Tumaini

I just got my electric teakettle to work and it's pouring down rain outside my window. The rainy season and Kenyan tea go well together.  Fun fact part deux, Kenya is the world's third largest tea producer behind China and India. The tea fields in the hill country near here are pretty picturesque to drive past-I've seen them shrouded in mist with the sharp, thin paths for the tea pickers making a criss-cross pattern across the hills.

 But enough of that. 

The major project that I'm on here in Kenya is with Tumaini Children's Drop-In Center.  Sadly, although I am a medical student, I have no real practical medical skills as of yet. I'm an excellent taker of blood pressures and asker of questions about your past medical history.  I can perch on your bedside and happily ask you all about what medications you're currently taking and your current maladies.  I can do nothing of value with this information.  So, going out and saving lives, not so much.

 Thus, I spend most of my actual work (as opposed to shadowing) helping the staff at Tumaini with a monitoring and evaluation project that they have implemented in order to see how well their programs are helping the street kids with their day-to-day lives. I'm also helping write up some data characterizing the street child population of Eldoret.

 The street kids are a pretty resilient bunch. They teach you a lot of slang and handshakes for the cool. They hang out in some pretty interesting places around town-the biggest group of them or "barracks" is in a dump near the vegetable market. We had a kid in today with the kind of swollen arm that makes you wince to look at-he'd been beaten by one of the guards that stands outside the shops downtown.  Day in the life, I guess-the opinion of the general public toward the street kids is pretty low.  The medical worker made him a sling out of gauze and sprayed some lidocaine-antibiotic ointment on it.

 I have some ideas about what the whole population is like (in reality only a small number of Eldoret's street kids come to Tumaini) just based on my interactions there, but we'll see if the numbers reflect that. Until then, I'll continue to come up with solutions to small-scale crises at the center. My latest problem was to re-engineer a community toothbrush holder whose handle holes were too small--with the simplest solution possible.  I'd tell you the answer but it's proprietary…

 

 

Posted at 16:47

Cardiology Clinic

Today, after some peanut butter and plum jam toast and a big cup of coffee, I spent the morning shadowing at the cardiology clinic.

 I like cardiology clinic; in fact, I have a history of generally liking cardiology, although that may be a lucky coincidence of meeting a lot of really nice cardiologists in my life.  In Eldoret, and perhaps Kenya in general, you tend to see a lot of rheumatic heart disease (and thus get to listen to a veritable cornucopia of weird, uncorrected heart murmurs), pulmonary hypertension and right heart failure.  You also end up finding a lot of cardioembolic strokes, especially in young people, which is always hard to see since it results in hemiplegia or some other disability many times. I have found I get the most out of it if I go and sit with the fellows one or two days a week and attend case presentations the following morning regarding the more complex cases.

 Today I sat in with the medical officer who works in cardiology at MTRH. The Kenyan system of medical training differs from ours in the sense that you do no undergraduate training (which tends to be the case in most countries outside of the U.S.), go through six years of medical school, then do "internship," then you must work as what's known as a medical officer in order to earn money to do residency.  Yes, residency in Kenya is not only unpaid, but you pay in order to do it.  You do get paid if you go on and do a fellowship, but not much.  This system was described in less than fond terms to me by a couple of the Kenyan doctors between patients, over chai and mandazi.

 I can't really cite the American system of medical training as perfect.  Although I must say that if I had had to go straight into medical school as an undergraduate I probably wouldn't be here, and I'm really glad I have a salary (however small) to look forward to as a resident. Thinking about coming out of medical school and not getting paid anything at all makes me unsurprised that the rough figure was thrown out to me of 50% of Kenyan medical school grads that don't go on to residency.

 The patient that I really remember from today was an elderly man who came in for a checkup on his hypertension.  His chart said he was 93.  His son, who was with him, corrected this figure to 103, born in 1909, and that he had been married to his wife for 83 years. I take these figures with a grain of salt, because I know birthdates and time periods tend to be less exact in Kenya, from my experience.  No one writes birthdates on medical charts, just the year.  I don't know that that really matters when you start thinking about it, though… Regardless the man was pretty venerable, and his length of marriage was impressive.

 He was Kalenjin, which is the majority tribe around Eldoret. Fun fact, it's the so-called "running tribe," since most of the great Kenyan runners have been Kalenjin. But I digress. The really remarkable thing is thinking about what this man has seen in his lifetime. That could be said of any 100+ year old person I suppose, but even more so, perhaps in Africa where borders and political control have been in flux for a long time.  He was around for the fall of British colonialism and the formation of an independent state.  The advent of motorized transportation and cell phones. Heck, he saw the AIDS epidemic happen. 

