Roadside clinics, tiny hospitals led to 'shotgun therapy'

Roadside clinics and tiny hospitals with only a few beds often treat patients on the basis of a deficient evaluation that leads to incorrect diagnosis and shotgun therapy. [iStockphoto] The Maseno Mission Hospital, a few single-level buildings clustered below a hill in southwest Kenya near Lake Victoria, is accessed by a dirt road that passes through a school President Obama's father attended. It has adult male and adult female medical wards and pediatrics and obstetrics units-about 40 beds in all-and buildings for basic radiology and laboratory services, records, pharmacy and administration. The verdant surroundings, songbirds and vervet monkeys playing in the trees belie the suffering inside. During the three weeks when my wife, a retired registered nurse, and I volunteered there in 2010, we were amazed by the great resilience, warmth and hospitality of the people. Nominally sponsored by the Anglican Church of Kenya, the hospital hobbles along on a little church support, minor government assistance, donations from the US and the United Kingdom, and fees collected from patients. The administrators try hard to collect payments, even refusing to release of deceased patients until the family pays the hospital bill. Until his recent departure from Kenya, Gerry Hardison, a retired San Diego gastroenterologist, had worked for more than a decade caring for patients. I decided to volunteer at his hospital because he welcomed the assistance and I wanted to work in Africa. I had done medical work in two other underserved areas, St Lucia and the West Bank (Palestine), but many of the challenges in Kenya differed markedly: The hospital lacked basics I could have supplied such as soap, thermometers, and workable syringes. Dr Hardison used a briefcase-sized ultrasound machine to extend his examination of the chest, abdomen, and pelvis and to measure fetal head size. I was impressed that so many diagnoses could be made without consultants and modern diagnostic tools such as computerized tomography. Illnesses or disease stages common in Africa are inextricably linked to the physical environment, poverty, and cultural milieu. But there were other challenges: High unemployment and low wages, alcoholism and abuse of women and with regard to HIV, the small Maseno outpatient clinic had about 5000 registered cases while language barriers caused difficulty in obtaining medical histories. Transportation difficulties and pervasive poverty have major effects on health care. Patients with chronic illness usually purchase only a few days of medication before discharge and cannot obtain more. Thus, proper treatment and monitoring of hypertension, diabetes, and other chronic disorders rarely occur; treatment of acute disease, especially infectious disease, is most effective. Long-term treatment of HIV is an exception, as an American agency provides drugs, some of which are taken to remote villages by motorcycle riders. Generally, health care is poor in Kenya. Roadside clinics and tiny hospitals with only a few beds often treat patients on the basis of a deficient evaluation that leads to incorrect diagnosis and shotgun therapy. Dr Hardison often measured patient temperatures with his own glass thermometer. However, these deficiencies must be viewed in light of the circumstances: some of the staff struggle with HIV themselves, child care is lacking, and home life is rough: One nurse often brought her child to play in her ward while she worked, and another nurse came to work with a forehead laceration inflicted by her husband. While surgeons repaired an inguinal hernia, I saw the anesthesiologist walk out of the operating room and remain absent temporarily. One of the greatest contrasts with American medicine that I noticed was a detached attitude toward relieving pain. Not only did patients accept untreated pain more readily, but often nurses did not independently give medication for pain. I think life is so difficult, suffering and death so common, and individual empowerment so limited that acceptance of one's own pain occurs routinely and relieving others' pain has little priority. Dr George F Longstreth is a gastroenterologist, Garfield Specialty Center, San Diego, California. Editor's note: This article was extracted from "Wherever You Go, Remember Africa": Memories of a Medical Experience in Kenya, in the Permanente Journal, 2013

Roadside clinics, tiny hospitals led to 'shotgun therapy'

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