Student Reflection by Heather Millar

Women’s Reproductive Health in Western Kenya

Evelyn Dunn with Mosiko, one of the Gynecology Oncology patients, her son and her sister

Evelyn Dunn with Mosiko, one of the Gynecology Oncology patients, her son and her sister.

The Department of Obstetrics and Gynecology at the University of Toronto and the Departments of Reproductive Health at Moi University and Moi Teaching and Referral Hospital in Eldoret, Kenya entered into a partnership – AMPATH-RH – in 2006 as part of the long standing the AMPATH (Academic Model Providing Access to Healthcare) Consortium between Moi and other North American academic institutions, led by Indiana University. The aim of AMPATH-RH is to improve women’s reproductive health care in Western Kenya, with a focus on maternal morbidity and mortality, cervical cancer treatment and prevention and obstetric fistula prevention and repair. The partnership seeks to achieve these goals through clinical care, education and research.

For my final clerkship rotation in 4th year medical school, I spent 5 weeks at the Moi Teaching and Referral Hospital in the Department of Reproductive Health as part of this partnership. I spent 2 weeks on Labour and Delivery, 1 week on the Ante- and Post-Partum ward and 2 weeks with a newly-developed Gynecologic Oncology group (2 Kenyan physicians, 1 Canadian Gynecologic Oncologist visiting to help train, and a couple of nurses). I acted as a final year medical student and was given responsibilities that, overall, were at the same level as those I would be given in Canada (with some opportunities for more hands-on experience than I may have received at home). I also worked with an American cardiologist living in Eldoret to develop a protocol for the care of women with cardiac disease in pregnancy.

This was my second trip to Eldoret (the 1st was in 2008 as a summer research student) and my sixth visit to a low resource country. Before medical school, I completed a Masters of International Public Health with a focus on low resource settings. I felt that I was prepared in many ways for what I would experience in Eldoret. However, I have never done clinical work in this setting and I found that this experience affected me in new ways and on a different level emotionally. In the end, I felt a renewed excitement for global health and a desire to continue to be involved in this partnership throughout my residency training in Obstetrics and Gynecology.

Working in a low resource public health care system
Once I got settled in to my elective, I quickly developed the daily experience of feeling frustrated by the health care system. By the end of the day, I often felt that I had to “get out of there”. The lack of resources – which, academically, I knew existed – was emotionally frustrating in practice. There were days where there was no IV solution in the hospital, where I had to run around for 20 minutes to find an IV cannula, where there was no blood, and where we could not do a sterile speculum exam because there were no speculums. Sometimes there was no paper for progress notes. There was no soap at the sinks and, often, only one bottle of sanitizer that was used for cleaning hands and for wiping down beds. In addition, it felt like there was no sense of urgency on the part of staff. Antibiotics were not given as scheduled, IV’s were not started, and orders written in a chart were not carried out. I heard stories about a woman dying of post-partum hemorrhage because there was no blood readily available and no one ran to find some. I also experienced a lack of accountability on the part of staff for their actions. I saw a couple of medical errors on the part of interns, nurses and physicians that, in Canada, would have resulted in an investigation and, possibly, probation. At MTRH, however, none of this occurred. Patients usually do not ask many questions, explanations for medical decisions may or may not be given to them and they may not even know that a mistake has been made.

Even though I thought I was prepared for much of this reality, when trying to work within it, I could not help becoming frustrated. I tried to be patient and friendly and to remind myself that I was a guest in this country and in this health care system. However, I often felt like screaming. When I left the hospital in the evenings and when I arrived back in Canada, it was a little easier to reflect on the system as a whole and to try to understand why some of these realities might exist. In a public hospital in a low resource country, where it is normal for supplies not to be available, it makes sense that health care workers would have to accept not having what they need. It seems that it would be difficult to maintain a sense of urgency when, for example, there is no blood to run for or when the right antibiotics are not available. Also, when illness and death are common and the public hospital offers the best care available to the poor, it must be hard for patients to demand better (or know that better might be possible). In Canada, where almost everyone has some level of formal education and now, has access to the internet, patients are incredibly well informed. Many Kenyans, I imagine, do not have this same knowledge and, therefore, are not able to ask the questions that would challenge their nurses and doctors to provide information. While it is easy to philosophize about all of the big picture explanations, the emotional reactions I had on a daily basis gave me some understanding of what it really means to work in a low resource health care system.

