Mtu ni Watu

Have you ever heard the expression "it takes a village to raise a child"? Well, I always personally thought the saying was a little lack luster. Don't get me wrong, the meaning is not lost on me - nor is the importance of a plethora of support for the advancement of children - but does the value of a "village" decrease once that child becomes a young man, a new mother, or an elderly woman? Of course not! Call it what you will (village, tribe, etc), their support will always matter.

In much the same way that the village raises the child, communities of healthcare workers are integral to the advancement of population health. More importantly though, individualsfromyour "village" - whether it be Community Health Volunteers, trained personnel, or even other individuals with similar diagnoses - are the timeless, invaluable support system without which the maintenance of population health is impossible. This analogy might be a bit of a stretch, but I've already taken it this far! What I'm saying is this: where healthcare workers intervene for a short period of time, one's community is the enduring context within which we live - and it should therefore be the focus of any truly sustainable population health program.

Now you're probably not here to read my thoughts on local-global health practices, but this introduction is important to the stories I want to share with you. Moreover, it is a tangible way to demonstrate the effect that a short time at AMPATH can have on anyone lucky enough to work here. After 5 weeks at MTRH and out in rural communities, the power of community-contextualized care has fundamentally changed the way I see the practice of medicine.

The first story is about a young Clinical Officer (kind of like a Physician's Assistant) named Robert and a small community in Sonoko. Daktari Robert, as he is called, comes from the Sonoko area and works with BIGPic - which is a large, multi-faceted effort to take healthcare out of the clinic and into the community. Beyond speaking local languages, he understands the needs and interests of the population with which he works. So we show up, van full of meds and wazungu (white people), while Daktari Robert addresses an assembled group.

This group is a collective of individuals, many with Hypertension(HTN)/Diabetes and many without. As a cohort they form a microfinance GISHE group that works to support wealth-care, meaning the members collect funds form their own income and pool it together to produce small loans for group members. That's the most basic version of the story. It also just so happens that this group is made up of many individuals with similar diagnoses, ensuring stigma and discrimination of group members based on health status is minimalized. Robert's job then is to provide health literacy and interventional medical care during these GISHE meetings.

This brings us to a patient I'll call E. E is an elderly woman who came complaining of a severe headache - as she described it, the worst of her life. She had been off HTN medications for 8 months by the time she came to see us. Disclaimer: HTN and headaches are a really, really bad combination. Take into account that E's blood pressure was 225/150, her breathing was increasingly labored, and she had been under added stress due to recent deaths in her family? That's the recipe for a stroke/MI right there. Oh, and the only facility performing ECHO/ECG/CT is Moi - which is 2 hours away by car. So there was no time to lose! Yet despite all of this information, and the urgency with which Daktari Robert explained the situation, E refused to come back with us to MTRH. What good is our medical training when the patient refuses care?

And that's when her community got involved. The group of women who had been attending the GISHE group and collecting their meds gathered around E, convinced her to come back with us, and promised to take care of her home/family while she was away. You see her greatest concern was not her health, it was her family and their funeral arrangements - concerns even Robert couldn't qualm. But her community understood the barriers preventing her from seeking care, and so they overcame them by coming together. That's the village at work.

The next story is of Elias. He is a tall, lanky, middle-aged man with a great smile and funny mannerisms who also just happens to be HIV positive. Because of his status, Elias works as an HIV Peer Navigator/Counselor for the HIV Resistance Clinic. His job is to be a village-of-one for the most difficult patients - those with poor adherence, those facing stigma and discrimination, those who need a little extra support. How can someone with no medical training be such a critical member of the medical team? He speaks a language that none of the physicians can, and I don't mean Swahili or Kalenjin. It is one that he shares with our patients - both because of their mutual diagnosis and because he understands the sociocultural context of HIV as well as the unique difficulties our patients face. It is absolutely not an overstatement to say that Elias has been and continues to be the gateway to care for hundreds of people.

The first patient I saw in clinic was a severely wasted young woman who had seemingly given up hope. She presented with partial right-sided paralysis due to a ring-enhancing lesion in her brain - probably crypto, maybe TB. Elias told me that she had worked as an engineer in Mombasa and feared discrimination from her coworkers so much that she'd almost let it kill her. Now she had come for her second visit at AMPATH, with her family by her side, and the whole gang lit up when Elias entered the room. In a mix of Kalenjin, Swahili, and English they shared their joy at her recent improvements: weight gain, recovered movement, and so on. At the same time, Elias cautioned her about allowing fear to take her backward. As she left he wrote his personal number on a card, handed it to her, and said: "take heart, sister" - to which she smiled broadly. He then turned to me, smiled, and asked Dr. Adrian Gardner: "Who's next?"

"But, Grant," you might be thinking, "what does this have to do with that longwinded intro??" - which is a totally fair criticism. I could have just told you these stories and let them impact you in their own way, and maybe I should have. But I want you - whoever you are - to ask yourself these questions: what comparison do we have to Elias in the United States? Where are the individuals with well-managed diabetes who work with our newly diagnosed patients? Why don't we have group medical care to inspire support and openness amongst individuals with similar diagnoses? Where are the volunteer healthcare workers caring for others in need?

