“Start small, start now, learn quickly”

Over the past week, I have been trying unsuccessfully to describe concisely what this summer has meant to me. What was I supposed to have accomplished while being here? What did I actually accomplish? When discussing health disparities, is personal accomplishment the correct metric?

Perhaps I should start with what a Slemenda Scholar is. The program is named after Charlie Slemenda, an IUSM epidemiologist with an intense interest in global health who passed away suddenly from a heart attack at a very young age. Funded completely by the IU Center for Global Health, it sends 2-3 medical students who have just finished their first year of medical school to Eldoret, Kenya, to experience everything that AMPATH is, and see what role global health might play in their future careers. It is without a doubt an investment in us, the Scholars, and our development. While there has never been an ounce of pressure on us to return or commit to a career with AMPATH, the Slemenda legacy is strong-the majority of Slemendas return during 4th year, residency, and eventually, long-term, to serve as team leaders for 2-4 years or live permanently in Eldoret as practicing clinicians. The current medicine team leader, a Slemenda, is married to another Slemenda, who has also served as a team leader before! What is truly amazing is that the partnership between IU and Moi University is so strong, and that IU is so committed to the work being done here, that IU departments, from their own budgets, fund their faculty members to come here and practice for 2-3 years at a time. It makes me proud to attend a school that believes so clearly in improving healthcare everywhere and supporting long-term efforts to do so.

After movie night last Thursday at the children's hospital, Faisal, a triple board resident (pediatrics, adult psychiatry, and child psychiatry) from IU, mentioned that he wanted to check on one of his patients, and I joined him. His patient was a three-year-old boy suffering from cerebral malaria, throwing up blood and bleeding from different parts of his body. Faisal worried that he was going into shock and tried to take the child's blood pressure, but there was no working blood pressure machine or cuff at the hospital. To get a sense of the child's BP, Faisal used his pulse oximeter to check the heart rate and then pressed on the child's foot to check his capillary refill. The heart rate was high, but the pulse oximeter also showed that the child's O2 saturation was 70% because due to the nurses' strike, his nasal cannula prongs were not being checked for proper fit. He recommended strongly that the child be moved to the ICU, but no beds were available. The next day, the child went into respiratory and renal failure and ultimately passed away.

So many stories like this one have stuck with me since being here for the same reason it stuck with Faisal-patients like these may have made a full recovery in a more developed country, without as many resource-limitations and barriers to care.  It seems sometimes that the days are equal parts hope and frustration, and that no difference is being made. The clinicians that work here must learn how to treat each patient like the first one of the day and develop incredible resilience to continue working in less than ideal situations. So many times, I have wondered how they continue to have such a positive attitude. My view is biased-I have spent such a limited amount of time here and I see only the short-term. The truth is that so much progress has been made, progress that can only be made when people commit to a community for a long period of time, and that is the macroscopic view that people saw and continue to see in these developing communities. The title for this blog post was inspired by Joe Mamlin, of course, quoted from a meeting with clinicians at a rural health facility.

What I have taken away from these encounters and conversations with physicians is that even though there is so much to be done, there is so much hope, and that is what draws people here, and what makes me want to come back. Progress anywhere is not instantaneous, but if we start small, start now, and learn quickly, over time, it will be made.

 

Roshni

This sign is on on the side of a very plain road on the way to Nakuru County, but pulling over and taking a picture with it is a must before leaving Kenya

 

Posted at 05:32

Only two weeks left!

Life here has become more routine, but also relaxed, over the last two weeks, since we have transitioned to working on our research projects. I get to design my own schedule and am enjoying the flexibility and my days here so very much. I'm not sure how researchers do this on a regular basis, but I am quite enjoying the freedom to self-discipline. Is that paradoxical?

This past week did have quite a few highlights though-this past weekend, we went to Masai Mara National Reserve-a safari! We spent three days on the reserve seeing so many different animals, including elephants, lions, more wildebeest than you can imagine, a leopard, two cheetahs, jackals, vultures, hippos, crocodiles, and zebras!

Roshni

The 7 of us with our safari driver Moseti after lunch on the reserve! 

