The cry of our young doctors

By Jenny Luesby

Ronald, not his real name, is just 27-years-old, but is already a senior doctor in the Kenyan system. Like most of his agemates, he works for nothing: instead paying the Government Sh400,000 a year to allow him practice as a surgeon at Kenyatta Hospital.

He is one of the few who have not given up on the Government system despite a training structure that sees them work without pay, as a trainee, 10 years after his start at medical school in 2003. Even without a salary, he works a relentless schedule, almost every day and often nights, just to pay his rent from overtime as a ‘locum’. He has a thesis to work on as well.

“One day, there will be an end to it,” he says. It is an end that will come when he graduates as a specialist consultant – in 2015 or 2016.

For now, he is a registrar, studying to be a specialist. But for Ronald, and many others like him, three to five years of free work is the only road out of an even worse equation, as a Medical Officer – a doctor who is qualified, but has no specialism.

“If you don’t get through to the specialism, there is never an end in sight,” explains one of his agemates, who, like many of his colleagues, has resigned from the Government system to try and find a way forward he can live with. Their year group produced more than 200 new doctors in 2009. Just four years later, fewer than 30 are still left in the public health system.

“Most people don’t realise that almost every doctor they see is a student, often unpaid, if they are more senior, and almost certainly working to earn extra money,” explains another from the same year group, also still working inside Kenyatta.

These are the doctors who take extra shifts in clinics and in casualty, working through the night on even a Sunday night, for typically just Sh800 an hour. It’s work that few would want. “KNH is supposed to have seven doctors in place in casualty, but rarely has more than two – it’s just cost-cutting, they don’t want to spend the money,” says another of the young registrars.

The results, combined with malfunctioning equipment, bed shortages, and short supplies, are close to hellish.

“We wake up to death,” says Daniel, not his real name, also from inside Kenyatta. “Every day, people die in front of us who should not have done. The only question is how many we can save.”

It’s a journey that begins, for these doctors, with five years of study, much of it as practicing doctors inside the teaching hospitals. After that, they must do a year’s internship, and this is where the trouble begins, as they leave for their internships with hardly any practical experience under their belts.

“In the 1980s and 1990s, we had maybe 150 students coming through in each year group, now it can be 300, but the facilities are the same,” says Dr Nyaim Opot, Chairman of the Kenya Medical Association and  lecturer for the University of Nairobi and a consultant surgeon within KNH.

As a result, inside KNH, consultants can have as many as 200 student doctors for training at a time, in a hospital that manages just four operations a day in theatre.

“This leaves us without a hope of giving them the skills and experience to actually perform surgery”.

Doctors spread

Yet they are then ‘distributed’ across Kenya, first as interns, and then with their one-year internship completed, as Medical Officers. “From there, you’re in a complete Catch 22,” says Daniel. “You know you don’t have the experience, but people arrive who will die if you don’t act. You don’t even have blood very often, and you know you should refer them. But if you refer them, they will die.”

Two of the doctors talk of one of their colleagues posted to Lodwar, where he arrived aged 25, and had three people come in with gunshot wounds on his first day – a baptism of fire after his years of university study. 

Interns and Medical Officers also face a volume of work almost unheard of elsewhere. Typical, explains one, might be a night shift at Kisumu, where they can perform as many as six or even eight C-Sections - surgical birth deliveries - in a night. Elsewhere in the world, researchers study whether high through-put surgeons do a better job, and conclude that they do: but their definitions of high throughput stand at a maximum in one Florida study of 171 operations in a year, or a rate, in an Australian assessment of surgeons, of around 200 operations a year.

In Kenya, young Medical Officers can be asked to perform the same number of operations in just one to two months. “Of course, you get tired,” said Dr Opot. “It gets harder to concentrate, the theatre lights are hot, you are standing the whole time, often for hours.” Junior doctors put it more strongly than that, saying it just gets to be “blood everywhere”. Globally, researchers concur that sheer tiredness can make a huge difference to results, especially where judgements need to be made, and the methods are delicate.

And judgements do have to be made. Even as Dr Opot is talking, his own phone is ringing, repeatedly. A junior surgeon has someone in surgery at Kenyatta whose intestine has turned gangrenous. The two doctors go back and forth as the operating surgeon establishes which parts, if any, are still ‘viable’, and they try to work out how best to save the patient’s life. The options are several. The choices will make a difference.

