There is a small gland that lies in your neck. Hugging your wind pipe. It is butterfly shaped, each wing (called a lobe) delving into that groove between your windpipe and the gullet. It is small but vital. It is the engine that makes you wake up, have the energy to talk, walk. 

When it overworks, people feel like they are running a marathon. They sweat, fidget and have a racing heart. Even when sleeping. Their eyes pop out, some being alerted by their colleagues to their ‘mannerlessness’ of staring daringly even at strangers. 

It weighs a paltry 30 grams, unless it is enlarged. And enlarged it does get. Especially in ladies. You must have heard of goitre. Scientific theory has it that there are female reproductive hormones that share similarity with the driving hormone for thyroid gland functioning. This causes the gland to get confused and respond to this other hormone once in a while. 

Mountainous region

In the mountainous region where I work, there are so many ladies with goitre. For myriad reasons. In a year, I get to do nearly hundred thyroid surgeries.

It has since become easy for me to tell a patient who has had thyroid surgery when I walk into the clinic. She will have a scarf around her neck; even when the weather is not as chilly. 

The case was not different on this particular Wednesday as I walked past the throng of waiting patients and eased into my consultation room to begin the surgical outpatient clinic.

Among the patients I was to see was a young lady in her late 20s. She had  commuted for three hours from Nakuru for her post operative review clinic. As she walked in I could immediately recall her story.

She had presented with goitre that was compressing her windpipe causing her shortness of breath whenever she lay flat. 

Gland replaced by nodules

Having examined her and done the preliminary blood tests and neck scan, we noticed that her thyroid gland was replaced with multiple nodules. It is called multi nodular goitre. 

She needed surgery to relieve her symptoms. We discussed the dangers, risks and possible complications. When I invaded her neck to flush out the culprit gland, I was aiming at doing subtotal thyroidectomy-removing the diseased gland and leaving behind a sizeable piece of normal tissue.

Since surgeons operate from the right side of the patient, my practice is to proceed to remove the left lobe which in this arrangement lies opposite me. 

I found her left lobe totally nodular with no normal tissue to leave behind. I removed it in totality. 

The same predicament would befall the contralateral lobe a few minutes later.

“I found your gland totally destroyed by nodules and we had to remove it.  What you have left is really small. I am afraid you will have to use hormone supplementation for the rest of your life,” I had told her the next morning during my post operative ward round. 

Hormone supplementation

Now that the gland was out, she needed to take a tablet each day to replace the hormone that is normally produced by the gland. Otherwise she would not move, eat or wake up. She would go into coma-myxedema coma, in our surgical lingua.

We had had an agreement before surgery. That was how we got to her consenting for surgery.

Now, researchers have found that after surgery majority of patients do not remember what they discussed with their surgeons before their surgery. May be anxiety is to blame. I chose to blame it, not her, when she began to [not] talk.

At surgery I had left just a piece of normal appearing right lobe of her gland and was sceptical about its reliability to sustain her thyroid hormone requirements.

So we had commenced hormone supplementation. After some months she wanted to find out how the remaining tissue was faring at its ordained task. So we had reduced the dose. 

Disappointing lab results

When she left her home that morning, she was hopeful that the lab results would show that she was okay to drop the tablet. That the remaining thyroid mass could sustain her. All this hope had been crushed by the time she walked into the clinic. The lab results were disappointing.

We began with a moment of silence. Not because I requested for such, but because she would just not speak. There was pin drop silence in the room, often interrupted by the giggles of a rambunctious toddler from the waiting bay outside.

We looked at each other, then looked around, then had our eyes lock again. My intern was feeling awkward. From past similar moments, I knew what was next. It was either going to be an outburst of sobs or a torrent of tears deluging a silent face. It would be the later. 

My intern passed some tissue paper to her. Another eternity of silence.

Finally the conversation began. We dwelt a little on how she never expected this. How she did not sign for this. I kept quiet and listened. An impatient patient pushed the door and peeped. I signalled him to shut up and shut the door. 

I heard her. Then I prompted her to confront the elephant in the room. 

“What makes you so sad? Like I mentioned, even if you had remained with the entire gland, you would soon be without hormone since it was entirely getting replaced by nodules. I would like to know how I can help moving forward.”

The eyes that had started to dry up began drenching. 

Three hundred shillings is too much

“I cannot afford this. It is nearly three hundred shillings a month. I am jobless and NHIF does not pay for the medicine.”

I learnt from her that she had just completed her diploma course and was yet to get a job. Her family was not well off, meaning she struggled to pay for the blood test that I had requested. I assured her that I was not interested in any more blood tests as long as she got her tablets and she felt okay. Even the tablets would not be easy to get, unless there was a way NHIF could cater for them. 

“Thyroxine is not in the essential medicines covered by NHIF (National Hospital Insurance Fund),”my contact at the pharmacy confirmed. So did the credit controller. 

“I can see her in perpetuity every month, NHIF will pay for the consultation. How come they cannot pay half that amount which can ensure a month long supply of the pills?” I knew I was not winning. I just said it to vent out. Just the way I find myself screaming and stumping my foot on the ground every time I miss a clear shot at a badminton game. 

We made peace with the predicament. I promised that if she got enough for the pills, she needed not come to clinic. She could spare the fare to get money for the meds. Watching her back as she left the clinic did not give me relief. It left me pained. 

Essential drugs package is good. It means we make rational use of the resources we have. It is driven by prescribing patterns. I know it is well intentioned. But if antimalarials are essential medicine in Western and coastal Kenya, why shouldn’t thyroxine be in Mt Kenya region? 

Especially when a month long dose costs under three hundred shillings. There are various efforts and suggestions about how NHIF can improve their service, especially in the era of Universal Health Coverage. If I was to add my voice, I would suggest a review of the list of drugs covered by NHIF.