 I was reminded of this giant tree that we saw last weekend in Kaptagat forest that we were told was estimated to be 1,000 years old. Mind. Blown.

Posted by Rebecca Sorber at 02:18

Turbo clinic visit

This morning I got up and made my way along the red dirt paths on the sides of the roads from the hostel to the IU House compound to meet with Joe Mamlin and accompany him to his clinic in Turbo.  Turbo is west of Eldoret, right on the highway that passes from the Kenyan port of Mombasa to the landlocked country of Uganda, so we were constantly weaving in and out of an endless line of tanker trucks and matatus. Kenyan traffic and the roads upon which it runs are the kind of marvels you have to see to understand. There are ruts in the road 3-4 inches deep from tanker truck after tanker truck running over unreinforced tarmac that's been baking in the equatorial sun. As put by Dr. Mamlin, "It's a mutually beneficial relationship. The guy who makes the roads skims off the top, does a bad job and makes a fortune. The government who contracted the road skims off the top and makes a fortune by contracting cheap work. The roads are so bad that we all have to drive slowly and are forced to not kill one another, and they have to be replaced so often that everyone has a job."

 We picked up several of Joe's clinic workers on the way to Turbo and managed to pack 10 people into the vehicle before we were finished. That was certainly the first time my morning commute included conversation about a man being killed by a rogue hippopotamus and symbolically negotiating a bridal price in cattle. Arriving in Turbo, we parked at the clinic and took a tour of the AMPATH HIV clinic and the adjoining health center. As we walked through the health center, I couldn't help but notice the price board for various procedures. Want a chest x-ray? Price, 350 shillings, or less than 5 US dollars.  And that's still cost prohibitive for many of the patients.

Dr. Mamlin gave me a bit of the history of AMPATH and of the founding of the Turbo clinic thirteen years ago ("They told me I couldn't construct anything, just renovate. Well, I set a brick in this field and started renovating around it.  Oops.") Just a bit of history-at the height of the AIDS crisis, AMPATH was founded to provide Kenyans with access to free anti-retroviral (ARV) drugs and prevent the spread of a pandemic. It's grown to serve hundreds of thousands of patients throughout Kenya, and now provides free drugs, social support, mental health counseling, and nutritional assistance at over 60 village clinics. More than that, though, the presence of these clinics has done much to raise awareness and destigmatize the HIV positive label on a village level.

 We finally settled in the back room of the AMPATH clinic and started to see the patients queuing in the halls. I've been around HIV positive patients before, so that was not a new experience for me, but seeing active TB infections was not something I'd seen in the States.  I'd not seen TB ever before today, and today I saw at least 5 chest x rays showing TB infections in various states of seriousness, including one miliary TB film. The problems that the staff tackles are enormously complex. You have a woman who comes in who has been inadherent to her ARVs and is showing signs of resistance.  Problem.  She has lost a worrisome amount of weight and has a nasty cough-chest x-ray strongly suggests TB. Even more of a problem, considering one of the anti-HIV drugs that would help her most as a second-line therapy is not compatible with the first line treatment for TB.  She has a 6 month old baby that is the size of a newborn, has undetermined HIV status, and probable TB.  A complicated puzzle indeed, especially when one considers that the everything is resource limited. And that wasn't the only complicated case we saw. There was usually some convoluted mix of medical conditions, interpersonal issues, poverty, malnutrition, and healthcare access that made case after case its own puzzle.  It's a testament to the clinical mastery of the staff that they are able to sort through these cases efficiently.

 We headed back to Eldoret after an extended morning of seeing patients and a hearty lunch of ugali, sukuma wiki, and a little chicken. It was gratifying to be at this clinic with a staff that wants to be at work more than anything and help patients. The village clinic model works because most of the workers have actually been helped by the clinic. They know how the system works, they are local, and understand the cultural nuances of the village and region.  It is the village that is driving the clinic and helping its own people, and there is so much help that is possible.  A free course of ARVs is invaluable for an HIV patient-I saw patients that looked normal today but, by looking at their files and hearing stories from the staff, were literally on death's door when they first began coming to the clinic. To work with a warm staff that was passionate about helping people and achieving massive, tangible results in their own community is a wonderful thing. 

 I also can't say I've been anywhere else that I got invited to a staff member's wedding after shadowing there for one morning. I have previous plans to go to the rainforest this weekend but may your cattle negotiations be fruitful!

Posted by Rebecca Sorber at 17:35

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