“And this patient arrived at casualty Wednesday evening,” says Dr Opot, “but only made it to the ward yesterday – Friday.” The two extra days saw more of the patient’s guts rot away.

Faced with challenges like these, the vast majority of young doctors just get out, unable to live with the daily, weekly and monthly reality of poor equipment, patient volumes, exhaustion and unrealistic demands. Others just die.

As doctors, they are exposed constantly and up-close to communicable diseases, be it tuberculosis, even pneumonia. Many succumb, for Kenya’s health system has no better system for making sure the doctors stay alive than it does for any other Kenyan. One of the doctors relates how a fellow doctor he had known since high school was referred to Kiambu with kidney failure caused by malaria, and needed dialysis, which meant KNH.

But the Kiambu ambulance had no fuel, so he had to wait until the next day for transport. He died in the ambulance - for the cost of a tankful of petrol - an 8-year trained doctor, one of Kenya’s brightest and best.

The problem is not confined to the public sector. There is only one private teaching hospital in Kenya, Aga Khan. This leaves the rest of the hospitals feeding off the publicly trained doctors too. They cannot even retrain them on entry.

“The middle class in Kenya is living in a fantasy,” said Philip, not his real name, now a registrar at Mathare, also unpaid. “They think if they can go to private hospitals they will get world-class medicine, but the doctors are the same, and the management is often far from world-class”.

World class standards

In fact, few Kenyan-trained doctors manage to reach world-class standards anywhere. The UK reported this year that despite having almost 3,000 Kenyan doctors in the country, just 52 of them had been officially registered as doctors. Even these 52 are now being asked to resit competence tests, or risk being deregistered, following revelations of higher rates of malpractice among foreign-trained doctors.

Kenya’s private hospitals, additionally, suffer from the same problems that blight the public sector, in ‘eating’ by hospital administrators, widespread under-investment and patient overload.

Kenya is also bipolar in healthcare between Nairobi and elsewhere. “Tourists have no idea the risk they are taking just going to Masai Mara – if anything happens, there are no private hospitals, no consultants, they will get pushed into the same public health system as the rest of us, and their chances are with God,” says Philip. He also cites the chances for any senior manager caught up-country in Bungoma when ill-health strikes: “Then, they find out what a broken health system means. There aren’t any other options.”

Yet the problem is getting worse over time, not better. “Training standards have really deteriorated,” says Dr Opot. The rate of flight by doctors has also accelerated, with still just 2,500 registered doctors in the public sector.

Many leave for elsewhere in Africa, where the pay and conditions are better. Most of the rest leave for NGOs, where they become project officers, running public health projects. Some leave medicine altogether. Two years ago, Philip was himself leaving to do an MBA, until the Government announced a pay rise for interns and Medical Officers.

As it is, almost all the doctors who make it are rich kids, from affluent backgrounds, where their parents can help with rent and food money, with private health insurance, and with fees.

Managing for a decade and a half, much of it without an income, is simply beyond the reach of anyone else. It’s worst, says Daniel, for those with families, who find themselves, even after years of study, working every hour and struggling to pay school fees. Most of them simply have to leave.

For the rest, the answer is superhuman hours, day and night, as locums, at which point the best pay goes for the most responsibility. “You can get locums in Eastleigh, working for the Somalis, for even Sh1,000 an hour, but then you’re really running a hospital, and must do everything,” explains another 10-year trained doctor, who left a posting on the other side of the Kenya to return to Nairobi for pure locum work. Even in Eastleigh, he says, “someone comes in with an intestinal rupture, you know they can’t get referred and treated in time: you operate or they die.”

Moreover, back in the public sector, “none of the equipment works, even basic pumps,” says Daniel. “Sometimes we don’t even have oxygen for the anesthetist.”

Across Kenya, patients complain of the arrogance of these young doctors, as they work night and day, without adequate training, without adequate equipment and supplies. But scratch the surface, and what most patients are really facing are doctors who are exhausted, in despair, and often set to be the next wave to leave: beaten by a system nearly starved to death of funding.