You win, Kenya

Over the last few days, these have been the top 5 problems that I have faced:

1. An HIV positive woman with a vitamin deficiency
2. An HIV positive woman with a seizure disorder who has been unable to get care or medications for the past 10 years
3. An HIV positive woman who is 8 months pregnant and has received no prenatal care because of the doctor strike
4. A group of HIV positive women who do not even know what HIV stands for
5. An HIV positive, mother who suffered a traumatic brain injury who keeps having kids because she can’t tell men she doesn’t want to have sex

Over the last few days, I thought I could solve the following problems:

1. An HIV positive woman with a vitamin deficiency
2. An HIV positive woman with a seizure disorder who has been unable to get medications
3. An HIV positive woman who is 8 months pregnant and has received no prenatal care because of the doctor strike
4. A group of HIV positive women who do not even know what HIV stands for

Over the last few days, I actually solved the following problem:

1. A group of HIV positive women who do not even know what HIV stands for- After an education session during their therapy group, they have a little more information about the disease that has held them captive for many years.  

Over the last few days, I have felt 100% beaten down by the following problems: 

1. An HIV positive woman with a vitamin deficiency
2. An HIV positive woman with a seizure disorder who has been unable to get care or medications for the past 10 years
3. An HIV positive woman who is 8 months pregnant and has received no prenatal care because of the doctor strike
4. An HIV positive, mother who suffered a traumatic brain injury who keeps having kids because she can’t tell men she doesn’t want to have sex

This means that I was at least able to tell a group of women the name of the disease they have.  Otherwise… Kenya: 4, Megan: 1.  And what do all of these have in common?  The fact that they involve people who are all HIV positive and in this country, that makes your value as a person drop way down.  

Needless to say, it has been a very difficult week.  Paige and I met the woman with the seizure disorder two weeks ago.  Ten years ago, she started HIV treatment and within a few weeks, developed a left-sided tremor and stiffening episodes.  With some further investigation, we determined these episodes are likely seizures.  After a very detailed history with a confounding language barrier and a thorough physical exam, we developed an initial differential.  Often, when patients who have been immunocompromised are treated and their immune system starts to improve, the body targets areas of infection that were not recognized by the body while the immune system was absent.  We think that this woman had an indolent infection that her body was not combating because her immune system was destroyed by HIV.  When she started her HIV treatment, her reconstituted immune system attacked that infection in her brain and caused damage to the area.  The timing lines up perfectly with the start of her HIV treatment.  Luckily, Paige knows a neurologist who specializes in patients with HIV and its effect on the brain!  He confirmed our suspicions and I have to say, it felt really good to realize we weren't totally off base.   

“They nailed the diagnosis… treatment should be no problem,” you might say.  Yeah… nope.

We took the woman to the hospital and helped her explain what has been going on for the past ten years.  She has been to the doctor multiple times but explained that no one ever understood AND not one doctor has ever examined her.  For all of my medical friends, that probably makes you cringe, especially because if you do even a simple neurological exam, you can clearly see her profound cerebellar signs.  After going through the ringer at the hospital, the doctor finally agreed to treat her with broad seizure medications.  We then had to go back and forth paying for the consultation and labs.  We finally got to the counter to get the medications and learned they would cost 60 US dollars.  That is completely unsustainable for a woman who barely makes 5 US dollars a week.  The doctor then told us she could get her medications for free at another hospital but she would have to start the process all over again.  Finally, her husband was able to take her to the hospital on Friday and they did get the medications.  This was a major victory but the poor woman got a stomach bug over the weekend.  She cannot catch a break.  

We truly hope she is on the mend and her neurologic symptoms are under control.  This condition has caused so much stress for her and her whole family.   This whole situation makes me appreciate my medical training and once again, the importance of a physical exam.  

I'm hoping to learn that by next week when I return from safari, this woman's symptoms have improved and that we have found a sustainable source of treatment for her.  I'm hoping for a Philly-style comeback in the final quarter of my trip.  

