For all of the good things I have said, there are still many areas that need a lot of work in this health system. Some of these are related to cultural elements of practice or poor quality of care from training deficits or environmental factors. Others are related to low resources, period, like access to essential medicines.

I will illustrate with an example.

It was some time in the morning before starting rounds during my last week. Alex had left one week prior and some new faces had joined the fray. One of them was Sol, an Afghan American general practice doc who split time across several different sectors including military medicine, NGO work, urgent care locums, and hospitalist attachments in the US. He was senior to me by ten years at least, and his experience showed. I was surveying the territory on the wards, with plans to round on the female side that day as opposed to the male side I rounded on the day prior. Four beds from the nurse’s station I saw a lady looking stiff in her bed. Her eyes bugged out of her face like they wanted to escape.

‘She doesn’t look good,’ I said to Sol next to me. ‘What’s her story? Thyrotoxicosis?’

‘I’m not sure.’

‘We should probably round on her first,’ I said. ‘I’ll examine her now.’

Stepping closer to evaluate her, Sol and I picked up on the obvious right away. She was middle aged, maybe late thirties. She was sweating in bed, and lying awkwardly, almost like she was tensing on purpose. Sweat collected on her brow and her eyes twitched while remaining fixed on the ceiling. Placing my hand on her wrist, her pulse was flying. She grimaced in response to pain, but was non-verbal. She had all the hallmark features to go with her protruding eyeballs to tell me right away that she was in a thyroid crisis secondary to Graves’ Disease.

The thyroid gland is a collection of hormonal tissue at the front of the neck that produces a compound called thyroxine. Thyroxine is like the fuel that keeps our physiological furnace running, it modulates the metabolism of our cells. Too much thyroid hormone creates a surplus of metabolic activity, people run hot and get sweaty; they start to lose weight, and their heart beat accelerates (sometimes even entering abnormal rhythms). Women can also stop menstruating, and their hair begins to thin. Inversely, if the thyroid becomes underactive, the opposite happens, the weight goes up, people put on layers and layers yet still feel cold, and they get constipated. In severe cases of overactive thyroid, people can enter what we call thyrotoxicosis.

Thyrotoxicosis basically means there is so much thyroid hormone activity that the body can’t function. The effects are widespread, with severe cases presenting like this lady in front of me. She was burning hot, her heart rate was going crazy, her muscles were twitchy and her neurologic function was approaching comatose. She needed acute management, and fast.

The team had already gathered and we began to discuss her case. She was a patient that had been admitted to the hospital for another issue that I can’t remember (self-limited asthma flare, or something along those lines). She already carried a diagnosis of hyperthyroidism before her admission and was on medical therapy. Her diagnosis was Graves’ Disease.

Graves’ is one of the most common causes of hyperthyroidism. It is an auto-immune condition where the body creates antibodies that stimulate the thyroid gland receptors, triggering them to go into overdrive. It characteristically produces deposition of extra fat around the tissue behind the eyes, causing them to bulge forwards. I remember when I was in medical school, our class tutor stood at the front of the lecture hall scrolling through photos.

‘Think of Gollum from Lord of the Rings,’ he said.

Not politically correct, but it holds true.

Point is, when she was first admitted, she had run out of her thyroid medicines. We treat Graves’ with a medicine that basically binds to the thyroid gland receptor preventing those crazy antibodies from hijacking the system. Throughout her stay, the pharmacy was unable to get access to methimazole, and she stayed for treatment, only to begin gradually worsening from her thyroid perspective. I was told that the day before she was starting to look ill, but this was a whole new level for her.

‘Right,’ I said to the students. ‘This has all the hallmarks of thyroid storm. Now remember that thyroid storm is an emergency, and we need to act quickly. Do you guys have a way to remember the four medicines we give for thyroid storm?’

I got blank looking stares. It was like one of Gollum’s riddle.

‘There is a mnemonic that tortured me when studying for my board exams, have you guys heard of it? The four Ps?’ I continued

‘Can’t wait to hear these,’ Sol said. ‘I know the meds but these mnemonics are very new age for me.’

