Will the real healthcare crisis please stand up?

I can't decide which case is more troubling or unique,....is it the scrotal hematoma, ...or the roundworm impaction? Perhaps the adenoid hypertrophy or the circumcision that also resulted in injury to the ureter (which most certainly would be cause for a malpractice suit in the U.S.). The 16 year girl with Downs syndrome being treated for tuberculosis was interesting, but other than her Downs syndrome, not unique,... there's a lot of TB here. But I think the cases that most captured my attention were the Mother and two sons who had been sexually abused and consequent to "prophylactic" antibiotic treatment, developed gluteal necrosis, which is almost never seen in the U.S. Caused by injection techniques totally devoid of sterile measures, these infections were difficult for me to comprehend, but not for the rounding physician who I accompanied on this, my last day in Kenya at St. Mary's Missions Hospital. Dr. Johnson was well familiar with the unjustified horrors of the routine sexual abuse that occurs here. He understood that many face life difficulties here that have no basis of comparison in the U.S. He understood that for those without financial resources who face traumatic circumstances as a way of life, when medical services are needed, they can be found at St. Mary, provided by overworked, understaffed, yet caring physicians, nurses, pharmacists and others. St. Mary's will treat outpatients for 100Kes (Kenya shillings) (approximately $1.25) or inpatients for 350kes/day/bed ($5.00). Quite a bargain for health care, yet you will be seen, evaluated and treated for these prices. Its not Jefferson University or Einstein Medical Center, .... there may not be the latest medical technology or lab evaluations, but St. Mary's can be the difference between whether you live or die. Here, that's the very basic difference that counts. The very bottom line.

We've been in Kenya 42 days. During that time , we've established a solid and enduring relationship with the medical and pharmacy staffs of St. Mary's Missions Hospital, met with staff and faculty of the University of Nairobi, where I've lectured twice, and soon to be Drs. Cheam and Nguyen have collaborated with the U.O.N. pharmacy students, conducted five medical camps, toured Glaxo SmithKline Pharmaceuticals, M.E.D.S (Mission for Essential Supplies and Drugs),and met with individuals from KEMRI-Wellcome Trust to establish a method of database development for the hospital. So its been a busy time, and, an enjoyable time. Yet, I hadn't spent significant time in the medical clinics or the medical care areas, so as it turned out, when we asked who was doing rounds today and the response was 'no one', we did what any self-respecting physician and pharmacist would do, we started rounds. You see, St. Mary's is the sort of place where sometimes you work where you're needed. If you happen to be a physician and pharmacist team and no one has made rounds that day (for whatever reason), well,... you get the picture.

The pace is dizzying and exhausting, from the pedicatrics ward, to Women's Surgical and finally on to the Mens surgical,..with an array of disorders, discomforts, patients who have late-stage cancers, victims of road traffic accidents, those in need in skin grafts, and yes, those with necrotic tissue disorders consequent to inappropriate and incorrect use of antibiotics. We treat, order lab tests, correct orders, cancel some antibiotic use, discharge some patients, and overall, make sure that patients are receiving the appropriate care. Completing this, we move on to the outpatient clinic, where the pace is just as frenetic if not more so. St. Mary's sees more than 277,oo0 outpatients yearly, by the most recent estimation. Are there other hospitals in Nairobi? Yes, but none that serve the poor with the compassion and dedication seen at St. Mary's, and so, patients flock here. You can imagine that maintaining this pace on a daily basis, yields fatique, disconnection and often disillusionment. But those who keep this pace realize that the patient's need for care outweighs their need for rest (at least at the time). Its energizing but concerning to think about the over half-million people (patients plus those accompanying them) who come through these doors in need of physical and emotional healing. The goodnews is that, here, it can be found. The bad news is that the staff is overworked and 10 more St. Marys could maybe begin to quench the overwhelming medical needs of Kenyans. We finish for the day at St. Mary's,.. haven't eaten,.. we're drained emotionally, but excited about the child we were able to discharge because his adenoids were no longer swollen, or the women whose antibiotic burden was lessened because of the teachings from Drs. Cheam and Nguyen on pharmacokinetics, but saddened because of the 100 year old man who will die from prostate cancer because at this stage there's little to be done (his PSA was greater than 100).

But this happens everyday at St. Mary's,... a lot of patients are seen, yet only a small fraction of those who could be seen, ....if they could get here, ....if they had the $1.25 or $5.00/day for in patient treatment. The if's, like the why's, could fill this page...

We talk about the health care "crisis" in the U.S. But it begs the question,...even in the most desperate situations, will patients be denied care? Is there a way to treat all patients? Will medications be made available all, even to those who cannot afford them or are without health insurance? The truth is that even without the recent healthcare legislation, we all have access to healthcare. The question has been whether or not we're willing to create equality in order to erase the artificial boundaries to access. Are we, as a society, willing to do the work, up front, that will allow all of our neighbors the freedom to pursue our common human right for access to the state- of-the-art care. Too often, those without the time, without the resources, or,.. without the energy are forced to create their own access through avenues that are the birthrite of us all, but remain hidden in a thicket of bureaucracy and frustration. Too often, these potential patients lack access, not because the care is unavailable, but because of the inherent fatique, disconnection and disillusionment created by our system. So, maybe this is the biggest and most profound WHY. Perhaps one could understand, although not justify, inaccess to care, and resultant fatique, disconnection and disillusionment at an overworked Missions Hospital in a developing country, ..corrupt governments and all of that,... but then, maybe all of us are corrupt in our denial of the basic human right of healing for all. ..Hmm?!

Our collective blessings are many. Our collective challenge and our call is to insure equal access to all of those blessings. Perhaps its instructive to remember the universal implications of Martin Luther King's statements about the illusion of democracy, and that none are truly free until all have access to, and enjoy the freedoms.