We also celebrated 4th of July with cookout food, sparklers, and a few renditions of different patriotic songs. Astrid, head of the OB-GYN department here, gave the toast with some beautiful words about USAID providing funding for AMPATH, which gave a different meaning to 4th of July and the impact that the US has on the world.

It was also my birthday a few days ago and my fellow Slemendas surprised me with a cake and ice cream! 

 

Roshni2

 

Things at IU House are winding down as everyone is starting to leave before the election. It's really hard to believe we only have two weeks left here!

 

Posted at 03:49

Evolving Sustainability

Karibu! Asante! Mbogatarian!

Welcome! Thank you! Vegetarian!

(Me, after 5 Swahili lessons, showing off my newfound language skills-guess which one of those I use the most?)

For a long time, I have been very, very interested (read: obsessed) with the concept of sustainability, especially in the context of global health. I would be remiss if I didn't discuss an extremely important conversation I observed one of my fellow Slemendas have with Sonak Pastakia, a Purdue PharmD-PhD-MPH (expert on everything). During the conversation, they were debating whether AMPATH is replicable in other countries that need similar healthcare services. Some background information: one of AMPATH's current goals is to encourage patients to sign up for NHIF, which is the National Hospital Insurance Fund. Through this insurance, treatment for patients is covered, and AMPATH receives payment for services through the government. This is necessary to sustain AMPATH services in the long-term. Currently, a great deal of AMPATH's funding comes from USAID. Before USAID, AMPATH relied on small grants and private donors. (Recap: Stage 1: small grants to Stage 2: USAID to hopefully Stage 3: NHIF.)

This chronology is important to understand because it is absolutely correct that the current AMPATH model and variety of services is not replicable in its current form, because it took time, vision, demand for services, and so many other factors to get to this point in time. Demand for services really drove what AMPATH offers now, and this factor was what really changed my thoughts on sustainability. In the beginning, HIV was a death sentence, with no available treatment. Treating patients in sub-Saharan Africa was considered to be impossible. It really was a humanitarian emergency. To test the idea of treating patients, Joe Mamlin used personal funds, donations, and very, very small grants to buy medications-certainly not "sustainable." Stage 1. He proved the concept, so larger grants came along, and AMPATH could treat more patients. Stage 2. HIV became treatable-the initial emergency was beginning to pass. Now, AMPATH is looking to encourage the growth of NHIF, to be less reliant on external funding. Stage 3. It suddenly became so, so clear to me that emergencies must be treated as just that-as emergencies. In an emergency, whatever is necessary to help the situation must be done. Only after the initial situation is resolved can sustainability come into play. Sonak really drove this point home by emphasizing that what is sustainable also changes-mind-blowing. He gave the example that NHIF can only work if enough people enroll. So, if NHIF fails, Sonak will be there with the next long-term solution.

Whew! If you made it through that (and all my previous musings on this topic), please let me know what you are thinking. This concept has bothered me for such a long time and I am so happy with this new understanding.

I continue to love all the supplemental lectures and activities planned for us on a weekly basis. The latest Slemenda initiative has been to screen movies/cartoons on the pediatrics ward on Thursday nights. The first Thursday, we watched Sing and last week we watched Tom & Jerry. With the nurses strike still going on, fewer patients are being admitted, so those who are in the hospital are extremely sick. Just like other children, they love crude humor and mild violence, so it is really fun to sit with them and watch them laugh. 

Roshni1

Watching Sing at Shoe4Africa, the children's hospital-over 60 attendees!

 

We also have great lectures and workshops from and with the visiting faculty from universities within the AMPATH consortium. I've gotten to learn how diabetes in sub-saharan Africa is drastically different from diabetes in the US, pretend to be a trauma patient with a GCS of 5, and try to redesign the Kenyan healthcare system. This morning, we had a great lecture on biostatistics (8 AM, with over 40 attendees, if that tells you anything about how engaged everyone here is!), with two more later this week on global surgery and population health.

Wednesdays are also a special day at IU House because of fireside chats followed by catered dinners. Fireside chat topics range from post-election violence to palliative care (although we did play Jeopardy! last week). It seems like every restaurant in Eldoret serves at least one Indian dish, though I have yet to find any as good as my mom's cooking...