Medical education
After two visits to MTRH and interactions with the Kenyan medical students who have come to Toronto through the AMPATH partnership, I have had some exposure to and discussion about medical education in Eldoret. It seems that Kenyan medical students have much more book knowledge than we do but have less opportunity to develop their clinical knowledge (at least when they are students). Morning rounds involve one staff physician and approximately 30 medical students moving from bed to bed. It is very difficult to hear anything and, as a student, the opportunity to practice presenting histories and physicals is limited. After rounds, students would often have lectures to attend or would go study. They had little responsibility in the management of patients. Certainly, I did not see a single Kenyan medical student on Labour and Delivery. In the OR, again, there would be a group of them observing, trying to get a glimpse of the surgery. Once they are done medical school, Kenyan medical students become interns and suddenly, are given a lot of clinical responsibility without the same level of supervision that is provided to interns in Canada.

I wonder what affects the system of medical education in Eldoret. Like all other aspects of health care, I imagine that it suffers somewhat from a lack of resources. Most physicians work in both the private and public health care systems because the public system does not pay well enough. They receive little financial reward for teaching medical students. Medical school seems to be a more didactic experience than it is in Canada and students are not rewarded adequately for involvement in day-to-day patient care. Education – for all levels of physicians or physicians-in-training in Eldoret and in Toronto – seems to me to be one of the most salient benefits of the AMPATH partnership. From speaking with one of the Kenyan students who did a rotation in Toronto, I know that he now spends time on the wards managing patients with the nurses and interns – and enjoys it. Another Kenyan student has described how, upon returning home from Toronto, he wants to spend more time communicating with his patients. From my trips to Kenya, I have realized that many Kenyan students know a lot more than I do about medicine. I have learned how to deliver a baby without all of the amenities that are taken for granted at home. I appreciate on a more personal level that our public health programs and our health care system in Canada make a difference in women’s lives. I know that this will make me a better clinician as I start my own career back in Canada. While I was in Eldoret, Dr. Barry Rosen, a Gynecologic Oncologist, was visiting from Toronto to help with the development of Gynecologic Oncology prevention and treatment programs. It was inspiring to see Kenyan and Canadian physicians working together and learning from each other.

Oncology
Cervical cancer in developing countries has been a long-standing interest of mine – since I first learned about it at a women’s health conference in 2003. This visit to Kenya, however, was the first time that I truly experienced firsthand the devastating impact that it has on women’s lives. Throughout my two weeks on Gynecologic Oncology, I saw many young women who were going to die from their advanced cervical cancers, cancers that we never see in Canada because of our screening and treatment programs. I remember a woman in her 30’s who had come from a village to be seen in the clinic. When we walked in to the room, Dr. Rosen said quietly to the other medical student and me, “I can tell by the smell that she has at least Stage 3 cervical cancer”. In addition to facing death at such a young age, she was facing the embarrassment of the smell and of copious vaginal discharge as well as severe pain as the cancer spread throughout her pelvis. Over the two weeks, I also saw a number of women with vulvar cancers the size of oranges, suffering again through pain, discomfort, embarrassment and fear. I helped to look after a young woman with advanced ovarian cancer. I was struck by the knowledge that these women were my peers (many of them were my age or only a few years older!) and that, in most cases, their deaths were preventable.

