The Wards

My routine during the week consists of morning rounds at Moi Teaching and Referral Hospital (MTRH) that usually start around 9am. Tuesdays and Thursdays we have 8am morning report, where students and staff will give presentations of interesting patients or topics commonly seen on the ward. I’ve been grateful for being able to sleep in until 6am or so, when Kim & I go on a 35-45 minute run just as the sun is rising. It’s peaceful in the mornings, compared to midday when people, bicycles, and cars hurry around the hostel and hospital across the street. Plus, the morning air isn’t filled with diesel fuel fumes from all the cars and matatus (or buses), which are quite noxious.
When walking from the hostel to the hospital in the morning, I usually pass by relatives of patients on benches outside the hospital gates waiting for one o’clock in the afternoon when visitors are allowed into the wards. I next walk past workers diligently mopping the outdoor stone hallways, which sometimes look cleaner than the ward floors themselves. The hospital consists of a number of small buildings, with covered walkways connecting them and beautifully landscaped grounds in between that starkly contrast the dark, decaying building interiors.

As I enter the main building housing the men’s, women’s, and pediatric medicine wards, I take a deep breath and prepare myself for my next few breaths of the hospital air. I’ve talked to other students about how to describe the smell of the wards, and the most consistent response is that it is a mixture of bleach, urine, human body odor, and musty old shoes. The first few days I had to suppress my gag response upon entering the unit, and was advised by our medical director to keep a low-threshold for stepping out should I feel faint. The hospital scent is now expected and I’ve adapted, now only occasionally being caught off guard by especially foul odors, like when an elderly patient with a purulent pleural effusion pulled out his chest tube, filling the wards with a smell of decay.
The patient’s records are all kept on paper, and often my morning is spent rummaging around the nurses’ station or wards to find the charts. The patients keep their X-ray films and CT scan films at their bedside – there are no computers at the hospital at all to read radiology scans or enter in orders or prescriptions. Treatment sheets are present for every cube of beds, and it isn’t uncommon for a patient’s medication schedule to be missing, thus leaving us to guess what medicine’s he has been receiving! Our pharmacy students do a wonderful job of working with the available stock of drugs, advising the team on what medicines are on hand from day to day to treat patients with, as supplies commonly run low. We have to ration a lot of our resources, like the oxygen tanks for example. The men’s ward, which houses anywhere from 50-150 patients, has only 2 oxygen tanks that are available for patient use! ICU-level patients in the US often sit on room air on the medicine wards here, and we’ve had patients die during our rounds in the morning. One patient, with an intracranial mass of unknown origin with subsequent hydrocephalus, herniated and died two days ago, because the neurosurgeons procrastinated coming to see him for 1 week. My intern told me this isn’t common for many surgery-related consultations, because the surgeon’s don’t get paid as much for treating these patients and also know they will be more ill, and more work, than patients in the private world. To me, this goes against the Hippocratic Oath let alone respect for human life, and has been one of the most bothersome realities of this experience for me.

My frank comments about these hospital conditions are made to illustrate the difference between our standards in all hospitals in the US. Though Wishard County Hospital in Indianapolis might not have the flat-screened televisions or posh interior design of Clarian West Hospital, it at least meets basic sanitary requirements and standards to keep patients and staff safe. If there is one good thing about living in such a litigious society, it is that physicians adhere to their Hippocratic Oath and are monitored for malpractice to ensure that patients are not harmed or killed because of physician negligence. A dichotomy most definitely exists here between the public and private wings of Moi Hospital. The private hospital wing across the street allows neither students nor residents rotate there, and is where Kenyans who can afford care turn for medical attention. I asked a sixth-year medical student on my team, Philip, what he thought about health care in his country, and he told me he is a supporter of basic coverage for his people. Within the last few years, some legislators have proposed different plans for health care coverage, but the plans were shot down quickly. The government officials get paid an extremely large salary by Kenyan standards: the Prime Minister gets paid $450,000 a year compared to the average income of $100 per year for an average subsistence farmer in Kenya. Philip said the officials are very far removed from the common people, and have no concerns about health care, since they are able to pay for their health care services without issue. Though the US has its own health care issues, I cannot help but be thankful for our standards of care and the faith I have in my physicians.