This weekend, we did two extremely fun day trips. On Saturday, we went to Kruger Farm, where we climbed a mountain and tried to follow giraffes around stealthily (and failed), followed by Kerio View, where we ate lunch overlooking the Great Rift Valley. On Sunday, we went to Torok Falls, a 10 mile, 6 hour hike/rock climb up a mountain to the base of a waterfall. For someone who really does not like hiking (and took a pretty impressive tumble during the rock climbing and have a fierce knee bruise to prove it), I find myself doing a lot of hiking this summer… 

Roshni2

Giraffes, just 50 feet away!

 

Roshni3

Torok Falls (when you travel with med students, they warn you about bare feet and schisto, which you ignore anyway) 

 

Roshni4

Pictured, left to right: adventurous, well-traveled, expert climber, and me

 

 

 

Posted at 04:09

Don't let perfect be the enemy of good

Another two weeks have flown by so quickly! Actually, I have been terribly sick these past two weeks, because I jinxed myself by bragging that I haven't been sick since October. But, I am recovering well and finally able to blog again (thanks to everyone who pushed me! So grateful y'all are reading!)

We have (mostly) finished our rotations through the different clinics. With the current nurses' strike, public hospitals are operating at sub-optimal levels, which has led to changes in our schedules. But, my focus now is working on my research project, a diagnostic mobile x-ray truck that operates in the most rural areas of Busia County. The truck was a response to the spread of TB in Kenya, which goes undetected and kills many people, especially in areas of close proximity. I have been traveling out to these clinics (about 3 hours away from where we are) with Joe Mamlin (undoubtedly something I will treasure forever and ever) to talk to the clinicians and ask them about the challenges they face in utilizing the truck services. Everyone has such great perspective and honest feedback. The operation of the truck really reflects many challenges rural medicine faces, including basics like lack of functioning computers to access the XR images or Internet. I approached this project quite timidly (after all, who is this kid asking questions of these amazing clinicians who do SO much to help their patients?), but I have found that everyone is so willing to talk to me, and it seems, really happy that their perspective is being solicited and valued. This is something Joe has mentioned too-he travels out to these clinics every week "for 12 different reasons", one of which is to go out and get a feel for how everything is actually running, something you cannot gauge from three hours away. He wants to make sure the clinicians out in these rural areas feel supported and I am continually amazed by his genuine, personal connections with both patients and clinicians.  

 

Roshni1

Me with Joe at Lake Victoria-already one of my favorite pictures

 

I have been reading, too! I just finished the book Mountains Beyond Mountains, a biography about Dr. Paul Farmer. Dr. Farmer is regarded as a pioneer in global health and has worked in Haiti, Peru, and Russia to provide healthcare in rural areas, to those who otherwise do not have access. I think this book really helped me continue thinking about how I fit into a global health landscape, especially why me, why now, and why here. My blog post title is inspired by a quote in the book-one that I've heard before, but that really resonated with me this time. Of course, undergraduates and fledgling medical students are not fully licensed physicians with a developed skill set, but exposing students when they are young, and giving them the opportunity to learn and grow from their mentors is how the next generation of global health leaders will be shaped. Arguably, this is good, and makes sure the work keeps getting done. So, if I'm here, and if I don't come back to work in global health, are these opportunities and resources wasted on me? I posed this question to my wonderful, thoughtful friend Ashley over Facetime and she assuaged me much more concisely and beautifully than I will put it now-that my time here, even if it doesn't manifest into me coming back to this exact organization to work, that I will still pay it forward in many way, by telling others about my experience, in my interactions with my future patients, and in ways I have yet to imagine. In a perfect world, the most qualified people would be here, doing this work. Actually, in a perfect world, every healthcare system would be fully developed and independently functioning within their own communities. But, it is important to remember thatgood,maybe not perfect, butgood, work is done by individuals who want to make a difference, bring others into their vision, and build together.

