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Monday, October 17, 2011

A Tale of Two Hospitals

In the massive, sprawling, congested city of Nairobi there are two hospitals.  There are actually many hospitals, but these are two of the most well-known, and since they host he only two paediatric residency training programs around (there is a third program in Eldoret at Moi University) they are the two that I've wanted to visit.  Since we have a visiting paediatrician in October as well as back-up from another visiting med-paeds ICU doctor, we came up with the grand plan for the three long-term Kijabe paediatricians as well as our colleague who runs the Neonatal community health program here, to take a field trip.  Together. 

So yesterday Mardi and I set out in the mist at 7:30 to drive into the city, where we met Immaculate and Mary (who live in Nairobi). It was an 11-hour eye-opening day.

Our first stop was AKU, as upscale and private as it gets in Africa.  This is a hospital where one needs a culture-shock debrief to leave the doors and re-enter the rest of the world.  It was established by a wealthy Persian hereditary prince, as part of the world-wide foundation that promotes development in the name of that particular branch of that particular religion.  We were treated royally as well:  greeted by the department chair, hosted to tea and sandwiches, invited to interact with all available faculty (all Kenyan, young to middle-aged, professionally styled, friendly), then given an extensive tour highlighting such technological wonders as the completely digital radiology department, nuclear medicine scans, well-equipped intensive care, state-of-the-art linear accelerator radiation therapy, carpeted luxurious hotel-like super-private wing where all the diplomats stay.  The Paediatric ward is new, bright, sunny, clean, creative, calm.  They have about 25 beds, with probably 20 kids.  The neonatal ventilators and monitors were state-of-the-art, and only two babies had the full-time attention of a nurse and a doctor.   The clinic has huge exam rooms, and a handful of well-dressed babies waited to see the consultant.  I felt like I could have been in any suburban high-quality American hospital.  This program takes 3 or 4 residents per year, who are paid to work there.  The only drawback for them is that the patients are all private so they are superseded by the private consultants to care for them, and the spectrum of disease can not include much that is common and poverty-related, because only the wealthiest Kenyans (or best-insured) can get in.  These residents already rotate at Kijabe for their surgical month, and we will now be on the lookout for improving their general paediatric experience while they are there as well.  We've referred a couple of patients back and forth, and it was good to find out about the wealth of subspecialty consultants there.  But few in our population would afford care at AKU.

From there we fought traffic (actually it was surprisingly not bad) across town to Kenyatta Hospital, the massive historic public institution and main teaching hospital for the University of Nairobi (medical school, nursing school, clinical officer school, public health).   Multi-storied, with dark stair wells, marginal cleanliness, obscure arrangements, a bit of a prison/institutional atmosphere, and CROWDS of patients.  The architecture was reminiscent of Mulago and Mwanza, I wonder if they were all constructed in the peri-independence colonial days of the early 60's, with open-air halls and central courtyards, unpainted grey-yellow stone stucco, formidable.  We sat in on the weekly Paediatric teaching conference, which was amazing, led by a personal hero of mine Ruth Nduati who proved that bottle-feeding HIV-affected infants was MORE DANGEROUS than exposing them to potential HIV infection through breast milk.  She is the department chair, and brilliant.  Here they take 25 or more residents per year, who sat in a steep lecture-hall with it's old furniture and peeling paint.  After the rounds we met a neonatologist (both she, the chair, and another lecturer were 50-something sorts of well-established academicians) who took us to see the newborn nursery and intensive care.  The space was brighter than I expected, and reasonably well equipped, with again the same amazing modern ventilators (only 3 of 7 functional) and monitors.  But 75 babies were crowded into what should have been space for less than half that many.  In the incubator room for the preemies, the babies were turned sideways to fit two or even three in each plastic box.  Mothers stood shoulder to shoulder with their hands through the little doors doing feedings.  Every inch of the other rooms was cluttered with cots, chairs, parents, files, etc.  Sometimes there are up to 20 students as well.  We had a good talk with the charge-nurse about the challenges she faces.  From there we toured one of the four Paediatric general wards, each with about 50 beds but bursting with a hundred or more patients.  Again the bright yellow paint, oxygen, IV tubing, etc showed a fairly functional and active system, but the place was packed, room after room with more than one patient in each bed, milling parents.  One lady ran up to me smiling and at fist I thought she was mentally a bit off, but then I realized she was the mom of a patient we referred a couple of months ago who was still languishing in a forgotten corner.  My guess is that the over-taxed residents focus on the sickest handful, and the vast majority get little attention after admission.  The consultants round only two mornings per week and then they only see 5 or 10 or 20 of the hundred inpatients.  The emergency room was lined with waiting patients, but there seemed to be an excellent triage system in place, and a very sick child was receiving oxygen by face mask with a paediatric resident attending to him.  Patients pay small fees at Kenyatta, but for EVERYTHING, from a bed to a dressing to an injection to a medicine.  Overall the costs probably end up similar to Kijabe or a bit lower.  If you have a competent aggressive parent who can advocate and navigate and has a bit of cash on hand, Kenyatta has the expertise and resources for some of the best care in Kenya.  But for the masses of the bewildered poor, it probably turns out to be a frustrating and overwhelming place, easy to slip through the cracks.

I don't think there could be two more different hospitals in the same city offering such similar services. One is all about money, modernity, efficiency, customer satisfaction, excellence.  One is all about inclusion, the public good, stretching resources, making do, thinking nationally.  Both fill an important niche.  But you can probably tell my heart is with the latter.  It would require a strong heart to work there, because I'm certain that death is common.


Heidi said...

hooray for extra peds coverage help and for field trips. Remembering how you used to describe Kijabe coming from BGO :)

Anonymous said...

I know a professional in the field who would say that the Kijabe NICU offerings are superior to AKU, in spite of the money and new equipment. . .