Waiting

I have heard all to often from my friends during social events about some of their pet peeves when interfacing with health care in the US. One of the most common complaints I hear is about "waiting" to see a physician for a primary care visit, or how "long they waited" in an urgent care waiting room with their child. As a parent and a consumer of medical care in the US, I too have had my fair share of playing the "waiting game." I often have to keep my mouth shut during these rants on the part of friends, family, and even colleagues, because until I rotated in Kenya in 2011, I had no concept of what some patients will endure, in waiting to see a physician.

I spent today in the Oncology and Palliative Care clinics in the basement of AMPATH building seeing patients referred for pain and symptom management. MTRH serves as the tertiary referral site for most of Western Kenya spanning from Kisumu near Lake Victoria, then East to Nakuru, and North towards Lake Turkana. To millions of Kenyan's, MTRH is the last resort for medical care. My patients often travel two to three hours by "matatu," a small cramped bus, on back roads and poorly managed highways to see me. There is nothing more humbling as a physician, to hear that a patient has traveled so far to see you, let alone to have a patient wait in "queue" for three to four more hours to see the "daktari" for a prescription for pain medications or anti-emetics.

So today when "Janice" painfully walked into the clinic, I knew that she had been through quite a journey to see me today. She had left home at 2am in order to catch a matatu to Eldoret, a 2.5 hour ride later, she then waited over three hours to see the oncologist, and then over another hour to see the palliative care team. A waiting time that I know neither I, nor many American patients, could tolerate.

Janice, a vibrant 38 year old Kalenjin women, is married with four children. She had been enjoying being a homemaker living near Kakamega with her family when she began having abnormal vaginal bleeding and pain in her pelvis. She delayed seeking health care due to tight finances at home, and thus her diagnosis of cervical cancer was made very late. She had been diagnosed at a local hospital near her home after a biopsy, and then referred to MTRH for consideration for surgery. Unfortunately, her cancer had advanced past any benefit from surgery, and so she arrived today for consultation for chemotherapy and radiation, as well as some hope for pain and symptom control.

Compared to the developed world, women in Kenya are at the highest risk of dying from invasive cervical cancer than any other malignancy. Invasive cervical cancer (ICC) is the most common cause of cancer deaths in Africa accounting for 10.4%, which represents one in five of all cancer deaths in African women.  (Note: Please see this 2013 article from PLOS One on the issues surrounding cervical cancer screening, treatment and care in Kenya http://bit.ly/1lAoVqH)

Once Janice had finally made it to our oncology clinic, her cancer had spread into her pelvis, causing pain with most activities at home, and was severely limiting her quality of life. Our team, in conjunction with oncology, developed a plan for palliative chemotherapy, a referral for radiation treatments (which are unfortunately not available at MTRH, and so Janice will have to travel to Uganda for this therapy), and I initiated an aggressive symptom control plan for her pain.

Despite her long travel, and even longer day, she smiled and thanked me at the end of her appointment for "giving me hope." She expressed that her biggest hope was to be able to walk around her home, with little pain, so she can continue to care for her children. It is my hope, that with her palliative therapies, and the psycho-social support of our team, that we can help her achieve this goal for some time to come. I just hope that I get see her, and her vibrant smile, again next month.