In an exclusive MedPage Today commentary, Jon Fielder, MD, co-founder of African Mission Healthcare, writes that “the specter of another deadly viral pathogen raised alarm throughout an African public health community scarred by the history of the AIDS pandemic, Ebola outbreaks, and other devastating infectious diseases.”
MedPage Today Editor-in-Chief Marty Makary, MD, MPH, of Johns Hopkins University in Baltimore, speaks with Fielder about the reasons COVID-19 did not create “an apocalypse in Kenya” or the rest of Africa, despite scarce resources and medical vulnerability.
Following is a transcript of their remarks:
Makary: Hi, I’m Marty Makary and I’m here with Dr. Jon Fielder, who is a physician practicing in Kenya right now. Jon, great to see you. Great to be with you here.
Fielder: Great to be with you, Marty.
Makary: Tell us where you are right now.
Fielder: I’m in a place called Kijabe, Kenya, where there is a large, mission-teaching, referral hospital.
Makary: How long have you been practicing in Kenya?
Fielder: I first came here in 2002 and our family has been in Africa since then, except for 2 years back in the U.S., and we spent 5 years in Malawi in southern Africa.
Makary: Tell me a little bit about your family.
Fielder: My wife, Amanda, is trained as a social worker and she works at a boarding school as the mental health counselor. We have three children who all attend a school called Rift Valley Academy.
Makary: Great, and tell me in what capacity are you there?
Fielder: I’m the chief executive of an organization called African Mission Healthcare that helps mission hospitals in a variety of countries in the areas of patient care, medical education, and infrastructure. I also am a part-time practicing clinician. I actually spend most of my time at another hospital that’s about 7 hours north of here called Maua Methodist Hospital.
Makary: Where did you do your training in medical school?
Fielder: I went to medical school at Baylor College of Medicine in Houston, which is where I grew up, and then I did my internal medicine residency at Hopkins.
Makary: Tell me, what prompted you to decide to pick up and go to Kenya and practice medicine there? I don’t think it’s something a lot of people think of when they finish training.
Fielder: I was very fortunate in medical school that I had a mentor, who had been a medical missionary in Uganda in the 1980s, and he taught medical school there. That really fired my interest in Africa. I ended up coming here to Kenya to take over for a missionary doctor who was leaving that had started some important HIV work and it was the height of the AIDS epidemic. That’s really what I focused on in my early years here in Africa.
Makary: Now, you have a piece in MedPage Today that talks about what we can learn about COVID-19 from your experience there in Africa. What can we learn from the African experience about COVID?
Fielder: I think there’s a few things. First of all, for me personally, it’s some humility because many of us feared that the situation would be much more dire than it has turned out to be. We feared that based upon the health system not being very well developed yet in many parts of Africa — limited oxygen, for example — and then we also feared because Africa’s populations are medically vulnerable. There is a lot of HIV, tuberculosis, and malnutrition. But what we found is that that situation that we feared really hasn’t come to pass. Although there have been hospitals, like the one where I was working, that have been strained by COVID, the system didn’t break and I think there’s a few reasons for that.
Makary: I was looking at the Hopkins map and it really shows a remarkably low number of cases in Kenya. Is that because of an inadequate testing capacity or are you truly seeing fewer COVID cases there per capita?
Fielder: It is a combination of both. The testing capacity still is limited, but I think it’s really a question of, “How many severe cases have we seen? There was a paper that some Kenyan epidemiologist put together recently that suggested that in the larger cities at least a third of people had been infected and exposed by the beginning of August, yet the hospitals were not overwhelmed with sick people with pneumonia. There were a couple of large hospitals which had significant numbers of patients, but nothing like what we saw in Italy or New York.
Makary: Why do you think the burden of severe COVID cases has been so much lower in Kenya and other parts of Africa?
Fielder: The epidemiologists have put forward a few possible explanations. I would say that right now people are probably resting on age and the age structure of the population is the leading explanatory factor. The median age in Kenya is 20 years. I think in the U.S. it’s around 43 years, maybe a little bit more. In Malawi, where I used to work, the median age is 17.