Kiotani

Four years ago, during my very first weekend in Kenya, I stood on a dusty piece of land in the middle of nowhere, hot, sunburned, thirsty, and waiting for a piki piki driver to bring a tire for Mary’s broken down car.  Having met Bee and the Sponsors for Kenya girls a few days before, I was well aware of the dream they envisioned for the land.  “A sanctuary for children,” Bee told me.  “I don’t want them to be institutionalized.  I want them to have a childhood because in the slums, you have to grow up so fast.”  I deeply admired her enthusiasm and determination, but in that moment, was unsure if it could be done.

However, for the next 3 months, Positive Life Kenya showed me that of which they were capable and those initials feelings of doubt were quickly blown away.  As an intern, PLK immediately got me involved in home visits, group counselling, educating women on their sexual health, and in helping to secure sponsors for children.  During my time, I learned how important it is to get children out of the slums and to a place where they can sleep knowing someone will not attack them.  A place where they can go to school without trekking miles along a dangerous highway.  A place without constant interruptions in their schooling.  And most importantly, a place where they will be empowered.  In those 3 months, the PLK staff also helped to foster my own dreams for what the organization might become and how I could become a lifelong partner with them.  

Since leaving Kenya, I have spent the past four years in medical school, however, if you’re reading this blog, you know that I have actually spent the last four years talking about PLK and dreaming of the day I could finally return to work with this amazing organization.  Last weekend, I finally returned to Kenya and the first place I visited was Kiotani.  I have followed along on Facebook, but the magnitude of what has emerged on that dusty piece of land cannot be communicated through the internet.  Watching the buildings of Kiotani appear in the distance as I bumped around in the back seat of the car praying once again that we wouldn’t get a flat tire, I realized that the dream has in fact become a reality.  

This past weekend was the official inauguration of Kiotani.  We took a group of kids form Tuamini (the day school PLK runs in Kicheko slum) out to join in the celebration and I have to say, I have never seen happier children in my entire life.  Many of these kids have never seen a place where they can run around without fear of landing in a trash dump or on rusty metal.  There is a swing set out at Kiotani which, to the Tumaini kids, is a complete novelty.  The kids from both Tumaini and Kiotani prepared songs, dances, poetry, and skits to entertain all of the guest.  Despite many interruptions in their education and an often non-traditional path, these children are smart, enthusiastic, creative, and driven.  Each performance was better than the next.  Four girls wrote and recited a poem about AIDS which again, showed how fleeting childhood is in this community.  Their understanding is vast and the impact of HIV on this community is felt very deeply.  

We also got to plant trees with the kids that board at Kiotani.  Each child will be responsible for their tree.  I planted an avocado tree with Simon, one of the boys I met last time I was here.  He is one of the five boys cared for by my first host, Kate “Mwikali” Watson.  I cannot begin to express how meaningful that moment was for me.  

At the end of the day, I sat waiting for our matatu to take us back to Mlolongo.  I watched kids playing on the swing set, undisturbed by the dust and hot sun, and listened to so much laughter.  It was the best medicine and provides such perspective on life.  I have a lot of change coming and many things I cannot control but watching these kids, who have nothing and have faced unspeakable horrors, laugh and play in the middle of vast plains in Kenya, pushed me to reevaluate what really matters.  

There are many “next steps” in the growth of Kiotani and Positive Life but I have no doubt that they will accomplish them, especially with the help of all of the community and international partners.  I look forward to being an ongoing partner with this organization and group of people.  I also look forward to watching this organization continue to grow and affect change in this community.  Despite what seem to be insurmountable obstacles, Positive Life Kenya faces each day with passion and dignity and holds true to their mission of seeing empowered families living with hope in a positive environment someday free of HIV and AIDS.  