‘Potassium?’ One of the students said. ‘Potassium Iodide? That’s one.’

We went on until they got all four: Propranolol, Prednisone, PTU, and Potassium Iodide. This cocktail slows down the heart (Propranolol), decreases the conversion of active thyroid hormone into its more potent state in the blood (Propranolol again and Prednisone), and shuts down activity of the thyroid gland (PTU and Potassiume Iodide given together). It was a simple combination, and should have been an easy fix.

‘We can start the Propranolol and the Prednisone now, and then we’ll have to talk to pharmacy about getting the potassium and the PTU. It’s important that we only give the potassium after the PTU, otherwise we can worsen her state as the thyroid takes up the iodine load and uses it to make more hormone,’ I said.

‘That was part of our issue with her yesterday,’ Sol said. ‘She wasn’t this sick appearing but she was definitely starting to show signs of hyperthyroidism. We tried to get the PTU but apparently it has to be ordered a special way since the pharmacy here doesn’t carry it.’

‘Fair,’ I said. ‘Maybe we can talk to Adeline or Pascal about getting this moving.’

So we set the plan, talked about a few other things and moved on. I was able to pull Pascal and Adeline aside later that morning and made them aware. Pascal told me he would see about it.

By the time we came around the next day, she looked marginally better from half of the Ps.

‘We are still waiting on pharmacy about the PTU,’ one of the students said.

Then the next day.

‘Still having difficulty getting access to the medicines,’ the clerk said again.

Then the next day.

What the heck is going on here? I thought to myself. Sol and I decided to run it up the ladder again, asking Pascal to see the patient with us. He told us he was pushing as hard as he could but there was limited access to PTU or any equivalents.

‘Can we just go into the pharmacy in town and buy it ourselves?’ Sol said. ‘I’ll pay for it. Not a problem.’

‘The Pharmacy in town will not be carrying it,’ Pascal pointed out. ‘This is why we have to put it on special order.’

For days and days our patient sat there. We felt powerless. This was a matter of resources in the form of greater infrastructure, supply chain, and health networks. The fancy facilities of the university, funded by MasterCard and Bill Gates paying to house specialists from all over the world, was still hitting an impasse at the government hospital because we didn’t have any way to interfere with the existing national healthcare structures that cared for patients in the hospital. In some ways it begged the question: why put all this here if the university doesn’t even have their own hospital and are going to be victim to the same deficiencies as the state-run health networks?

This conversation is commonplace in the humanitarian medical sector. The question of how we should see the role of these humanitarian medical initiatives. Is the goal to prioritize patient care for a population in need above all else, in the most Hippocratic essence? If that is your goal, then sure, go with the model of aid organizations like Doctors Without Borders or mission hospitals run by multinational church groups. They build their own facilities, bring their own people, practice with their own guidelines, and do the best possible work they can to provide care for the maximum amount of people. That’s one way. We must recognize on the other hand though, that stepping over the existing healthcare structures and implementing your own may lead to better patient care, but it doesn’t necessarily work to augment the existing structures in a conducive way for self-sustenance. Doctors Without Borders has seen this in countless places for years. They build their facilities and then when it’s time to pack up and leave, they simply can’t, because the local healthcare structures remain ill-equipped to resource and handle the burden. In some ways, you can argue that having the presence of a mission hospital or a temporary facility from a large-scale NGO de-incentivizes local governance from filling that void. Like I have written about before (Afghanistan), there still remains a role in this world for pure aid, but sometimes aid comes at the cost of development.

Partners in Health and UGHE aren’t in the aid sector, they’re in the development sector. This means they have to play ball no matter how lousy the pitch is. UGHE is already here and progress is being made. It hurts to see this patient suffering when collectively we could do better. Still, we have to grin and bear it, what else can we do?

For me, that answer to that is I can do what I do best: teach clinical medicine. So back to the classroom I went.

More specifically, I went to a simulation lab on the UGHE campus.