09:17:00.000-08:00

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

2007-11-14T11:35:00.000-08:00

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

2007-11-13T09:46:00.000-08:00

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

2007-10-21T21:24:00.000-07:00

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

2007-09-25T07:18:00.000-07:00

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

2007-09-22T01:22:00.000-07:00

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

2007-09-09T01:08:00.000-07:00

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

2007-09-01T13:56:00.000-07:00

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

2007-08-24T09:58:00.001-07:00

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

2007-08-24T09:52:00.001-07:00

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

2007-08-19T11:44:00.000-07:00

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

2007-08-10T14:04:00.000-07:00

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.