Don't Send Us No Patients...

You are critically ill.
You go (nay are carried, nay rushed) to the nearest health facility. It is however only an outpatient facility that will be able to offer only an acute relief from your distress. You require more intensive tests and more importantly treatment that is well beyond what they can give here. And that right there is just the beginning of your nightmare...

You are a clinician working here and when called to the emergency room you do not expect to find smiling faces and all. It is a critical time where speed, accuracy, material resources and acute clinical skills count a lot. Here is one life on the line and you have to step up to the noble task of shoring it up to safety again. You are quite unprepared for the rough bump that your day is about to hit...
It is conventional knowledge in the public healthcare corridors that one of the truest test of the quality of care in a hospital is the A&E (accident and emergency) department. If you are not going to save lives in critical condition then what the heck are you doing in the serious business of saving lives? Our healthcare system is organized in such a way that you find an ascend in the expected scope and range of services. The lower level facilities will offer basic and less complicated services. The depth however increases as you go up the chain.


As the devolution of healthcare took off, there was a frenzy by county governments to spend the billions of shillings at their disposal on what they called service delivery improvement. But the line between service delivery improvement and unprecedented wanton wastage became blurred as a baffling spending spree was witnessed in many instances. There were cases of governors spending millions on ridiculous items; wheelbarrows, wooden bridges, hospital gates, hospital curtains, executive trips and really a whole lot of confounding expenses. Some governors even ran up mighty humongous hotel accommodation bills citing the lack of official residences or rather residences befitting their instantaneously magnified stature. Then they did the unimaginable by having the county government clear the tab! One was left to wonder if they could open the purse strings thus if it was their personal money that was on the line..
County governments have sunk a lot in the health sector. From refurbishing run down facilities to the installation of complex machines and treatment facilities. We now have some counties running dialysis centers and critical cares facilities. This is all very commendable.
There is however one stand out acquisition by nearly all the county government hospitals. Ambulances. Some bought, some hired, some as donations. But they can all be seen moving from point to the other, ferrying the very sick or critical.
Our referral system has been set up in a way that conditions that cannot be handled at that level of care are sent up to a higher level or better suited facility. But this process can be painstakingly slow and arduous. This perhaps might have informed the big investments that county governments incurred to procure these machines and vehicles. Enabling faster transfer of patients in critical states.
But sometimes a very important link in this process gets broken...

Her breath was coming to her in short raspy gasps. Visibly restless and distressed, she was in a state of progressive systemic and physical deterioration. This was clearly beyond here but here she was...
An initial assessment, propping up, intravenous access and vital basic tests. Then a protocol of jabs that will go a long way in sustaining her greatly threatened existence. All this as the referral arrangements are ongoing.
So the phone calls begin..
The first public hospital referral..
Me; hello, is that K Hospital?
KH; yes.
Me; my name is (my name) and I am calling you from (my facility) over a patient I am referring to you.
KH; yes, what is the patient's name and what is their problem?
Me; (give brief history) is in severe respiratory distress, pneumonia, could be tuberculosis.
KH; have you done a sputum test on the patient?
Me; c'mon, only done the basic tests now...
KH; what are the vitals?
Me; okay (I read all the vitals to her)
KH; what else have you done?
Me; the usual pre-referral management...
KH; but why do you want to refer the patient to us?
Me; okay I cannot offer the patient anything more than what I have done so far. Definitely requires respiratory support and hospitalized management.
KH; Sorry but I thought you had heard we are not admitting any patients...
Me; I have not heard it. Where and when did you broadcast it?
KH; we are on a go slow so we are not admitting any patients...
Me; tell me one thing though...
KH; yes, what?
Me; how is this patient to be assisted? What would you do if you were in my shoes?
KH; I don't know. Maybe try M hospital. Sorry but we can't help you.
Me; this is hard..
KH; try M hospital (hangs up)

It is Friday evening and by this time everybody is out of the facility but here you are calling up numbers.

Me; (after two cold calls) is that hospital M?
HM; yes. How can I help you?
Me; my name is (my name) and whom am I speaking with?
HM; (gives me her name) where are you calling from?
Me; I am calling you from (my location) I have a patient with this and that I want to refer to you right away..
HM; what have you done for the patient?
Me; the basic pre-referral treatment. She is not in good condition and thus the need for further treatment. That is why I am calling you.
HM; sorry but right now we don't have bed space for the patient...
Me; let me ask you something...
HM; yes. please..
Me; how are we to help this patient?
HM; try KH...
Me; I just called KH and they told me to call your facility...
HM; they told you to call here? Why can't they take the patient?
Me; damn, something about a go-slow...
HM; of course we are on a go slow.
Me; Okay, so what happens now?
HM; I don't know...sorry (hangs up)

So here stranded with the patient. The ambulance we had called is here. But what to do now? Patient can't afford private hospital treatment and even despite her very sick condition says that she will just go back to the house! That must be a silly joke...