Meeting these women and seeing their suffering made me feel both sad and hopeful. It was such an obvious example of the disparity between women in Canada and women in the developing world. And it made me feel that maybe this is a cause I want to focus on as part of my career. It encompasses so many important issues – poverty, health care system resources, public health, and women’s sexual and reproductive rights. Pap screening and, now, the HPV vaccine, have to ability to almost eradicate cervical cancer. And yet, these women do not have access to these technologies because of the part of the world in which they were born, because these programs so far have been too costly to deliver or, perhaps, have not been a priority. For me, pap screening is a routine part of my health care. For my peers in Kenya, it is not accessible and, for many, it is something of which they have no knowledge. Gynecologic cancers may also become advanced in many cases because they affect a part of women’s bodies that is considered private and that is not discussed publicly. Women’s wombs are considered central to their identity and the idea of losing this part of themselves is another factor preventing them from seeking health care. During one cervical cancer teaching session with a group of nurses, the head nurse spoke at length about their role as educated women to ‘spread the word’ about cervical cancer and to make its prevention and treatment a new movement in Kenya. I felt inspired and excited. I saw real potential to change the course of a preventable disease and, at the same time, to advance women’s health and women’s rights.

Relationships

With my friend Tecla

With my friend Tecla, a Kenyan nurse, and her children, Chemutai and Andrew. I met Tecla the first time I was in Eldoret and enjoyed seeing her again.


As with all of my clerkship rotations so far, the most memorable part of my elective in Kenya will be my interactions with patients and with co-workers. I spent part of a day with a young woman who was in labour with her first child. She was nervous but incredibly strong. In Kenya, many husbands are not involved in the delivery. However, her young husband seemed to want to be with her and, once I told him how to help, he stayed for the whole thing. She ended up needing a c-section for failure to progress and, when I went to see her in recovery, he was still with her. He told me he had stayed for all of it because he loved her. Compared with some of the upsetting experiences and frustrations that I seemed to have every day, this couple made me smile and reminded me that love exists in every culture. A young woman with advanced ovarian cancer also touched me. We met as she was being prepared to have a large debulking surgery. She was incredibly thin and had lost her hair from chemotherapy. But, she had a smile that lit up her whole face and made it impossible not to smile back. She was intelligent and inquisitive and grateful for everything. When the other medical student and I said goodbye to her on our last day, she thanked us for caring about her. She said that her family had mostly abandoned her since she had become sick. Another woman on the Post-Partum ward, only 25 years old, quietly thanked the medical team every day for saving her life, after an urgent c-section for almost unbelievable polyhydramnios. She had a twin pregnancy and had not had any prenatal care. She was gentle and shy and she smiled with her eyes. The nurse from the Gynecologic Oncology team told us one day about how her mother had passed away from cervical cancer and how her older sister had raised her. She talked about how committed she felt to cervical cancer programs because she felt that no one deserved to lose their mother at such a young age from such a preventable illness.

These brief relationships are what make medicine real for me and are what make me want to be a doctor. In Eldoret, they made women’s health issues in low resource countries real for me. From these women (and, at times, their partners), I was given a glimpse of the strength required to face health problems that my friends and I will never even have to consider. I felt and saw universal emotions of sadness, fear, gratitude and joy. And I imagined how it would feel if my mother, sister, daughter or best friend had to experience illness in the way that Kenyan women do. This is what makes me want to be involved in improving global women’s health.

Conclusion
The AMPATH-RH partnership is one of the main reasons that I ranked the University of Toronto first for my Obstetrics and Gynaecology residency training. Of my experiences so far in developing countries, my time in Eldoret and my overall experiences with the partnership have been the closest to how I imagine incorporating global health into my career. Despite feeling frustrated at times, when I finished my 5 weeks in Kenya, I felt inspired and excited about the possibility of going back. The partnership seems to be an example of true long-term commitment to women’s health in a low resource country with a genuine focus on skill development not only for Toronto physicians (and medical students!) but also for Kenyan health professionals. I feel excited about the potential of this partnership and honoured to have had the opportunity to be involved in it as a medical student.