The implication of that is that at the higher end of the age scale you just have 3% to 4% of the population who are over age 65 and we know that those people are much, much more vulnerable, with infection fatality rates that are maybe even 100 times what it is for people who are much younger.
Makary: How much of a component is the outdoor nature of the society in severe COVID cases being lower?
Fielder: I think that’s also an important consideration. We don’t have a lot of air conditioned buildings here. Most people don’t work in office buildings that are hermetically sealed. They don’t go to restaurants that are tightly packed. Most people live, as you suggest, outdoors, particularly in the rural areas and the villages. We just don’t have those kinds of buildings and that lifestyle.
We also don’t have a nursing home, so older people tend to leave the more densely packed cities to retire here — we call it “up country” in Kenya — and so you don’t have a high concentration of people living in nursing homes.
Makary: Do a lot of people in Kenya wear masks or take basic precautions in terms of social distancing?
Fielder: Certainly, at the onset of the epidemic, there was quite a push by the government to both encourage and enforce social distancing measures and a mask mandate. I think of late I’ve seen a little bit of relaxation in the population, if you just are out on the roads, in terms of wearing masks.
Makary: You mentioned that not having enough oxygen at hospitals is an issue there. Can you tell me more about that?
Fielder: Yes. There was a recent paper in the New England Journal of Medicine that found that only about half of Africa’s hospitals had access to any kind of oxygen and only about 20% percent of all health centers. There was another paper by some individuals involved with oxygen provision in Africa and they cited one analysis from Nigeria that only 5% of oxygen concentrators were actually functioning and producing medical-grade oxygen.
Either there is no oxygen at all or it comes in the form of non-functioning or partially functioning oxygen concentrators, like what we would use for home use in the United States, or it’s in cylinders. Particularly for COVID-19, cylinders are just … it’s not enough because even a very large cylinder could not last a day for a patient with severe COVID-19.
The number of hospitals with what we take for granted in the U.S., piped oxygen — you turn on the wall, you get 15 liters or even 50 liters — those hospitals are few and far between.
Makary: The main hospital where you worked, what’s their capacity in terms of beds where oxygen can be delivered? In other words, how many patients can they have on oxygen at any one time at that hospital?
Fielder: Maybe I’ll put it in terms of their actual oxygen-generating capacity. They are much better resourced than most African hospitals and they can produce about 325 liters per minute of oxygen.
They do have problems with those plants breaking down at times. I read an analysis of their use, and really, the main plants never turn off, suggesting they’re always running at peak capacity. That’s for a hospital that has 300 beds, a number of ICU-level beds, and nine operating theaters.
We had at times four or five patients that were using 120 to 130 liters of oxygen per minute because they actually have high-flow nasal cannula at this facility, so we had patients who’d be on 50, 60, 70 liters per minute via high-flow nasal cannula.
The other hospital where I work, called Maua Hospital, have a 45-liter per minute generator. Again, even the fact that they have piped oxygen, they are one of the only facilities in that entire region of 1,000,000 people that that has piped oxygen.
You can see if they have 45 liters per minute, that’s going to overwhelm the capacity of the hospital if they even have just a few sick COVID patients. Then most places just can’t provide that much oxygen.
Makary: At that hospital, that’s the capacity for the entire hospital, 45 liters per minute of oxygen for the entire facility?
Fielder: For the entire facility. Now, they do have some portable oxygen concentrators. We had a young man with … we’re not sure what he had. It was almost like maybe he had an allergic pneumonitis, but he was very sick. He was isolated for the concern that he may have had COVID — I don’t believe that’s what he actually had — and we could only have him on a 5 liter per minute oxygen concentrator because of the isolation room where he was.
So, yes, for the entire hospital, their operating theaters — they see a lot of trauma there — for all of that, they only have 45 liters per minute. But again, that is a hospital that is fortunate. Many don’t have any piped oxygen at all.