So on a Friday evening having to call to call all these places and ending up with negative responses is just a rude jab in your face...
Your Friday can wait but what is the real meaning of this sad scenario? That we still will see more and more senseless morbidities and mortalities of this nature despite all the investments in this area?
What is going on here?

Tales I Get To Hear: Urban Poverty, Inner City Crime: The Vicious Cycle.

The two teens lay on the hard concrete, lifeless, shot through the back at close range. The crowds milling around, some excited, some shocked, others just there, not sure what to make of what they had witnessed. Two lives albeit young ones had been snuffed out by the police. Accused of a host of crimes in the neighborhood, the 'worst' being the gunning down of a police officer. Once they crossed that red line, they became goners. The official Walking Dead. If they had just kept to their usual backstreet and dark alley ways and blood sport mischief they perhaps would have survived longer. Just perhaps.

The previous week as I went about my work in one of our facilities in the vicinity of the incident I had met a lady who had missed her appointment since early December last year. I had asked her, "How come you missed your appointment?"
"It's a long story daktari!", she had solemnly responded.
"Huh, long story, what long story is this now?" I had just asked in a matter-of-fact manner.
"I had taken my son to my mother's place"
"But what about him and what about it?" I had inquired.
"My son was shot by the police, so I was advised to take him somewhere where he could be safe. I could not easily find the money for transport back. That is why I have delayed.
"The first time they shot him they only hit him on the hand but he was rescued by a Good Samaritan who hid him in his house. But the other boy was not lucky, he was killed.
"Now tell me something, what had your son done?" I had asked her with a rising curiosity.
"My son is very innocent and obedient but the police claim he is bad. So they traced him again and swore this time he was not going to survive. In fact it was just the intervention of my neighbors and the area elder who know him that the police released him otherwise he was being taken to be finished.
"So what exactly does he do? Is he school going?"
"No he completed school last year. He has just been doing odd construction jobs here and there ever since. He had been helping me a great deal with the other children.
"How many children do you have?" I delved deeper.
"Daktari I have ten children." She had frankly replied. I had just stared at her not able to determine whether she was stretching this. In my mind I was trying to picture the family of ten plus in their modest shanty. However seeing my disbelief she had gone on to clarify. That two were actually grandchildren and that she was taking care of two other foster children. This did not even make it any better. Two of her children were not mentally stable and required constant watch.
"And what is it you do for a living?"
"I used to prepare and sell bhajia but now I have stopped, it has been hard to raise any money to buy the necessary items. So now I just go to the food market to scavenge for any discarded foodstuffs so I can fix something for my children. Everyday.
"Husband?"
"He died many years back."
"Do you think your life is better off here or in your rural home?" I had pointedly asked her.
"Daktari we don't have any home to go to. My husband just had a small piece of land which he had sold off a long time ago, we even had to negotiate with the buyer to grant us just a portion for his burial site.
I caught myself in the middle of musing, "damn, what a concoction of problems". Aloud I had said, "Anyway you have to realize that your health is of supreme importance. No need to emphasize that. The moment your health will start failing is the moment your problems will multiply.
"I realize that daktari, it won't happen again I promise.
You do not have to promise anything, already there is a problem as you have been told before. You just need to realize that you have a little chance of making amends.
"That I will take seriously doctor.




That was how we had ended that little conversation; with her promise to be more keen on her treatment...It was the third time in a few short years that she had been going off medicines for months at a time...

