As a second year OBGYN resident based in San Francisco, I spent my second year elective at the Kenyatta National Hospital (KNH) in Nairobi, Kenya. The hospital is referred to locally as KNH, the largest referral hospital in East Africa. KNH is a public hospital, meaning it is largely funded and subsidized by the government. It is also the oldest hospital in Kenya. Officially, it has an 1800 bed capacity, although in reality it houses two to three times that number of patients. It is also serves as the main teaching hospital for the University of Nairobi Medical School, the Kenya’s oldest medical school. It provides subspecialty care in many fields including Urology, Neurosurgery, Gynecologic Oncology, Orthopedics, and specialty HIV care among others. It recently launched laparoscopic surgery for some of its clinical departments. It is also the site of many research collaborations with faculty from the University of Nairobi, and from Kenya Medical Research Institute, KEMRI, and other local research institutions. It also hosts a number of international research and clinical collaborations including with the University of Washington in Seattle, the National Institutes of Health (NIH) through the Fogarty Research fellows program, and the University of California at San Francisco, among others.
As an OB-GYN resident training in San Francisco, California, my experience at KNH was typical in certain aspects, but atypical in others. I grew up in Kenya. I have family in Kenya. I went to primary and high school in Kenya, before migrating to the U.S for college and medical school. Compared with your average American medical resident, I am quite conversant with issues related to poverty, weak health systems, and scarcity of trained health providers that are commonplace in places like Kenya. I was born in a small district hospital in the Western part of the country, where the physician to patient ratio is woefully inadequate. This ratio was estimated at approximately 1 physician for 10,000 people, compared to the U.S where it is 27 physicians for 10,000 people. I obviously can’t remember, but by all accounts a nurse midwife likely delivered me. Pregnancy is a health risk for women in many parts of Kenya, and other low-income countries. Because of the weak health infrastructure, poorly funded public health systems, few doctors and nurses, lack of emergency medical care in rural areas, maternal and neonatal mortality (mother and infant death surrounding pregnancy and childbearing) is unacceptably high. Unlike in my hospital in San Francisco where you can have a trained neonatologist at hand for any high-risk delivery, 24 hours a day, in Kenya most of these hospitals don’t have one within miles. An infant born alive in many such hospitals, but in need of newborn resuscitation and support is very likely to demise within a few minutes of life, resulting in what is called a neonatal mortality. Thankfully, my mother never experienced a neonatal mortality. But, like many Kenyans, I know many women who did.
This was the context in which I walked onto my elective. I had previously done Global Health work in Kenya, ranging from research and advocacy, and a small amount of clinical work. But this was the first time I was actually a doctor, a resident, and more importantly, one who was training in a “far from perfect” but a more functioning health system that is the West.
The grounds of KNH are gorgeous. There are well-maintained lawns, and blooming flowers from the blazing sun. Kenyans are friendly people, not in a hurry, quick to offer a smile.
One quick realization one has as an American trained physician is the volume of patients. There are a lot of patients, in the wards, in the hallways, and waiting to register. In our labor and delivery unit in San Francisco, on a high census day, you’ll have 12 -15 laboring women, and another 3-4 in triage, at a time. We typically have anywhere from 2-4 residents on at a time, and almost always with 2 supervising OB-GYN’s on. This is the standard of care.
On a typical day in December when I was at KNH, the labor unit had 40-50 laboring women, often times more. And this was the low season, as my Kenyan colleagues explained. The numbers can come close to double during peak months, with no change in the number of providers. The patients ranged from normal low risk labor to those with HELLP syndrome, multi-fetal gestation, preterm labor and other complications. Two residents – one running the floor and the other in theater and about 3 – 5 nurse midwives ran the unit. A supervising OB-GYN (referred to as a Consultant) was there for morning and evening rounds, and on call in case of emergencies. How can two residents safely run a labor ward of 40-50 women, some of them very sick?
In San Francisco, with glance at the ‘electronic board’ (large screen TV), you can tell how many patients are in house, when a woman ruptured her membranes, when she went into the active phase of labor, and how long she has been in the second stage of labor. At KNH, it was obviously impossible to know this amount of detail for the volume of patients at hand, or to easily access it, given paper charts. It is true to say that the quality of care these women receive is greatly diminished by the small numbers of providers caring for them, the lack of facilities, use of paper documentation, among other factors.
Because of this high volume, unlike San Francisco where you have on average two scheduled cesarean sections a day, the operating room at KNH labor unit is always running, day and night. A different resident is assigned to do the scheduled cesarean sections, and once again, has an attending on call, but not within the premises. On a normal shift, this resident scheduled in ‘theatre,’ as the operating room is referred to, will do an average of 6-8 cesarean sections, often more, depending on their speed.
There is a running list of patients waiting for cesarean sections, which is divided into two, elective (non emergency) cases vs. emergency cases. Both lists spanned 8-12 names at a time (the elective list often much more), with new names added every hour. It didn’t escape my attention that there was a wait list for emergency C-sections (some of whom would wait hours before they get to the operating room) as by definition, emergency C-sections should be done as soon as possible, and usually within 30 minutes.
Surgical care provision at KNH too was different. Surgical principles are largely the same around the world. But unlike San Francisco, there is not unlimited suture availability, you often have no routinely available electro-cautery to easily achieve hemostasis, and sometimes anesthesia capacity is limited. As a result of these constraints, the residents I worked with were excellent surgeons in many regards, as they had trained in this system. Many were able to do a C-section in 15-20 minutes, as anesthesia would sometimes tell you “I am are running out of anesthesia…” At the same time, their ability to optimize surgical outcomes for patients was often limited, for example, but use of a large suture on skin resulting in poor cosmesis. More crucially, without routine availability of Physician Anesthesiologists (due to human resource constraints) supervising the nurse anesthetists, a surgery may need to be aborted earlier, or a patient experiences a preventable morbidity due to anesthesia constraints.