Doctor Strike

When planning this trip, Paige and I had absolutely no intention of using our medical skills.  I know that I earn my degree in three months, but I still do not feel like a full-fledged physician.  Right now, however, doctors in Kenya are on strike and small problems in Mlolongo are snowballing because people cannot access any medical care at the government hospitals.  The private hospitals are simply too expensive.  Surprise surprise... Kenya and America have something in common.  Clearly neither country has figured out how to make healthcare both accessible and affordable while compensating medical professionals appropriately.  But let's not get started with that topic.

When the word got out that there were two Mzungu medical students in the area, people flocked to the office.  We had to be very adamant that WE ARE NOT DOCTORS and still have a lot of training ahead, but we were able to handle many of the small complaints that walked through the door.  We saw many with common colds, some joint pain, GERD, and one urinary tract infection.  Unfortunately, just as in the US, we had a patient with severe liver disease.  When she walked in the door, she looked so hopeful that we could offer her a cure.  Even in the US, liver disease is complicated and difficult to treat, requiring many years of fellowship to understand.  The etiology of her liver disease was also unknown and, obviously, I could not order LFTs, a hepatitis panel, nor a right upper quadrant ultrasound.

We also had one patient who left us completely stumped- HIV+ with some unknown surgery to remove an unknown mass in the intestine who has had darkening and tightening of the skin, ongoing post-prandial vomiting, and a 30kg weight loss over the past 2 years.  With about 10 different diagnoses running through my head and confidence that I missed some of the history with the language barrier on both ends, I left feeling frustrated and confused.  If I have learned anything yesterday, it is that we, the American medical community, are too reliant on lab tests and imaging.  I tried desperately to channel the Doctors Berg, Majdan, and Mangione, leaders of my medical school's Physical Diagnosis class.

Like I discussed in my first post, expectations are high.  Even people that are getting over the flu came to see us because I think they thought we could somehow magically cure them.  To make matters even more difficult, there are barriers that seem insurmountable, the lack of lab tests or imaging notwithstanding. The language and cultural barriers make communication of medical issues borderline impossible.  I kept trying to ask people about their bowel movements and many would simply not tell me.  The way I ask questions in America just does not translate appropriately.  All of these barriers created more questions than I had answered about the patients I saw and, needless to say, it was an excellent test in my ability to tolerate ambiguity.  (To my fellow Jeffersonians, Dr. Mangione would be proud.)

If anything, this experience reinforced both the need for a free clinic and training for community health workers who may be able to screen many of these simple conditions before they spiral into a fatal ending.


SPECIAL THANK YOU TO ALL THOSE FRIENDS AND FAMILY WHO DONATED MEDICAL SUPPLIES!
We could not have gotten through yesterday without your generosity!

Mambo, Kenya!

(I apologize for what is going to be the longest post ever... I promise this won't happen again!)

It took everything in me to keep from running down the ramp to the grinning faces of Mary and Cait at Jomo Kenyatta International Airport... well everything in me plus the 250 lbs of luggage on my trolley.  Of course, there were many happy tears on my part during our reunion.  

On Sunday morning, Mary, Daniel, and I drove out to Lukenya Hills where Kiotani, the school for orphans and at-risk children, has taken full form, thanks to help from Sponsors for Kenya and New Hope.  After the 45 minute journey across dirt paths where zebra and wildebeest lazily grazed in the burning Kenyan sun, the buildings of Kiotani appeared in the distance.  Last time I was there, it was a dusty 2 acre plot with no water and one metal sided hut.  

While at Kiotani, Mary pointed to a girl and explained that they brought her to Kiotani because she was the victim of rape at 5 years old.  Mary told me that the girl's mother died from AIDS shortly before she was attacked.  "Guess who it was, Megan," Mary said.  "Her father," I replied, without missing a beat.  Of course Mary nodded, surprised that I guessed so quickly.  It appears that I have picked up on a common tragedy, as she is not the first girl that I have met with this story.  I even shocked myself at the ease at which I figured it out.  