Nile River Explorers Rafting Adventure

I'm safely home in the hostel now, after a wonderful weekend of white water rafting on the Nile River with my new Purdue pharmacy friends.

Our journey took us to Jinja, Uganda, which is the source of the Nile River. On the drive from Eldoret to Jinja, we noticed that Uganda was much more green and tropical than our area of Kenya, and was more of the African environment we had envisioned prior to arriving in Eldoret.

The drive took about 6 hours because of poor roads and your occasional baboon crossing the street, but we finally arrived at our campsite to rest up for our big day Saturday.

We awoke to find that our campsite overlooked the Nile, which we could hear but not see in the dark of the night before. It was absolutely stunning! Below the area pictured here were showers that were open on one side facing the Nile River, so you could shower while looking out at the beautiful landscape.

We hopped on a truck with open-seating and began our trip down to the river. There we met our rafting guide, Paolo Bala, who is actually training for the world-championship of kayaking to be held in Switzerland later this month! He was an awesome guide, and we made it down all 12 rapids without flipping the boat (even though I secretly wanted to)!

Our tour of the Nile included 12 rapids, several of which were class 5 rapids. (For rafting pictures, check out the company's website (www.raftafrica.com/gallery.htm) We went through 8 in the morning, and 4 in the afternoon, with a lazy river break in the middle where we got to jump into the river and let the current take us downstream. We had lunch on the boat, which consisted of fresh pineapple and glucose biscuits (yes, that is the name of the shortbread-like cookies) and was a well-earned treat.

The Nile was surprisingly clean and very warm - it felt like bath water! Our day had started out sunny but become overcast with scattered sprinkles, so jumping into the river was actually warmer than being on the raft. In between rapids, we saw groups of people bathing in the river, women washing laundry, and others fishing. Luckily, we didn't see any crocodiles or hippos, which our guide says are rarely present in the calmer waters.

On the ride home, we drove through fields with small mud huts lining our path. Children ran down to the truck to yell "Mzungu!" and "Jambo!" and tried to get us to wave. They thought it especially exciting if we gave them the thumbs up sign, while some stood wide-eyed and pointed at us, for seeing white people was scary to them. Being from America, seeing so many different races from an early age, it is hard to comprehend that these children found our appearance so foreign and frightening!

Once we returned to the campsite, a spread of food and beer was laid out for us, and we ate, danced and celebrated our victory over the Nile. Later on in the evening, we were able to screen the video highlights of our rafting adventure (which I later bought a copy of because it was so well done)! I'll try to post it when I get back in the states with faster internet :)

We slept in the next morning, did some shopping at the small stands around the camp, and left beautiful Uganda and The Nile River with fond memories!

Weekend #2: White Water Rafting on the Nile River in Uganda

Ok, this is a short post, but I promise I'll have much more time Sunday/Monday to fill you in on this week's and weekend's adventure.

I'm getting ready to hop in a van with 6 Pharmacy students from Purdue to head across the Western border of Kenya into Uganda to go white water rafting on the Nile River! I'm a excited (and a little scared) but my med student and resident friends all highly recommend it :) The company we are using for the adventure is called "Nile River Explorers". Not sure if they have a website or not to check out . . .

Wish me luck and a safe return!

Weekend #1: Hell's Gate National Park

The weekends in Kenya are like those in the US: they go by way too fast!

John, Ryan, Kim, Marissa, and I had a wonderful time at Hell's Gate in Naivasha, Kenya which was about a 4 hour drive from Eldoret. Naivasha itself was a fascinating area with hundreds of football-field length greenhouses lining the main highway. Our driver told us that the town is known for growing beautiful flowers, which are flown out daily to European markets. He said about 80% of the town is employed by the various flower companies.

We stayed at Fisherman's Camp, a campground with a few cabins right on Lake Naivasha. Our first night was spent in a "Banda" which traditionally would've been a mud hut but instead was a regular one-room wood cabin. We dropped our bags and headed to the lodge, which was a large open-air restaurant and bar that looked over the lake and campground. It was a beautiful night, and I got to enjoy the yummy food and my first Tusker beer. It's the Budweiser of Kenyan beers, I've been told, but I thought it tasted much better than a Bud. According to the label on the back of the bottle, Tusker was the name of the elephant that killed one of the company's founders.