When I was a seventeen year old lad I was still very much within the thrashing range of my old man's cane! This however did not restrain me from engaging in the usual boyhood hanky panky only that it remained discrete. For instance me and my friend Caleb were doing each other favors that you can only imagine and covering for each other. Our afternoons could be spent listening to all of Bob Marley songs. Caleb was of a musical orientation but he could not get around to loving the genius that was Tuff Gong. But we listened to him anyway. Or our afternoons could be spent at some church or school where he would be training the choir. I learnt very early on from him how hard the world of labor relations was; I candidly remember him lamenting how church work had been turned to school work and school work into charity, meaning that the churches which he had offered to train for free for lack of stable means were indeed appreciating him by way of a little allowance whereas the schools which had agreed terms with him took him round in circles concerning his choir training dues...
Some days however we could spent in very vain pursuits away from our homes! I was the man of letters from an early age and was the go-to man if you wanted a penned message home. Caleb was the more practical man who got us through tight wires with his brusque, fast talk. On hindsight I realize how ridiculous we really were, getting all those passes. But all this was the usual coming-of-age experiences. Nothing too alarming. One day however I think I was getting too bold and convinced myself that I could get away with shit and that was the day that I got a stark reminder that I was not really out of the reaches of the old man's wrath..
What happened was that me and a younger uncle of mine went off to an overnight vigil of our friend's departed mother far off from home. Nothing wrong with this only that we did not have the requisite stamps of approval before hand. We just decided and off we went. Now considering what debauchery and licentiousness that actually took place during that night I believe there was no way any right thinking and responsible parent could have okayed such an outing...it could rank very high on the scale of irresponsibility!
When we came back the following day we found a reception party awaiting us! That was the first time I intensely hated parental authority...but I saw the error of my ways and with submission accepted what befell me...

The mood in the consultation room was icy. The mother to the seventeen year old boy who sat before us was just distant and obviously distraught. She had brought the boy to the facility after he had hurt his hand in unclear circumstances two days earlier. His official story was that the sharp edge of a door had cut him. Of course this was not in dispute but where this had happened and the actual events was where the diversion occurred. The suspicion was that it had been during a break-in. No way to verify this.




He was only seventeen, had dropped out of school and under the overwhelming influence of bad friends had been led into the quicksand that is drugs, alcohol and petty hood notoriety. His laid back mien and diminutive figure were very deceiving. But we had done a lot of work in talking him to reformation. Already he was showing signs of breaking off from the firm grip of his bad ways. You are here lazily thinking he was just a random neighborhood delinquent? Wrong. The mother held a very decent job in a reputable firm and his siblings were all comfortable in university. He lacked for nothing and absolutely nothing such as lack could have been the cause of his straying off the narrow, clean path. The mother had been too shaken by this turn of events. A black sheep right under her roof must have been such a stigmatizing reality that she had left the house and was now living with a relative...all over the neighborhood cases of youth falling under police bullets were reaching a crescendo and she feared for her son. A week before that she had told us that a boy she knew so well had been the victim and even though the particular circumstances remained contentious there was no denying the fact that at some point he had fallen off the right way. And so it happens that in the neighborhoods scores of young men many of them hardly out of their teens are living life on the edge. Neither schooling nor gainfully employed. Just hours on end to spend as they wish and what was it that was said about an idle mind?
With parents mostly mothers dead worried every waking day about their safety. Will it be the policeman's bullet or an irate public mob or will it be at the hands of a rival gang or a fallout?
But what happens if they happen to survive the minefield that is hood existence? No valuable skills to sell, a formidable mass of unemployable youth laying a claim to their stake in our midst...

The mothers in tears with stifled fears.
The unforgiving streets will eat their own..
And so merciless are the hood corners; an evil snare.
The fathers are all gone, so it's just the mothers in their tears.
The town that promised a little gold is now a hard shapeless rock.
Weeping for their sons.
The sons who grew out of hand..
The streets taught them twisted philosophies, chewed and spat them out.
Fattened them for the slaughter..
No vocations, no employment; just one hell of time on their hands.
Running the streets to run from lack, but how sadly it all ends..

Let Us Close Down The Godamn Hospitals...

Being thankful about the gift of life is a constant reminder we encounter on the regular. Maybe daily! Even if the quality of life is poor there is always the insistence in hoping for better days. That the tide might change in our favor one coming day. But we have to strive to remain alive first!
Health is a broad entity that encompasses both physical, physiological, psychological, emotional and environmental characteristics that individuals possess and experience at any given time. It is without any doubt one of the key indicators of the quality of life. An emotionally upset person for instance is least likely to actually partake in the normal expected humanly pursuits or activities and even if he did is less likely to actually enjoy or end up with good outcomes. This applies to the other characteristics of being.
It is noteworthy however that most of these swings in health are transitory, tolerable and short lived. No one is able to maintain a perfect health status all the time! This being stated it is therefore logical to assume that ill health affects the quality of life if it is acutely severe or becomes particularly prolonged. Then the amount of material, financial and time resources that are diverted towards the illness are not to be ignored. Appeals for public help in offsetting sky-high medical bills is an all too familiar and common feature on both mainstream and social media networks.
If you want to enjoy good health then for heaven's sake do not get sick! Prevention is better than cure on many scores as the age old advice tells. As simple as this premise appears it is of utmost significance in this matter. But it is in human nature to ignore simple sounding advice...we have to learn to live with this inexplicable stubbornness!
The Kenyan public health care system devotes a proportionally big amount of resources towards the curative services. This may not be a deliberate strategy but might be prompted by lackluster success of the preventive strategies in addition to many other unique and varied factors that boil together to give a portent concoction of poor health indicators and outcomes.