We picked Paige up from the airport that afternoon and stopped to enjoy a Tusker at Club Xenon, a truly wonderful way to introduce Paige to Kenya.  Mary and Daniel are full of questions about Trump and how America could have possibly elected this man.  It is important to recognize that Mary is terrified that Trump will defund US AID, which is how all of the women at Positive Life Kenya receive their HIV medications.  

Monday was our first day in the office.  I was reunited with Abby and met Anisia, the new social worker.  Mary, Cait, Abby, Anisia, Paige and I spent time getting to know each other discussing our backgrounds and what I have been up to for the past 4 years.  Mary explained to Paige more about PLK and I was amazed but all of the things they have accomplished and the drastic growth that has taken place within the organisation.  

We then toured around Mlolongo and visited brothel streets, that although quiet during the day, are the very foundation of the town.  Anisia was excited to have us along because so many women have medical complaints and there is a doctor's strike here.  Paige and I were very hesitant to use our medical skills at first but realized that there were many small problems with which we could definitely help people.  We had to explain very clearly that although we are in medical school, we are not full-fledged doctors yet and even in May, we will still have much training ahead despite having our MD.  Still, it seems wrong not to help with problems we so clearly understand.

In the afternoon, we went to City Carton, the worst slum in the region.  The homes are basically plastic bags on sticks. Picture the most dangerous living conditions imaginable.  Recently, the slum was set on fire at night to clear out the residents and move them farther back from the highway where wealthier people are starting to build new apartments.  Apparently that was the appropriate way to ask people to leave?  

On Tuesday, we visited Kicheko and Tumaini, the primary school run by PLK.  Agneta, the principle, roped us into teaching a class.  I "taught" Science.  We learned about clouds, the sky, and plants.  These kids are so smart and really interested in learning.  I think I did a pretty terrible job but we had a good time regardless.  Silly Mzungu.

17/1/2017

Although it seems like yesterday that I was trekking to Kicheko Slum to make a house call, I am still nervous for my trip back to Mlolongo, Kenya. I dream of my time there almost weekly and so much of that experience feels fresh in my memory. Last night, I re-read my travel journal from 2013 and, although it made me excited and nostalgic, my upcoming trip has presented new challenges that have me... worked up, to say the least. This time, Positive Life Kenya (formerly Living Positive Mlolongo) knows me. They have high expectations and I feel the pressure of accomplishing the goals that they have set out for me. "We want to create a mobile clinic, Megan. You can help us with that, right?" The faith that PLK has placed in me is both an honor and a challenge. I am grateful that they have such confidence in my abilities and returning to them with new skills with which medical school and CWiC have trained me, excites me. I still feel, however, that I will not be able to accomplish everything that I want in just one month. Along the residency interview trail, I had an interviewer ask me, "What impact have you had in Kenya?" Most of the interviewers wanted to know what impact Kenya had on me but not the other way around. I froze trying to think of anything that has changed since I left. Did I do anything to help that community last time I was there?  

And then I remembered that story of the child and the starfish.  

A man sees a boy picking up starfish and throwing them back into the ocean. He says, "Good morning! May I ask what it is that you are doing?"
The young boy paused, looked up, and replied "Throwing starfish into the ocean. The tide has washed them up onto the beach and they can't return to the sea by themselves," the youth replied. "When the sun gets high, they will die, unless I throw them back into the water."
The old man replied, "But there must be tens of thousands of starfish on this beach. I'm afraid you won't really be able to make much of a difference."
The boy bent down, picked up yet another starfish and threw it as far as he could into the ocean. Then he turned, smiled and said, "It made a difference to that one!"
(Adapted by Peter Straube from The Star Thrower, by Loren Eiseley (1907 – 1977)

In the face of overwhelming obstacles to helping the Mlolongo community, I have to keep in mind that just because I cannot see an obvious change for the community as a whole, I know that there are individuals who I have helped. At the end of the day, I "made a difference to that one." I have to believe that someday, the sum of all of those who I help will make "a difference for that one" community. 

Photo Credit: https://en.wikipedia.org/wiki/Starfish