We were getting bored and John volunteered to go to the cabin to grab a deck of cards when we saw that a hippopotamus had come out of the lake to graze on the grass of the campground a few hundred yards from our table! We didn't realize this was common here at night, until we saw the campground owners had hung lights to some of the trees to help guests visualize the late-night feeding of the hippos. I couldn't get any great photos b/c despite the lights it was still dark, but I did get a video where you can somewhat see a hippo (will upload once internet allows!)

We woke up early the next morning, rented our rickety mountain bikes, and rode them down to Hell's Gate. The day was overcast and cool, which was great for us working hard pedaling. Our bottoms were very sore later in the day from riding 13 miles on the bumpy gravel, but seeing wildlife without fences or car doors between us was worth the pain :) On our ride down the trail, we saw zebras, water buffalo, warthogs (pumbas), baboons, and antelope. We got to the ranger station next, hired a guide, and hiked down to Devil's canyon. I assume it is called this because of the hot springs located there, and the guide advertised if we had brought our eggs with us we could've boiled them. My pictures/video don't do the landscape justice, and our tour was breathtaking (both visually and physically) as we climbed up and down rock formations like Angelina Jolie when she shot the movie Lara Croft: Tomb Raider here.

We finished our hike and biked back home through town, and were greeted by "How are you!" yelled by the children along the way. Supposedly, instead of "Hello" as a greeting, they are taught to say "How are you?" We mzungus (white people) stand out on the street!

Back at the camp, we were upgraded to the cottage which had a comfortable front porch and more spacious rooms. We noticed monkeys running around the camp and through the trees, which was a sight to be seen. But John told us Kenyans think it's crazy that we were impressed by monkeys, because that would be like them coming to Indiana and being impressed by squirrels!

We slept well that night and into the next morning, then wished Fisherman's Camp and Naivasha goodbye. My first weekend trip in Kenya has set a high standard for future get-aways!

First Day on the Wards

Thursday was a very busy day - I wrote this then and just have had the chance to post it now!

I met the resident and staff physician from Providence Portland Health System that are on my medicine team at 7:30 for breakfast, and we've been going non-stop until now. We rounded all morning with our Kenyan counterparts on the team through one-half of the men's ward. Our patients are very sick - probably the most sickly people I have ever seen. Most are malnourished and have hollowed-out faces with glazed over eyes. Their diseases range from pericarditis, meningitis, sepsis, and tuberculosis, and 2/3 are HIV-positive.

Interestingly, we don't use the term "HIV-positive", because of the stigma associated with the label. Instead, we say "ISS positive" which stands for Immune Suppression Status positive, and we call the HIV test the "DTC test" or Direct Testing Counseling test. Following this sentiment, patients often refuse wearing masks if they are HIV-positive or TB-positive, because of the assumption people make when they see them wearing the mask. This, along with poor sanitation and the fact that up to 3 patients share a twin-sized bed increases the patient-to-patient spread of disease. For example, TB pneumonia is considered a hospital-acquired pneumonia at the hospital, which is absurd to fathom for those of us used to working in the US.

The nursing care is poor, and it is not uncommon for patients not to have received their medicines because the nurses didn't feel like giving them. Often, family members are at the bedside of their sick loved one, and perform a majority of the care including feeding, bathing, and rotating the patient in the bed. Coupled to the poor nursing care is unreliable laboratory testing, which takes on average 1-day to 1-week longer for most testing to be completed. For example, a simple CBC takes about 24 hours to be completed here, whereas in the US tests return in a couple hours usually.

Physicians here also have to be conscious of the cost of caring for the patients, because almost all of them are uninsured and pay cash for services. The hospital is notorious for riding the families for payment, so most people refuse tests or medicines if they cannot find the money. This is especially troublesome for some of our patients with altered mental status that are HIV-positive and need a head CT. This costs 5,000 kenyan shillings (ksh) which equates to about $71, which seems reasonable at first glance, but when you consider that the average family income is $7,000 per year ($100), you can see what a huge expense this is for these people. And at discharge, if the patient cannot pay his balance, he is not allowed to leave the hospital and remains in his hospital bed until he does. This leads to many becomming ill from acquiring infections from other patients, and the patient is often readmitted without ever leaving his bed.

