Local Medical Practice and Global Health Interventions: An Ethnographic Study of Biomedicine and the Dilemmas of Care in Kenya

Overview: The focus of this ethnographic project was on East African doctors and their struggles to provide medical care in a context of scarce resources, widening socio-economic inequality, weak government health structures, and uneven flows of international funding. The project?s objective was to explore the meeting between global health policies and interventions, and local medical practices and standards of clinical care, through a case study of biomedical practice, professional identities and patient care in a large urban hospital in the city of Kisumu, Kenya. The main research questions were: What kind of medicine do professionals craft in these situations and what are their ethical, social and political engagements with the public good? How do their experiences of medical practice affect their professional identities, their sense of public duty and citizenship? The project aimed to contribute to the anthropology of biomedicine and development in postcolonial Africa by exploring the ethical and moral dilemmas that constitute medicine in 'resource-poor' settings and related issues of citizenship, the public good, and professional practice. Methods: Methodology included interviews, focus-group discussions, the collection of case studies, and in-depth ethnographic research the hospital. In total we conducted 51 interviews with medical professionals and administrators, 12 focus group discussions with medical professionals and interns, and 85 interviews with patients, half of whom we have followed-up and made regular visits to. The PI conducted several periods of observation in the hospital, including on the medical ward, 3the surgical ward, the children?s general ward, and the children?s cancer ward. This material was supplemented by extensive document collection. Results: The material collected generate an understanding of the material, medical and moral challenges that doctors and nurses face in struggling to provide medical care to patients in Kenyan public hospitals. Several issues stand out from our analysis: a)Kenya government hospitals are run according to ?cost-sharing? agreements, in which patients are expected to pay for all services and medicines received. This puts intolerable financial pressure on patients and their families, which we have documented in our interviews with patients and their carers. It also means that medical professionals must act as social workers too, as they have to assess the patient?s socioeconomic circumstances and ability to pay for medicine and tailor their prescription according to the patient?s pocket instead of according to his or her needs. This often places doctors in an intolerable moral dilemma, as they know the correct medical the patient should have, yet they also know the patient cannot afford it. Often they end up prescribing a drug that is less optimal in its effects. b) The material scarcity of medical supplies and equipment in government hospitals has a detrimental effect on medical professionals? professional identities and their ability to provide medical care. Public sector health workers often have to improvise with less-than-optimal equipment and medicines. They often described to us feelings of impotence, frustration and a sense of not getting any recognition for working hard under poor conditions. They are overwhelmed by patient numbers and by the inadequacy of the resources ? human, medical, material ? at hand to address these needs. c)While many public sector health workers express a desire to serve the public, most tell us that they would rather work for NGOs, in research or in the private sector, as working conditions in the public health sector are very poor. ?We are not able to practice what we have been trained to do?, as one doctor explained. d)The relationship between medical professionals and the state/government in Kenya is fraught and there is a lot of criticism in the media about the government?s neglect of public health facilities. The publics' concerns are focused on cancer care, which is very poor in public hospitals. Cancer care throws into relief the huge inequalities within Kenya concerning access to medical care and the growing divide between private health facilities and public health facilities, which largely serve the poor. The project has resulted in scientific publications, an article in the Norwegian media, numerous conference presentations and papers. In one article we argue that doctors in public hospitals work in the 'shadowlands of global health'. They operate in hospital wards where the global funds for health interventions ?for example, HIV, TB and other vertical disease programmes - reach only as far as the patients who have been enrolled in these programmes. We highlight doctors' experiences of the inequities that result when global health funding flows into vertical disease programmes, largely ignoring and neglecting the public health-care system itself.

During the last decade, donor funding for health interventions in Kenya has risen sharply but has mostly focused on high profile diseases such as HIV/AIDS and malaria. This has produced islands of intervention in a sea of under-resourced public health ser vices, which are still struggling with the effects of the 1980s neoliberal health reforms. Biomedical practitioners in Kenya thus face an extremely uneven playing field. While there is a wealth of data on epidemiological profiles and treatment outcomes fo r high profile diseases, locally-relevant knowledge concerning other diseases, which would help guide treatment decisions, remains patchy. Meanwhile medicines and laboratory tests remain prohibitively expensive, and equipment is unreliable. Physicians oft en have to make diagnoses based on clinical rather than laboratory examinations, and they must tailor their treatment decisions to the medical technologies, medicines and resources available to them. Aware of the existing medical possibilities unavailable to them, physicians have to develop versions of "good-enough" practice through their knowledge and experience of the socio-economic realities faced by their patients, of disease presentations and treatment outcomes, and the availability of medical techno logies. This project will explore the meeting between global health policies and interventions, and local medical practices, through a case study of biomedical practices in a large urban hospital in the city of Kisumu, Kenya. It seeks to describe and ana lyze how global funding flows and international treatment guidelines impact on the ability of physicians in Kenya to treat the health problems and diseases of their patients. It will explore the ethical, political and practical dilemmas identified by biom edical practitioners in Kenya in their efforts to follow "best practices" and provide good care. The project will employ ethnographic methods to observe medical practices and interview practitioners.