Patients wait for services in a public hospital.

Deserted patient waiting areas during the recent strike.

What this scenario means is that our healthcare system is actually hinged on having our health care workers at their places of work all the time. We can hardly afford our doctors, nurses, psychologists, psychiatrists, pharmacists, physiotherapists, oncologists, laboratory technicians and all the coterie of health care workers vacating their positions in our facilities. The situation is however true even in the most advanced of nations.
These people have sworn a commitment to do their work in whatever conditions to all who need their services. It is thus the least of our expectations that we can ever come to a situation where they are withdrawing their services...
But it has happened. Again and again. Both at the national and county levels.
Health care worker strikes are a frequent occurrence here. That is the fact. But what happens when these people are away? How is the general health seeking public served?

Kenyan doctors' union officials under arrest.

Documented and accurate statistics are scant on the actual toll and casualties of these strikes but if the public outcry and lamentations during these times is anything to go by then we must have a situation of significant magnitude. The situation is compounded by the poor penetration of health insurance that may enable access to services at private health facilities. Even then the congestion and throngs that is usually observed at these facilities is not a good indicator of the bigger situation.
Working in any of the peripheral, faith based or government partner organizations will afford one a very clear impression of the situation. Getting stuck with patients who need lifesaving procedures or higher level treatments is traumatizing and emotionally draining. What is one supposed to do observing patients' cancers progress from stage to the other right under their own eyes because the only affordable oncology program has been shut down?
In a system heavily dependent on curative services procured at public health facilities it does not require genius to figure out where the majority of the patients end up. For one, these people prefer these services because they are either free or heavily subsidized hence affordable to a majority. Withdraw these services for one day and you get a fine serving of anguish.
One may be able to count the number of the dead or the ones whose conditions got out of hand due to the disruption in services provision. What is harder to quantify is the economic toll that is suffered.
The grey area in our jurisdiction is who to hold to account. When relations between health care workers and their employers sour it is the patients and other consumers of health services who bear the brunt. But who between the two is to be held to account?
Health care workers have a horde of issues they want addressed. Both the national and county governments agree that there are indeed issues that need addressing. The harmony however ends there. Conflicts arise on the 'how to'.

The twenty something old lady timidly entered the consultation. She had brought her nine year old daughter for attention. She was also clutching her infant son. It was at the height of the strike late last year. The daughter had fallen on her outstretched arm a day earlier and it being a Sunday she had waited for Monday to come to the facility. On asking why they had to wait;
"Government hospitals are not working!",
Me: But it is only doctors who are on strike, the others are on duty.
Her: what difference does it make, I have heard there are no services there.
Me: no, there are some services that are being offered. I know they will be able to handle this.
Her: but will I need to pay for anything?
Me: most definitely for the x-ray and maybe plaster application.
Her: how much?
Me: not sure how much.
Her: okay this is the thing daktari, I have no money and you have to assist me whichever way you can.

She is just one of the many many Kenyans who have to do without doctors and nurses and other health professionals frequently when these people go on strike.
What happens when hospitals close their doors is nothing short of a nightmare for the fickle health of the general public. Scenes of gravely ill patients being taken home can only remain so distant till a relative or acquaintance is affected. Then the stark reality that indeed something needs doing becomes very urgent.
And more innovative and captivating disease prevention and health promoting messages need to be adopted by the concerned bodies. There is no shortage of the creative resources that we need to harness in this seemingly overwhelming strategy of healthcare provision.
'To be alive first' remains my personal commitment because I don't want to have to contend with closed hospital doors when I certainly need them open!

The Problem With Some Schools of Manners!

"Primum non nocere", First do no harm.