Despite these frustrating circumstances, people are treated and helped by the services through the hospital. The AMPATH program is a shining star of the hospital/university, as they are successfully treating 86,000 Kenyans with HIV currently and have been keeping excellent medical records modeled after Wishard Hospital in Indianapolis. I hope the next few weeks will provide more positive outcomes I can share with you!

This evening, on the way home from the hospital we bought grilled corn from a woman on the street. Our attending physician had talked to her earlier in the day and found our her husband has recently died, leaving her to care for their 5 children (one little one pictured beside her above). Despite looking delicious, the corn was not the expected sweet corn, but actually maize (or feed corn) and was very tough and bland in flavor. No worries, though, because we had dinner at IU house shortly with a post-meal fireside chat with Dr. Mamlin who founded the IU-Kenya partnership.

Dr. Mamlin discussed living life as a global health professional, which was very interesting. He encouraged us to find our own way to contribute to the care of the underserved, be it in the US or abroad. "Don't pick a project because you know it'll work out. That's no fun," he said. He challenged us to find our opportunities where we can, sharing his theory that medical schools provide a great environment to establish programs to educate and promote development of health care systems for the underserved.

I'm certain tomorrow morning will be eventful as well at the hospital, seeing as I make it through my morning jog with my wonderful resident Chloe and her peer from Portland, Megan. My next post will be Sunday or Monday with plenty of pictures from Hell's Gate!

Arrival in Eldoret

Yay! I'm in Kenya! Finally arrived in Eldoret and it is absolutely lovely. The weather is very mild, but the sun is strong, and there isn't much humidity. Our drive in from the airport took us through cornfields and pastures with grazing cattle, which offered a sense of familiarity to this foreign place.

The buildings are simple and brightly painted, and a steady line of people were walking and riding bikes on the red dust paths paralleling the road. The poverty is obvious - rows of bathroom-sized clay huts speckled the surrounding countryside with women cooking over outdoor firepits. Despite their poverty, the people here seem to be happy. People stroll in pairs smiling, and even those alone have a spunk to their step that I can recognize from our taxi.

After passing through two guarded gates, we entered a quaint compound with several buildings, called IU House. The landscape is lush and welcoming. Even the house dogs smiled and trotted along to check out the new guests. After greeting the some of the staff, I was shown to my temporary room for the rest of the week. I'm in the servants quarters of one of the buildings with a mosquito-netted bed and teeny bathroom a few steps away from my door. My door abuts the back of the house of the medical director & his family, whose outgoing children (Bella, Ava, Basil, and Clementine) greeted me with their small dog. Next week, it's off to the student hostel, which I'm told is not as accomodating as the IU house.

The jet lag finally caught up to me, so I took a nap before eating lunch and touring the hospital with the medical director, an oncology fellow from IU named Dr. Matt Struther. I'll talk more about the wards after I begin working there tomorrow morning. For now, I'm catching up with the other 4th year medical students who have been here the last month. They've graciously included me on an excursion this weekend to Naivasha: Hell's gate National Park, which supposedly is one of the two national parks that allows you to walk and bicycle through it, rather than be in a vehicle. (http://www.kws.go.ke/hells-gate.html)

Tonight is dinner-out night at the IU House, where everyone goes into town to a restaurant rather than home-cooked meals at the compound. The fare this evening is . . . Chinese :) We'll see how the Kenyans do Far East cuisine!

Departure

Hi All!

Here I am, in the Detroit airport (sitting outside the NWA Worldperks Club so I can get free internet) blogging for my first time EVER. But I suppose now is as good a time as ever because I'm starting my journey over to Kenya for the next two months.

Now that I've begun my trip and can stop double-checking my packing list, I've reflected a bit on my expectations for the trip. I don't have many, but here they go in no specific order:

1.) To venture into an entirely different culture and learn what life is like as a Kenyan individual.
2.) To learn more about the history and traditions of the Kenyan people.
3.) To try and have a positive effect on those with whom I interact.
4.) To learn about medicine in a third-world country including the challenges facing distribution of care.
5.) To make new friends!
6.) To establish what will hopefully be a lifetime of medical missions.

Stay tuned for the results! Thanks for following me on this awesome adventure :)
Elisa