I know there are people who would be willing to do exactly that, but our current system has no place for them. Instead, our patients hear what we, as physicians, have to say and then immediately go home to scour the internet for resources written by - you guessed it - people with their disease/disorder! There are foundations and support groups and retirement homes and billions of dollars in healthcare expenses, so what is stopping us from having the healthiest population on Earth? In my opinion, the answer lies in our inability to learn from Kenya. These stories embody the lessons we must take back home with us to the United States. So often people think that we've come here to bequeath some elite system onto a needy population. Instead, I challenge you to see Kenya as an example from which Americans can learn the true meaning of population health - and, of course, the invaluable contribution of your own village. As it is said in Swahili: mtu ni watu - a person is people. 

Posted at 07:24

Tusonge Mbele Pamoja

There's a Swahili proverb that says "tembea uone"; essentially it means "walk and you will see", encouraging the listener to embrace new experiences as an opportunity to learn and to grow. Every time I anticipate another day-and-a-half of travel to reach East Africa, this phrase comes to mind. Each experience, each opportunity to return, is its own adventure with new things to see and an infinite number of things to learn.

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My name is Grant Callen and I am a rising second-year at Indiana University School of Medicine (IUSM) on the Bloomington campus. Over the past several years I have been extremely fortunate to spend a good deal of time in East Africa. Before my first year of medical school I chose to take a gap year in Tanzania while living with a host family and working in a rural HIV clinic. Finding your passion so early on in a career is truly a blessing, and I am so grateful for the chance to live out that dream in Kenya this summer.

Working at AMPATH as a Slemenda Scholar is pretty much the pinnacle of summer experiences, as far as I'm concerned. You're a baby doctor - as I like to refer to medical students, a research assistant, a world traveler, and a college freshman all at once! I say this because not only are you a practicing clinician (as loosely defined as possible) on rounds, but you are also: advancing the academic body of work that AMPATH puts out via an independent project; experiencing the intricacies of Kenyan culture alongside the natural wonders of East Africa; and living in a dormitory-style hostel with your fellow Moi University medical students.

I chose to wait to write my first blog post until we (Helen, Roshni, and myself) had been here for three weeks. Why? Because we have yet to do the same thing twice! Every single day is a new and different adventure - pediatric rounds one day, psych in-patient assessment the next, and traveling out to Sonoko for a community dialogue day following that. The goal of these first few weeks has been to expose us to as many parts of AMPATH/MTRH as possible while helping us to understand how it all fits together. Before I get too far ahead of myself though, check out these pictures - they're each worth a thousand words, right??

 

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The AMPATH Centre is the hub for HIV treatment, research laboratories, and TB services; as a part of MTRH, AMPATH has a catchment population of over 4 million people in Western Kenya

 

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Shoe 4 Africa is the first free-standing Children's Hospital in the whole of Central and East Africa, as well as only the second in all of sub-Saharan Africa (the first is in Cape Town, SA)

 

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Chandaria - as we call it for short - hosts palliative care, chemotherapy, HTN/Diabetes, and many more referral services - as well as the AMPATH research labs and consortium offices. 

 

Maybe now you can imagine yourself in our shoes! So you've just finished your first year of medical school, you have never truly been on a ward as a baby doctor - with your white coat on and stethoscope around your neck, nor have you ever really been expected to know more than the classic symptoms and buzz words for a single diagnosis. And now? Now you're being called "Dokta" by actual doctors; now patients' family members seek your advice while attendings grill you on liver enzyme levels; and now you're faced with patients two-to-a-bed suffering from diseases you were told not to worry about because "we don't really see this anymore…".

And that's day one - a Saturday that we volunteered to work. Since that first day I have learned more about the practice of medicine, the inherent inequalities of for-profit healthcare systems, and the barriers to quality care that affect generations of a single family and populations as a whole. Instead of trying to detail all of the ways this experience has impacted me, I want to share a single story.

This past week I found myself on the men's acute ward during rounds - a rotation that I wasn't even meant to be on (oops). I had chosen to follow two Purdue PharmD candidates - Shannon and Arthur - through their routine as they were essentially pharmacists and nurses for most of their time here. As the attending physician moved from patient-to-patient, I quickly noted that we had skipped one. The patient, a 17-year-old boy, was "discharge-in" - meaning there was nothing to discuss about his care. He was diagnosed as aphasic, paraplegic following meningitis at age 10. His story got me thinking of how the healthcare system had failed this child, causing me to focus on him for longer than most. As I watched him sitting there, admittedly ignoring the ongoing brief of another patient, he began to seize. So I called Shannon over to ask about his anti-epileptics, of which there were none; in turn, Shannon shared this observation with our attending and he was placed on a Carbamazepine regimen to prevent further convulsions

In that one moment everything changed for this patient. When I came back several days later it seemed nothing short of a miracle had taken place. As the attending passed the patient this time he asked "Habari bwana?" to which the boy slowly, but clearly answered "Mzuri.". My jaw must have been on the floor because the attending reached over, patted my back, and asked: "are you as surprised as I am?". Now I can't claim to know what happened or how (my pharmacology knowledge doesn't come close to explaining this situation) but what I do know is this: sometimes just being there makes all the difference. I absolutely do not credit myself with what happened - literally anyone could have observed his seizure and asked about the medications - but I was there. And now that patient is back home with his family, speaking to them for the first time in years.

In these first three weeks there have been many occasions when I have felt uncertain about my place here. As medical students we don't do ill-prepared and unsure very well, but that's exactly what we are at this stage of our training. Meanwhile, we are surrounded by some of the greatest minds in global health, all trying to mentor us while doing their part to "save the world". So sometimes it feels like you've been dropped in the middle of the ocean without a life vest. But if you get up every day, take your cold, hostel shower, and show up to work - sometimes you'll be in the right place at the right time. And for some patient, that will be enough.


Posted at 06:54

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