People of AMPATH: Winnie Rotich, observing Kenyan medical student
Written by Winnie Rotich, Observing Kenyan medical student with the Department of Obstetrics and Gynecology at the University of Toronto. Reprinted with permission from colleagues at the University of Toronto, an AMPATH consortium member.
A few days into my elective period in Toronto - 7:00 AM Saturday morning.
Bag on my shoulder and a coffee to go in hand (the Canadian coffee culture was catching up fast), ready for my 24-hour call at labor and delivery.
I was excited, a-kid-on-Christmas-morning excited!
I got to the nursing station ten minutes earlier before the start of the shift. I had a few minutes to kill by checking emails and texts. As expected, my mum back home had texted me several messages. “How are you doing?” “Are you eating okay?” “What time is it there?” “I hope you are working hard.” Of course, my friends were asking things like, “Has ugali withdrawal kicked in yet?” Soon the whole team arrived and the shift started.
This patient was handed over to us by the night team. Thirty-something-year-old female, second pregnancy with a history of previous cesarean section and a myomectomy. She was at term and presenting some lower abdominal pain. She was about one centimeter dilated. The plan was to get her in for a repeat cesarean section before she went into full labor because that would be a recipe for disaster given her past surgical history. She was a pleasant, but now obviously apprehensive, woman with her husband by her side giving words of affirmation and encouragement; basically, being husband of the year. She worked in finance at a company in the city. She seemed well-informed of her medical condition, judging from the questions she asked the team. On face value, I would say she belonged to the upper middle class. The staff and resident reassured the patient, and plans for an emergency cesarean were rolling. In 30 minutes or so, a bouncing baby boy was delivered.
Two days later, I was attending the high-risk antenatal clinic. Eager to learn, we met this patient referred from ultrasound who had come for the routine 20-week anatomy scan, only to find that she had a short cervix - less than a centimeter. For purposes of getting the gravity of the situation, a normal cervix should be at least 2.5 centimeters. The Maternal Fetal Medicine fellow took a history from which we gathered the following - she was a refugee, single and unemployed. She had one daughter who had just started high school and, she added voluntarily, "always had earphones on nowadays.” Her eyes lit up as she talked about her daughter - she was a proud momma. She smoked about five cigarettes per day during this pregnancy (regrettably so, she added). The fellow then broke the news to her. You could see that “my heart sank” feeling through her eyes. Then, in an almost-crying-this-sucks voice, she asked, “What do I do now?” The fellow and staff did a repeat ultrasound to confirm the cervical length and discussed, at great length, options of management with the patient. At the end of the visit, you could see a stronger, more hopeful woman.
As I thought of the two different cases later, I saw how efficient the health system was here in Ontario. Two women with two different socioeconomic backgrounds given the same level of health care, with the same urgency and importance. I was reminded of the situation back home in Kenya where health care is based on socioeconomic stratifications. The basic division of health care facilities into government/public and private. Patients in the public hospitals being mostly the uninsured, lower social class members who cannot afford to pay out of pocket for the high charges at the much better private hospitals. Doctor/nurse to patient ratios are too big at these public facilities (one doctor to every 16,000 patients and 83:10,000 for nurse-patient ratio). Basic amenities and facilities are wanting; not to mention attitude of caregivers to these patients that have no option but to attend public hospitals. Private hospitals, where conditions are better and these ratios are lower, are mainly accessed by patients with good insurance and drug plans due to the high charges.
It was refreshing to see how health care, especially for women, is accessible to all patients in Toronto. I’m a seeker of signs. I believe my coming here to Toronto for my elective is a sign. I could have been anywhere, but I got to come here. I believe this was for me to get perspective. To see that things can get better, that they must get better.
In the words of one of my role models, Shonda Rhimes - instead of wallowing in the problem, you can figure out what it’s “Yes” would be. I may not have a grand solution to the problem that is my country’s health care system, but I can certainly be inspired by the two scenarios above. I can do better. Treat all my patients with dignity and take all of my patient’s situations seriously. That’s how the system changes - if we each change it in our small way.
Who knows—maybe one day a woman in the marginalized communities of Turkana in northern Kenya will have access to the same health care as a woman in the leafy suburbs of the capital Nairobi.