My good friend Aparna, who is also doing wonderful public health work in HIV/AIDS in NYC, wants to hear more about the HIV resistance clinic here, so I will take a second to talk about that now. Yes, HIV resistance! I did not know HIV could be resistant until I got here, either. Here, after a patient is diagnosed with HIV, they are started on first-line antiretroviral drugs, which I have been told are "fairly easy to mess up." After six months of treatment, their viral loads are measured and their adherence is assessed. If a patient fails first-line treatment, they are started on second-line ARTs, which have more side effects and are typically taken twice a day. If a patient is failing second-line treatment, here is where HIV resistance clinics come in. 90% of the time, patients are failing treatment because of adherence issues-stigma against taking the medicine, side effects from medication, or just a lack of desire to take the medicine. The other 10% of the time, the HIV strain the patient has does have resistance against the ARTs. However, it is hard to have genotype services performed here, so clinicians look for the typical presentation associated with resistance, the major giveaway being that the patient's viral loads are usually consistent around a 1000-2000 copies/mL. So, more than in any clinic I have seen, HIV resistance clinicians spend time assessing a patient's motivations in taking medicine, home life, stress levels, access to food, and more, because most patients are not resistant to the virus they have.

Travel! Two weekends ago, I went to Kakamega Rainforest with a small group of people. We stayed at a resort in the middle of the forest, which was so relaxing and wonderful. We took two hikes, one of which was a hike at 5 AM up a mountain to see a sunrise. It was beautiful-I almost wish I woke up more often to see sunrises-almost.

 Roshni2

Sunrise hike at Kakamega Rainforest

 

Posted at 00:34

Hello from Kenya!

Hello! My name is Roshni Dhoot and I am a rising 2nd (!) year student at IUSM. I am originally from Valparaiso, IN and attended IU-Bloomington for undergrad. This summer, I am spending 8 weeks with AMPATH as a Slemenda Scholar, primarily in Eldoret, but with so many opportunities to visit clinics in surrounding areas and work in the field.

Tomorrow (6/8) will mark two weeks here in Kenya and these past 14 days have been nothing short of amazing. I am spending the first three weeks rotating in AMPATH's many clinics: from medicine and pediatrics to HIV resistance, diabetes, and palliative care. After that, my focus will shift to field research on AMPATH's mobile diagnostic X-ray truck that travels to clinics without imaging capability, to see what issues are preventing the truck from functioning optimally. I actually had the opportunity to observe it in action and talk to several clinicians and engineers involved the project about their opinion and I am really excited to see what I might be able to contribute to such a necessary and innovative initiative.

In addition to being in clinic and out in the field, it has been great to talk to so many amazing people in the field of medicine and especially in global health. At IU House, where I have been staying, people from many different fields (public health researchers, chemists, surgery residents) come and go, but everyone is willing to answer questions about their motivations and career goals. In fact, dinner has become one of my favorite parts of the day because everyone usually stays for 1-2 hours afterward just to talk about their day and any other topics that might come up.

My favorite conversation to have has been about the reason I came to Kenya-to learn about sustainable healthcare systems in developing countries and how I might fit into this extremely complex, important landscape. During undergrad, I became aware of the damage that can be done to developing systems and economies by volunteers who come with the best of intentions, but for short periods of time and without the skills that the community may need. Not wanting to do more harm than good, but still very interested in global health, I wanted to spend some time reconciling my desire to serve abroad with the potential negative impacts of my presence in a community in which I would not reside long-term. Reading Walking Together, Walking Far (a great and short read about AMPATH and its history!) really convinced me that if I wanted to learn about sustainable healthcare, empowering home communities, and what global health really means, AMPATH was the organization with whom to do it. And here I am-not yet having reconciled these seemingly conflicting ideas in my head, but definitely on my way. More on this to come, I hope!

We are also highly encouraged to travel on the weekends and so this weekend, we went to Hell's Gate National Park, Lake Naivasha, and Mount Longonot. Hell's Gate included a very fun bike safari and hike through a gorge and other rock formations. Lake Naivasha was a boat safari which included several species of birds and a few animals (read: hippos!). Finally, Mount Longonot was a five hour hike up to 2780 m (9180 feet) and by far the hardest physical experience I have ever had in my life. See very unglamorous pictures below!

 Roshni1

 

Posted at 06:49

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