Empathy

As far removed as I am from my internship days, every once in a while a specific memory pops into my mind from way back then. This one specific memory has been popping up from time to time; perhaps it's relevant for the times we're in. So here goes.

During the latter part of the Internal Medicine rotation, I remember early one evening, as I was almost leaving, I ended up being called to attend to a patient. This patient was neither in the ward nor in the casualty area; rather, he was at the TB clinic area, which was an Outpatient clinic where TB patients usually showed up for follow-up as they went about taking their medication. This was something that the clinic was able to handle so well without involving the other doctors, so it was something of a novelty for me to be called in to the clinic. I got there to find a young man - probably in his early 30s - flanked by another gentleman who looked to be in his 60s.  The elderly gentleman then proceeded to tell me a story. The young man was his son (I'll refer to him henceforth as *ALEX), and was a prospective patient; having been diagnosed with Pulmonary Tuberculosis (PTB) a while back, Alex had been started on treatment for the condition. Unfortunately, he was also an incorrigible drunkard, and his usual modus operandi had consisted of initially taking the TB medication (which doctors refer to as RHZE) then somewhere along the way - probably once his symptoms would subside - he would go back to his drunken ways and stop taking the medication.

Let's get a little technical here: the treatment for TB consists of 4 medications: Rifampicin (R), Isoniazid (H), Pyrazinamide (Z) and Ethambutol (E). You start off taking all 4 for 2 months (RHZE), then switch to 2 drugs - Rifampicin and Isoniazid (RH) for the remaining 4 months. There are variations to this dosing, but this is the simplest one for run-of-the-mill PTB. People should be aware that these drugs do have a whole bunch of side effects, most common of which is liver toxicity and injury.

So, by the time I encountered the young man, he had basically defaulted on taking his medication on 4 separate occasions. During that time, he had gone on to infect 3 other people in his village area; thus, he had been served with an eviction notice by his chief (and the villagers) that if he was found within the village, he would basically be beaten and burned to death! Father and son had thus ended up moving to the township area to stay with a relative as a stop-gap measure, and they had come to the TB Clinic in order to get him started on treatment. Because Alex was a serial defaulter, an option that has usually existed is for such patients to be institutionalised in a prison facility where it can be ensured that they take the full course of their medication. I remember making a call to the nearest prison facility, but they insisted that they were in no position to accept such a risky individual; the prison was already overcrowded, and imprisoning someone suffering from TB was a recipe for disaster.

With that option off the table, I called the Internal Medicine Consultant. He was very categorical that the patient was high risk, possibly suffering from MDR (Multi-Drug Resistant) TB, and thus there was no way he could be placed in our regular ward. I broached the idea that perhaps the patient could be placed into our TB isolation ward (our old Amenity Ward) while we tested him to confirm that he was in fact suffering from MDR-TB, but my consultant categorically refused. "Send him to Homa Bay" was the only solution I was given.
Now Homa Bay does in fact have a facility that can serve MDR-TB patients, but you needed to first have a confirmatory test (Gene Xpert) which confirms infection with a drug resistant strain of TB. Without that confirmatory testing, I worried that I would be sending the patient on a long journey only for him to be turned away once he arrived at the Homa Bay facility. In addition, if he was in fact infectious, he risked infecting an even larger number of people if he used public means to travel to that same facility.

My hands were tied in the matter, and I remember relaying this to Alex's father. This had been a surreal experience, sometimes so comical that a chuckle almost escaped my lips (damn that morbid medic sense of humour!). I was not expecting to see his elderly father almost break down into tears at the hopelessness of the situation! Contrasting that with Alex's laissez-faire attitude, this felt like a case where a careless man deserved to get his comeuppance. Sadly though, there was a family that was being inconvenienced by this man's carelessness, and that had to factor in there somewhere. Eventually, in contravention of my consultant's advice and against my better judgment, I ended up having Alex housed at the amenity ward so that he could have Gene Xpert testing early the next morning. I think my stomach was in knots that night as I thought about the prospect of having admitted a high-risk patient; worse still, if my consultant had found out, my goose would have been cooked. 

My elation was palpable on the next day when I eventually found out that he was suffering from "garden variety" TB. This meant that he could be treated at our facility. I hoped that the idiot would finally stick to his treatment for the prerequisite 6 months this time around, but, alas, I don't know how the story ended.

Seems like ever since this COVID-19 popped up, it really is the only infectious disease that's being talked about. In a most ironic twist, it has thankfully reminded people that hand hygiene and cough etiquette are matters of utmost important. You'd have thought that a high prevalence of TB and Cholera (among other things) would already have clarified that fact! After this is all said and done, we'll probably have the most hygiene-conscious generation of individuals ever.

The sad thing about being smack in the middle of this pandemic is that we can't even be 100% sure of the transmissibility of this virus. The asymptomatic carrier may have an extremely large role to play in spreading Covid-19. An oft-quoted line of wisdom with regards to Influenza used to suggest that you are most infectious before you start to show flu symptoms (might be more true for Influenza B than A). This same line of reasoning seem to hold true for Covid-19, and a pre-symptomatic or asymptomatic carrier might just go about shedding a lot of viral particles without being any the wiser.