Makary: Let’s say three patients are on oxygen at 15 liters per minute. That’s about the full capacity, then, of the entire medical center?
Fielder: That would be true. One of the things that happened at the larger hospital I mentioned, Kijabe, is that really when we were at our surge … which again, was nothing like what happened in New York City. But again, the resources are also more limited. When we were at that peak, we had the wall going maybe at 15 liters per minute or more.
Sometimes we would switch patients over to the cylinders and their oxygen saturation would go up, suggesting that what we thought we were getting from the wall was not what we were actually getting because the entire system was too stressed across this large hospital.
Makary: It sounds like oxygen is truly a scarce resource in many parts of Africa and in these hospitals that you’re describing. What are other scarce resources?
Fielder: Ventilators. We know that the outcomes on ventilators for COVID patients in the West is not great, but our COVID ward, which is probably one of the better ones equipped in the country of Kenya, only had two ventilators. They had put in place a policy that if you had severe comorbid conditions or you were over age 50 that they wouldn’t intubate you. We knew that the outcomes would be poor and it would not only take up a ventilator that could possibly go to a younger person with a much better prognosis, but also the stress on the nursing staff, the stress on the finances of the hospital, and the stress on the oxygen supply all played into that decision.
Makary: What resource do you think has the biggest bang for the buck in Africa?
Fielder: Well, number one is we need more trained people. This hospital where I’ve been working, years ago we started an ICU. Since then they’ve started an ICU nursing program and a program for physician assistants to learn ICU care. Now, they’re starting to fan out across the country and change care, so not just in the area of COVID or intensive care, but just generally we need more trained health workers.
Finances are always a huge limitation. Patients come in to the hospital to get this level of care, which is very good, but they could spend weeks in the hospital and easily have a bill north of $1,000, which in a country like Kenya is a serious burden on families.
That’s always in the back of your mind, like, “What can I do for this patient and how long can we have this patient in the hospital?” Because it’s a serious burden to keep the hospital going and on the families.
Makary: It seems like there’s a natural tension that I have observed between basic needs on the ground and those who would provide grants or support projects in African medicine, who require evidence to support the actions and the funding. Can you describe that tension, if you’ve seen it, and what that looks like?
Fielder: I would say that is a major pain point for us on the ground. Our organization focuses a lot on institutional capacity building, and so for us that might involve upgrading or even helping to start an operating theater. Of course, you’ve got to have water and you’ve got to have power. You have to have the right staff. You have to have the equipment. You have to have the space.
You’ve got to bring all those parts together in, what I would call, a horizontal way, not simply a vertical program coming from the outside, and what do we want to do there? Of course, we want to do things like provide C-sections.
We have a significant C-section sponsorship program in southwestern Uganda, but then that can also allow for appendectomies and trauma care. If you have to prove that hospitals need the ability to do an appendectomy, that gets to be difficult. Like, “Do we really need to prove that we need to be doing C-sections and appendectomies?”
When I lived in Malawi, if an expatriate needed an appendectomy, they would leave the country. People advised us to leave the country when my wife was pregnant with our third child. We decided to stay and everything went well, but that shouldn’t be necessary. We should be able to do an appendectomy safely in every region in Africa.
Makary: You think that sometimes clinical wisdom is crowded out by a demand to see a study in order to fund something before that funding is allocated?
Fielder: Yes. I think there is a lot of emphasis on research and a lot less emphasis on implementation because implementation is really a hard, long slog. You have to understand an institution. You have to understand a region and what the needs are.
We know, as you know, in academic medicine, they don’t give professorships in global health for doing implementation. It’s for research. But it’s that gap between doing the research and then, “How do we actually bring care to patients?”
I saw this early on in the HIV epidemic … and I will say that in the HIV field in Africa that research has informed implementation very nicely, I think, because the resources are there through the President’s Emergency Plan for AIDS Relief [PEPFAR].
