The Student Perspective by Jeremy Rife

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

Purdue Kenyans

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

Sally Test Centre and Children

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

Moses

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

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

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

Lilly Lazarus Effect

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

The Joys of Precepting

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

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

Moving Forward

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

Student Arrival

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

Perpetuating Stigma

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

The Contrast Between American healthcare and AMPATH

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