This is the premise upon which the whole noble profession of medicine is built. The Hippocratic Oath that graduating clinicians take is a solemn vow that affirms a commitment to this philosophy of only making well again and causing absolutely no harm. This is the whole essence of the Oath. The practice of medicine just like the practice of other professions has its toll on the practitioners.  But whatever the case this is the holy ground whose desecration has to be watched against. Do no harm is thus loosely the first law of medicine. In medicine however so much to the contrary has been observed. Left right center you hear of and experience treatment that is quite the opposite of this noble practice. Why? There is a whole load of reasons..

My interactions with both younger and older colleagues has made me appreciate that indeed old is gold. Nearly all of the elder practitioners strictly adhere to the code of ethics of practice. So do a significant number of the millennials. Every generation has its stock of bad eggs though! But we have so many cases of professional malpractice observed in the younger pool. Why? A whole lot of reasons. For instance it is a silent unwritten expectation that colleagues will not charge you for consultation. You observe this more in the older group. This has not prevented them from having brilliant, profitable and fulfilling practices. But now you have recent graduates who are so aloof, arrogant, petty, commercial and strikingly under-read waddling along hospital corridors with a feeling of self importance...one can only observe them as a scientist would observe a recently discovered specimen of existence.
It has to be noted that many do not really grasp what they are signing up for. This coupled with the very persistent hiccups in the health care delivery system can only worsen an already bad situation.

Some day in December I get this call. That one of my uncles is admitted in hospital, gravely ill. Well I know this hospital well and so my anxiety is sort of relieved. It is not that I have a few people over there but that I am in position to go there myself. And so the next day me and two of my cousins jump in a van and when we arrive at the facility I find out that true to what I heard he is in a pretty bad way. But what strikes me as odd is why despite being evidently dyspnoeic he is on no respiratory support. I inquire from the nurses and they direct me to the doctor on call. It happens that I had called a doctor acquaintance of mine who referred me to this very doc.
He comes after  a short wait and goes to the bedside. He requests for space and time to review the patient. We politely give him time to do his work and so wait outside. One hour later we come back. I request him for a little conference. He tells me what they are doing which is alright. However something is bothering me; the lack of oxygen support. When I point this out he tells me they will do something about it. But that is not even my biggest concern. What is causing the breathlessness? I ask him what he thinks and he tells me the patient is on antibiotic cover for what he believes is a bacterial chest infection. In reality this is ducking the question. "Your uncle is very sick", he bluntly tells me that and I try to shut out what this is supposed to mean.
"I can see that doc, I know you have covered him for bacterial pneumonia but don't you think it could be pneumocystic pneumonia or even tuberculosis?" I ask him having absorbed everything.
"I do not think so!".he responds in apparent agitation. But I press further, "You know PCP is a diagnosis by exclusion".
"I know what I am doing my friend and if you think otherwise then you are at liberty to take your patient elsewhere". He snaps and this surprises me. "But I was only trying to point out something doc, I have not come here to discredit you or any one else for that matter, it was just a polite observation".
Then he does two things; requests for a piece of paper to write the transfer letter and then engages my acquaintance in a long phone conversation, proceeding to tell him how he won't be taught biochemistry and pathology again, he already had enough of that in cold, hostile campus lecture halls!
We step outside for a little deliberation with my cousins and they really cannot start to fathom the perils and trouble of a referal to a public facility nearly one hour away. But it is very clear that our patient is far from getting the optimal care and so this little discussion is of mighty weighty significance. I am seething with internal rage but I try to keep my cool lest I jeopardise things. But I am enraged at this treatment and many things are going on in my mind.
When did doctors begin to be so aloof and distant from the people they should be serving? Of course this is not a new observation. People have always been aloof and distant since time immemorial and some are not even improved with time, privilege and education. But when did doctors and other health care workers start to actually believe they are the only people who matter in patient care? And how on earth are they able to get stingy with information about their patients? (this is not a breach in confidentiality) But just how did HCWs start to treat fellow colleagues thus?
We go over the merits of each course of action and we agree to let him stay here because of the nightmarish scenario that relocating a gravely ill patient will present and by this time the patient has been put on respiratory support and this is perhaps the only reason that sways my opinion.
I seek the doctor and try to speak with him.
"Doc I hope you are not offended by my persistent intrusion."
"No, I am not." he responds.
"Well, you must realise that mine and everybody elses' aspirations are the same; we all want the best outcomes for patients who happen to be relatives." I quip.
"But you must give us time to do our work, you know we get overwhelmed with work!" he retorts. I am in no moods to pursue this conversation further and so tell him to consider my opinion on the patient.

My uncle passed on in the night...and the grieving was not only for his passing on but for this disturbing occurence I seen happen pretty often.