But I saw this a lot with tuberculosis, that there was just this huge repository of research showing that TB in the HIV-infected host was a completely different disease than in the HIV-negative patient. It took forever to try to change protocols and give clinicians the freedom to pull the trigger and treat patients for TB based upon more subtle signs and symptoms. I saw so many missed cases and I saw so many people lose their lives because that implementation did not keep up with the research that was out there.
We definitely need research, but what gets the short end of the stick is direct clinical care. It’s my belief, it’s our organization’s belief, that there’s really no silver bullet to deal with the emerging and developing health problems and health systems in Africa. We need strong institutions.
I think a good example of this is a hospital called ELWA Hospital in Liberia, which was ground zero for the Ebola epidemic in 2014, and it’s where MSF [Médecins Sans Frontières, Doctors Without Borders] had their Ebola treatment unit. It’s a partner of our organizations. I was there rounding a couple of years ago with the family medicine residents that our organization supports. Ebola is now gone, but there’s diabetes, HIV, trauma, and TB.
If we don’t build institutions that can really focus on a wide range of problems and be nimble enough to respond to whether it’s Ebola or whether it’s chronic non-communicable diseases, then we’ll always be playing catch-up.
Makary: What has been the most frustrating part about practicing there in Kenya? Also, what’s been the most rewarding piece about it?
Fielder: Well, still for me, the most rewarding part was being part of the HIV treatment scale up under the PEPFAR program because you just saw then that the power of resources married to good technical assistance and working …
In my case, I worked with a lot of the faith-based institutions and we just saw lives changed. To have somebody who was virtually on their deathbed receive antiretroviral therapy and a couple of weeks later they’re out working in the fields, nothing beats that as a clinician.
I think in terms of frustration, I’d go back to some of the things that I said before. You never have enough resources. It’s always difficult to know that you could do something for someone and yet either the hospital doesn’t have that capacity or the patient doesn’t have the resources.
Where I usually do my clinical work, which I mentioned is further north in Kenya at Maua Methodist Hospital, I can talk to patients about, “Well, I think you could go to Nairobi and get this surgery. Or you could go to this mission hospital and get the surgery.” The patients just can’t afford it. Even finding their way there is often beyond them. That’s very depressing, to know that there could be help, but you can’t help people.
Makary: Is there a bit of a community of physicians working in African hospitals in a similar capacity that you are?
Fielder: I come from the missionary world and it’s a fairly small group of long-term missionary doctors in Africa who work at a variety of different hospitals. There is really an interest in mission-teaching hospitals, so we focus …
We have something called the Mission Hospital Teaching Network that we work with a variety of both established and emerging teaching hospitals. Some are affiliated with medical schools, many have internships, and many are now going on to do things like the physician assistant advanced training I mentioned, or even general surgery training or orthopedic surgery training. That’s very exciting.
Then we’re very fortunate that we have an increasing number of qualified and committed African doctors. When I first came to Kenya, there were few African doctors working in the hospital. Now, there are literally dozens and dozens of trainees from all across Africa at that hospital and that’s in 2 decades that transformation has happened. That’s very encouraging to us.
Makary: I think a lot of people may be listening to your experience and thinking about how they have either tried to help or would like to help. In my own personal experience, I learned early in my career that it can be a little challenging to help well. In other words, swooping in for a week doesn’t necessarily make sense with the specialty skillset that I have as a gastrointestinal and surgical oncologist.
What is the best way for a physician to help? Is it to build a relationship with a particular physician or a clinic or a hospital over a long period of time, or are there certain needs for highly-skilled specialists?
Fielder: I think that you put it well, that the key is relationship over a long period of time. If you’re not able to come long-term, then if you find a place and you say, “This is going to be where I commit. I’m going to go there every year, teach, help out, and get to know the people, get to know the staff.” Unfortunately, a lot of national staff are used to people just coming for very short stints and then they never see them again. That’s just a very hard way to actually make a difference.
I think a good example of how to do it well is the relationship that our clinic in Malawi, called Partners In Hope … it’s focused on HIV, but is expanding into surgery and other services. It had a good relationship, and still has one, with the UCLA Medical School.