With time, exposure to this system can breed apathy amongst residents and providers, as the system issues constraining care provision are immense.
It was wonderful working with and getting to know Kenyan OB-GYN residents at KNH. Unlike U.S OB-GYN residents, they have undergone a comprehensive internship year, often in a rural hospital, where they rotate in the major disciples (obstetrics/gynecology, surgery, pediatrics, internal medicine). Within a few weeks of being there, right out of medical school, they are forced to work independently because of the scarcity of supervising physicians. As a result, most of them are very technically skilled, often having 200 or more C-sections under their belt by the time they start their first year of OB-GYN residency, majority done independently.
I was always met by looks of surprise when I told the Kenyan residents that I always had an attending physician across the patient when I operated in San Francisco, even for primary C-sections. This is largely unheard of for them.
One night on call at KNH, a second year resident operated on a very sick pregnant patient with HELLP syndrome, with very low platelets, as sole surgeon, with a clinical officer anesthesia provider. There were no blood products on hand in the room, although technically available in the blood bank. The infant was to be born prematurely. There was no pediatrician, or neonatologist on hand for resuscitation.
This high level of independence, and even technical expertise on the part of residents at KNH and other places like it, borne of the low physician to patient ratio, and overall scarcity of providers, comes at a great cost to patients.
In San Francisco, if operating on an acutely ill patient with HELLP, multiple blood products would be in the room, ready for intraoperative transfusion if necessary. A senior Anesthesia attending would no doubt be present, backed by a certified nurse anesthetist or another attending. The presence of an OB-GYN attending in the case would not be negotiable. A pediatrics team would be on hand, ready to receive the infant for immediate resuscitation. The pediatrics team would certainly involve a Neonatologist, likely a pediatric resident, and two NICU (neonatal intensive care unit) nurses. Multiple pieces of equipment would be at hand in anticipation of a difficult resuscitation, and likely stay in the neonatal intensive care unit.
Luckily, this mother at KNH did fairly well, recovering from her surgery, which was mostly uneventful, and was able to go home. But not her premature infant, who received inadequate resuscitation, given the constraints of the system she was born into, and demised within a few minutes of birth. Most who have seen a more functional system would say she didn’t quite get a fighting chance. Unfortunately, this is the norm in many low and middle-income countries, where under different circumstances, mortality would likely have been preventable.
As physicians and residents with interest in global health, we are aware of the great disparities that exist between disease incidence, and health outcomes in high-income vs. low-income countries. Spending my days at the wards in KNH, it was easy to see how this came about.
With such high volumes, providers were stretched thin and quality greatly compromised.
How do you promote infection control when you have two laboring women sharing a bed?
How do you decide whether to deliver a woman with a severely growth restricted preterm fetus, when you know the lack of neonatal intensive care capacity will likely result in death soon after delivery, yet continued pregnancy is also dangerous for this fetus? A decision made even harder with the knowledge that this patient lost two prior preterm infants under similar circumstances.
How do you ensure adequate nursing attention to a preeclamptic woman, among many such patients in a large ward, who goes into preterm labor and delivers the previable infant on her bed, when the same nurse has 10-15 laboring patients, of equal medical acuity, to attend to?
Such was the situation providers at KNH faced on a daily basis.
As an American trained resident, it was certainly shocking, saddening, and overwhelming. Despite one’s best intentions, passions, and hopes, there is a huge sense of powerlessness to affect real change given the extent of systemic issues.
It’s equally as hard on the Kenyan residents, who have the medical knowledge to save lives, but often have their hands tied by issues of patient volume, inadequate staffing and supervision, overstretched health systems, lack of adequate equipment among other issues. Over time, this breeds apathy, if for no other reason – as a defense mechanism “for one’s sanity,” as a resident once told me. It’s hard to see tremendous suffering and unnecessary morbidity and mortality around you everyday and feel helpless to effect change.
One of the residents I worked with put it this way, “It’s sad and hard when you tell a mother for the first time that their newborn has died, but when you do it for the 20th time, it becomes almost routine.”
It was easy to see why Paul Farmer, a prominent figure in global health, said that countries need “staff, stuff, and systems” if improved delivery of healthcare was to occur.
In an increasingly global world, American medical residents, including myself, have the opportunity and institutional support to spend time abroad, participating in delivery of health care, as well as to getting a sense of the health challenges around the world. We get exposure to surgical cases and volume that we would not have access to at our home institutions. We improve our skills in many ways. Most experts in global health education would agree that visiting scholars often times benefit more than host institutions.
While at KNH, I kept asking myself, what more can American institutions do to be part of the solution? Sending American residents to these settings is great in trying to generate more interest in international work by these trainees, but how can we support the national trainees, who in reality are the real foot soldiers?
Pursuing more equitable global health partnerships is one place to start. When I told the Kenyan residents how the OB-GYN unit in San Francisco was run, they were often surprised at the patient volume, immediate availability of resources, staffing ratios etc. What if American institutions sponsored international residents to spend 2-4 weeks in American hospitals for every American resident who goes abroad? The exposure to a different system, and change in perspective could be a great catalyst that can precipitate change in the local institutions as these residents rise to become hospital administrators and health leaders in their countries.
- Kenyatta National hospital, knh.or.ke
- Kenyatta National Hospital. https://en.wikipedia.org/wiki/Kenyatta_National_Hospital
- Who Lives and Who Dies? The most important lessons from decades of global health care. Paul Farmer. Slate.com. http://www.slate.com/articles/health_and_science/medical_examiner/2015/03/global_public_health_development_goals_paul_farmer_on_who_lives_and_who.html