I keep thinking back to how my response to this virus changed as the situation has evolved. Even while at the clinic, initially I wasn't afraid to shake hands. At that point, before seeing a patient, I would casually glance at their notes and only don a surgical mask if the patient exhibited respiratory symptoms. From there, it evolved to no handshaking, having the surgical mask on at all times, and eventually progressed to preferentially donning the N95 mask. I went from looking at my scrubs as benign items that I was confident to walk into the house while wearing (at the end of a shift), to germ-infested items that are tracking this nasty virus to my humble abode each day.
In case you might not have guessed it, a lot of your doctors and nurses are the biggest hypochondriacs out there. It started out during medical training when we were exposed to a whole bunch of medical conditions in the literature. Sometimes we could feel the lecturer diagnosing us with the rarest conditions on the spot; but because we stoically kept quiet, I think we eventually just overcame our worries and fears to continue with our chosen careers. It does of course help that once we begin actually practising medicine, we discover that "Common things occur more commonly"; and in case something uncommon jumps out at us, between our hands-on practice and help from peers and superiors, we can usually fashion a suitable response to the task at hand. Truthfully speaking, Covid-19 has a lot of us worried. There are no standard treatment regimens as of today for the disease, and there is no vaccine in sight until next year (at the most optimistic estimate). The disease remains a really theoretical concept for the ordinary mwananchi, but we in the medical field can physically visualize the downward spiral for an affected patient. We've encountered these effects with other diseases, but never on scale that's potentially this massive!

I also keep thinking back to a few of the patients that I'd been encountering in the previous months. I was - initially - particularly annoyed at the patients who'd travelled from hotspots; instead of quarantining themselves off for the agreed 2 week period, they were breaking quarantine to come into the clinic to seek reassurance. Practically all of them were asymptomatic, but they still worried that they had possibly put their families/loved ones in danger and worried about the fallout. They wanted to have themselves tested, but the truth of the matter was that only government labs were conducting the testing, and due to scarcity they were only really testing patients with marked respiratory symptoms coupled with a positive travel history or contact with a Covid-positive individual.

I can understand their fears. For the longest time I have had 2 fears concerning this condition:

1. Suffering the most severe symptoms
2. Unwittingly spreading it to others

I daresay that if all I was going to encounter was the typical flu symptoms - with the assurance that I'd be immune thereafter - I'd rather get it over with (same way parents used to opt for their kids to get exposed to Chicken pox). All I could do was reassure them that they had an 80% chance of being on the good end of this condition. Until such time as they would develop severe symptoms, I advised them to simply continue with their quarantine schedule whilst monitoring themselves.

Lately, however, I've developed a 3rd fear that stems from our government's response. As a matter of policy,

"Until the Ministry of Health establishes the existence of sustained community transmission, all confirmed positive Covid-19 cases identified should be monitored closely at a HEALTH FACILITY ISOLATION ROOM...Once sustained community transmission has been established, home management of mild cases should be encouraged."

 *Interim Guidelines on Management of Covid-19 in Kenya (PDF Page 13) - Available for Download here

I'm of the opinion that because we have under-tested thus far, we have already reached the level of sustained community spread. This is the reason that I'm all for random mass testing of the general population because it will push the number of confirmed cases up exponentially, which will in turn escalate the government's response; ideally, this should mean home care for Covid-19 positive individuals with mild symptoms.

The government's understanding of the situation and its "playbook" keeps changing as time goes on. After a recent webinar by medical professionals, I feel like the government might choose to accommodate a Chinese solution, meaning isolation of POSITIVE people, whether they might be asymptomatic or mildly symptomatic. If that's the course they follow, picture a whole bunch of people who might at most only require Paracetamol, cough syrup and bed rest being isolated away from the general population in designated facilities like hospitals, stadiums and high schools.

I also appreciate that the government also needs to do contact-tracing of those individuals that have possibly been exposed to a confirmed Covid-19 patient. Defining the extent of the disease's spread is important, but I believe that we also need to safeguard the dignity of our citizen's who've been inadvertently exposed to this disease. These contact-tracing officials riding gung-ho into a neighbourhood in the name of carrying out their duties risk panicking residents, or even worse turning the infected/affected into pariahs within the community (like Alex in my initial story). Ironically, to quote Donald Trump,

We cannot have the cure be worse than the problem

    
Life will go on for most of us beyond this virus. We cannot afford to "burn" people in the community in the name of protecting everyone else. Despite how crazy things might be around us, we must retain our humanity through the whole experience.

I really sympathize with the government as well. It can't be easy charting a course in the chaos with all the differing opinions about their approach (though I suspect they're having a much easier time than the United States). I can respect that they've chosen to have people wear masks like the CDC recommended (but not the WHO), but hate that they've left us at the mercy of hoarders and quacks supplying the goods. Have they even stockpiled enough masks for healthcare (and affiliated) workers in this same period? Then there's the problem of indiscipline among Kenyans. In much the same way that overseas travelers failed to self-quarantine, it can be postulated that Covid-19 positive patients are unlikely to self-isolate of their own volition (as recent reports of mischief would suggest).

We have a powder-keg of a mess on our hands, but there is always hope if we empathize with those that we mean to protect. Worldwide, Covid-19 is showing us that traditional inflexible systems cannot work. Just like the fictional human society in Star-Trek, we might be forced to abandon concepts like "profit" and "individualism", and just work together to confront a common unseen enemy, if at least only for the moment at hand. At a countrywide level, our politicians need to make sensible policies for the citizens they govern. Despite all the buzz about Kenya being a middle-income country, they know that we are still a fledgling developing country with a vast vulnerable population. Their policy needs to acknowledge that and put in place measures to safeguard the most vulnerable; ignoring this will only lead to revolt.

At the local level, there needs to be public health education on a massive scale. People need to feel entrusted with the knowledge and acumen to fight this disease. They also need to be reminded that with all the RIGHTS that they exercise there are also congruent RESPONSIBILITIES. The only way we come out of this any better is by abandoning the inefficiency and bad habit that have failed us in the past; we need to empathize and we have to be better. Our very survival depends on it.

God Bless