We had a group of faculty that would come over. Most of them came over at least once a year and then they would come over with residents. Some of the faculty actually came for 6 to 9 months as junior faculty and really developed those relationships.
There was a strong tie between the clinic and the medical school and it was, I think, really mutually beneficial because they would come over and teach, and they would help, but they also were not a burden because they knew what was possible in Malawi. At that point, it was the poorest country in the world.
Just as a very sad, but simple, example: When someone coded on our small inpatient ward, it really wasn’t a code because we had already done everything that we could do for that patient. Maybe we had given them oxygen, antibiotics, antimalarials, or IV fluids. At that point, there’s no ventilator. There’s no ICU. Some doctors might come over and say, “Well, we’ve got to give adrenaline and we’ve got to resuscitate.” That’s just not possible in our setting. When we worked with these colleagues from UCLA, they knew what was possible and what wasn’t possible in the country.
Makary: Somebody once told me on one of the trips overseas that if you go with the attitude that you may do no medical care and instead just paint a fence or provide some company to those who are there, that might be the best attitude to go with.
Fielder: I think there’s something to that. I also would say that remember that there might be someone locally who could paint that fence, and so are you taking a job from that person? Another way, in that situation, the function or to help out is to find an organization or a person whom you trust and support them with resources. Maybe it’s such that the organization can actually hire 10 people for the cost of what it would have been for somebody to come over from the U.S. and paint that fence.
Makary: Is that true, also, with a lot of the food relief programs around the world? Does it simply flood local markets and create a similar type of situation?
Fielder: I have heard that criticism in the past. Marty, I have to say that food relief is not my area of expertise, so I probably have to demur on that question.
Makary: When we interview prospective medical students for medical school, it’s amazing the number of times that people bring up one of the reasons — it could be one of the many reasons — why somebody wants to become a physician is to be involved in missions in some capacity, if not full-time, as a part of their practice. It seems like over time the practicality of doing it becomes less feasible. Can you describe what you see as the journey in being able to aspire to do something like this and the feasibility of doing it?
Fielder: I’d probably start by dividing the options into two, or maybe into three. The one pathway is through academics. Can you get grant support to come out and do research? Then, in those cases, people might come out for a couple of weeks out of the year and then they have colleagues on the ground to do the studies while someone is not in-country. That’s one way and I think that might be one of the more viable ways simply from a practical financial standpoint.
Another one is to work for an international NGO [non-governmental organization] or a multilateral organization like the World Health Organization in the areas of policy and planning. But when you talk about actually being a clinician, seeing patients, and maybe teaching, that’s where the path gets a lot narrower.
There are a few organizations that offer those opportunities. Baylor Pediatric AIDS Corps, Global Health Corps is one. Seed Global Health, which was started by Vanessa Kerry — the daughter of Senator John Kerry, the former Secretary of State — they have early and late-career doctors come out to teach in African medical schools.
Then, in my community, which is admittedly small — that’s in the medical missionary community — people are sent by friends and family and Christian churches. That’s one of the ways in which people probably spend the longest periods of time actually practicing clinical medicine on the ground in Africa that I’m aware of.
Makary: We met through Mark Gerson, who is a founder of African Mission Healthcare, who is, I understand, trying to create a community of physicians who can have conversations like this, a sort of medical advisory board. If somebody is interested in it, and it sounds like there’s an open invitation for physicians to be a part of this, can they reach out to you and email you, Jon?
Fielder: Absolutely. Yes.
Makary: I look forward to being a part of that conversation. Thank you for a great piece in MedPage Today. I think there’s a lot we can all learn from the experience in Africa and the experience with COVID. It really, I think, helped shed light on how we can understand this virus in the United States.
Jon, I just want to say I have a tremendous admiration for what you’re doing, the commitment that you and your family have made, and it’s great to talk to you. I hope to talk to you many more times.
Fielder: Marty, thank you very much. I appreciate the opportunity to share.
Makary: Great to be with you, Jon.
Last Updated October 21, 2020
Source: MedicalNewsToday.com
