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Column: 'Over half my patients, often with contagious illnesses, have to share a bed'

The scale of the HIV problem in Kenya’s Homa Bay County is enormous, writes Dr Eamonn Faller.

Dr Eamonn Faller Doctor, Médecins Sans Frontières

“POLE SANA” IS a Kiswahili phrase that expresses sympathy quite tactfully and, last week, feeling overwhelmed and a bit helpless, I said it to a woman who had just lost her son. She responded with grace, dignity and gratitude despite the tragedy that had just befallen her.

Her son was a young, strong 17-year-old who presented to our facility with a new diagnosis of HIV, short of breath, with catastrophically low blood oxygen levels. Without access to most tests I would have liked, and with time fast running out, I initiated every reasonable treatment that might have made a difference – treatment for bacterial pneumonia, HIV-related fungal pneumonia, blood clot, TB, and gave fluids, oxygen and nebulisers.

What he desperately needed was an ICU for 24-48 hours to support his organs and to give these treatments time to work. I stood around, feeling useless, for the next few hours as I saw him slipping in and out of consciousness and tried to explain what I could about the situation to his distressed and devastated mother. He died shortly after.

I’ve had an eventful 6 weeks

It’s been an eventful 6 weeks since I had my mandatory Dublin airport long-haul pre-departure pint. I had been waiting for three months to go away with Médecins Sans Frontières and then alternating between excitement and apprehension when the opportunity arrived.

I had first decided that I’d like to do something like this about 18 months ago while working in Tallaght Hospital. I qualified as a doctor back in 2012, and the time had come to either apply for a 5-year specialist training scheme or to simply do something else for a while.

I love working as a doctor but part of me definitely longed for a change of scenery and a new challenge. Eventually, after some post night-shift Googling, I emailed MSF and applied for a tropical medicine course in Liverpool.

No shift-worker reading this will be a stranger to erratic, sleep-deprived
life decisions. But even after a decent sleep I thought this was a reasonable one. A definite perk of being a healthcare worker is the ability to do something interesting like this and make a useful contribution.

So I decided to stick with it, and a year and a half later there I was sipping my pint prior to boarding my flight. My eventual destination on this journey was Homa Bay, Nyanza Province, Kenya.

Homa Bay County is an area about half the size of my native County Galway on the shores of Lake Victoria in Southwestern Kenya. It has a population of almost a million people according to a 2013 census. To put that in context, it is a hospital a third the size of that in Galway City serving four times the population.

The HIV problem in Homa Bay County 

The scale of the HIV problem in Homa Bay County is enormous. The most accurate figures available show a prevalence of 24.1%, which represents the worst epidemic anywhere in Kenya. About two thirds of these people are aware of their HIV status and most of these are leading happy, full and healthy lives thanks to anti-retroviral treatment.

The MSF team here consists of primarily of excellent and committed national staff and 7 expats like me. MSF’s goal here is two-pronged. Most importantly, going door-to-door to increase testing and diagnosis of HIV and to get as many people on treatment as possible and to improve inpatient services in the Ministry of Health-run Homa Bay District Hospital which, as I mentioned earlier is the main inpatient facility for almost 1 million people. My mission for the next 6 months is to help with the second part, and contribute what I can.

Services are desperately stretched. The ward I have been working on was built 60 years ago to house 24 beds. The 32 beds that are now crammed in there contain an average of 44 patients. This means over half the patients, often with contagious illnesses having to share a bed.

Half of the inpatients are people living with HIV which in medical terms tends to make them much more complex and sicker than the average patient, and up to one in five of these people will be diagnosed with TB.

Young people become critically ill and die due to largely preventable complications of HIV. I’ve seen a lot of these and will see a lot more in my time here. There have been cases where I have had no access to tests that may guide treatment, and yet more where I’ve made a diagnosis and have been unable to provide useful treatment due to expense or unavailability.

The feeling of helplessness that comes with this has been by far the most difficult thing to come to terms with. It shouldn’t be like this.

Sometimes you can make a difference

Unfortunately situations like these are the things that stick out in your mind. The disasters are generally more dramatic than the triumphs in medicine. The well-managed patient who walks out of the hospital and proceeds to live a long and happy life never weighs on anyone’s mind. No one dwells for long on the potential death or disability averted in the patient casually diagnosed with HIV in the community and started on antiretrovirals.

But these are triumphs, and sometimes you can make a difference. Earlier this week a young woman turned up on our ward with severe malaria. Thanks to bedside tests provided by MSF, within an hour of arriving she had not only a diagnosis of malaria, but of HIV. We could get a precise idea of how advanced it was and we could provide a basic screen of TB and the most serious HIV-associated infections.

Within 24 hours she had been educated and counselled by specialised MSF-trained staff on her illness and its treatment as well as the need for her partner to get tested. Earlier today she was discharged well on oral antimalarials and HIV treatment with an outpatient appointment in the near future to ensure all is going okay.

Her life expectancy just increased from a sickly 3 to 5 years to a healthy 45+ more years. She can expect with good adherence to lead a nearly completely normal life, have HIV negative children and who knows? Perhaps even a cure some years down the line. With more than 15,000 tests performed in the district by MSF monthly that’s a lot of averted disasters, avoided transmission and most importantly healthy, happy patient years.

I’m extremely grateful for the opportunity MSF have given me to be here. It’s wonderful seeing a tangible and sustainable difference being made. And despite the obvious challenges and difficulties, as well as running dangerously low on factor 50 sun cream, I’m really looking forward to the next 5 months.

Eamonn Faller is a doctor originally from Galway who qualified from Trinity College in 2012. After completing basic specialist training in general medicine in Dublin last year, he studied tropical medicine in Liverpool. He has a special interest in HIV medicine and working with MSF had been a long-time ambition of his. He is currently working with the organisation in the epicentre of the HIV epidemic in Nyanza Province, southwest Kenya. Médecins Sans Frontières/Doctors Without Borders (MSF) is an independent international medical humanitarian organisation that delivers emergency aid in nearly 70 countries worldwide. MSF provides emergency medical care to people caught up in war, disasters and epidemics. For more see msf.ie.

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About the author:

Dr Eamonn Faller  / Doctor, Médecins Sans Frontières

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