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My time here in Eldoret has come to a close. I have had life-altering experiences, enormous shifts in perspective, massive broadening and deepening of my medical and cultural knowledge base, and ultimately, a wonderful time here. I hope you have enjoyed reading about it. What follows are a series of random thoughts, interests, events, and reflections that I want to capture in writing before I leave.
TRIBALISM AND POLITICS
There are 42 tribes in Kenya. When Kenya declared independence from Britain in 1963, Jomo Kenyatta, a national hero, was elected president and served until his death in 1978. Kenyatta belonged to the Kikuyu tribe, which today constitutes the largest tribe in Kenya, making up approximately 17% of the population, more than 6 million people
When Kenyatta took over, a lot of the national posts were filled with other Kikuyu, who subsequently hired other Kikuyu, and so on. What has been called the "Our turn to eat" mentality, well-described in a book of the same name by Michela Wrong (published in 2009), began. Kikuyu members benefited greatly. When Kenyatta's post was filled by Daniel arap Moi from 1978 to 2002, who belonged to the Kalenjin tribe (3rd largest tribe in Kenya, approximately 5 million people, about 13% of the population), all the power shifted, and was concentrated into the hands of his Kalenjin brethren. It was the Kalenjin’s turn to eat.
The ethnic stereotypes that have been propagated along tribal lines for generations are predictably absurd. In fact many of them can be traced back to roles imposed on groups of Kenyans by colonial rule during Britain’s reign. During that time, the Kikuyu were assigned to work in the fields, and benefited from entrepreneurial endeavors. Today they run many of the local transportation services, kiosks, restaurants, and hotels. Kikuyu are of course consequently considered outright thieves by other tribes. Taught as children to be wary and mistrustful of the Kikuyu, many Kalenjin and Luo instinctively reach for their wallet when in their presence.
Luos (4th largest tribe, making up 10% of the population) were domestic servants underBritish rule New Jackson siblings: Brennan and Dale. They now carry the reputation of being skilled in communication, and thus dominate industries such as media and academia. They are betrayed by their brightly colored fashion sense. Consequently they are of course considered to be of “all show and no substance,” and are thought to be quite cheap.
The Maasai remained nomadic during British rule, and their desire to move livestock from one plot of land to another without distinct land ownership left them the reputation of strength without intelligence. They are thought to be natural watchmen and security guards. The Kalenjin (the dominant tribe in Eldoret) are likewise reputed to care more about their cows than their women. Actually, based on how I have seen them treat their women (Eldoret is predominantly Kalenjin), that one might be true. See? Even I am susceptible to these associations.
Ultimately tribal allegiance runs deep, and continues to set the stage for interpersonal relations throughout Kenya today. I had the opportunity to spend a few minutes with a highly educated Luhya (2nd largest tribe, 14% of the population) physical therapist during one of my days in the cardiology clinic. Despite his obvious intelligence and education, speaking quite eloquently on matters of medicine and physiotherapy, when I began to press him on his perspective on tribalism in Kenya he immediately began unwinding tales of “those untrustworthy Kikuyu girlfriends” who had spurned him so many times before Poker night at IU House. “You can give them your heart, your money, everything,” he lamented. “And the next day they will be gone without explanation.”
Earlier this week, with the next Kenyan elections upcoming in early March, Obama recorded a youtube video message to Kenya, urging peace during the election process, and stated that “this is a moment for Kenya to come together, instead of tearing apart,” to “show the world that you are not just a member of a tribe or an ethnic group, but citizens of a great and proud nation.” Obama also spoke of Kenya in December, advocating an end to the tribalistic mentality that dominates the culture.
This “ethno-elitism” that has been perpetuated by those in power, and persisted downinto the populace, can reasonably be blamed for a significant percentage of Kenya’s internal conflicts. Obama’s comments are less well wishes for a country near and dear to his heart, and more a plea to avoid a recurrence of the murderous violence that took place after the elections in 2007. President Kibaki was the incumbent, a Kikuyu elected in 2002 to succeed the highly corrupt regime of President Moi. Kibaki was challenged by Raila Odinga, a Luo, who had formerly served as Kibaki’s prime minister. Polls leading up to the election, and official voter tallies through the first day of the election, suggested that Odinga would be victorious. But on the second day of voting, Kibaki closed a 2 million vote gap and surpassed Odinga, despite the remaining uncounted counties anticipated to be in Odinga’s favor.
Feeling they had been cheated, all non-Kikuyu tribes suddenly turned against the Kikuyu. The violence was especially prominent in Eldoret and Kisumu. Thousands of Kalenjin turned to the streets, and Kikuyu men, women, and children were murdered on sight. Within minutes of the announcement that Kibaki had been reelected, Kikuyu homes across the country were set ablaze. Kikuyu who resided near Eldoret were in immediate danger, and many were brought to safety here at IU House by Joe Mamlin, as I described in a previous entry.
There was predictably a sizeable Kikuyu backlash, allegedly led by Uhuru Kenyatta, the son of former national hero and first president Jomo Kenyatta. In fact today, Kenyatta stands charged with crimes against humanity by the International Criminal Court (ICC) for his alleged role in the violence. And here’s the most dramatic twist: Uhuru Kenyatta and Raila Odinga are the dominant candidates running for President of Kenya one month from now. When I arrived in Kenya four weeks ago, the polls had Odinga as a runaway favorite. Two days ago, Kenyatta trailed by just 2% – despite not having been ruled eligible yet because of the charges against him in the ICC! And on top of that, Kenyatta’s running mate, a Kalenjin here in Eldoret (whose house I walk past multiple times every day), has also been indicted on similar charges in the ICC.
All told, nearly 2000 Kenyans were murdered during the 2007 post-election violence. Every Kenyan I have spoken to during this month is optimistic that a recurrence will not take place in 2013. Many safeguards and requisite personnel have been implemented, and the general consensus is that the country has learned from its mistakes. But every time I ask this of a Kenyan, they always end the conversation the same way. You never know. Kenya can be crazy.
Tribalism and politics are my favorite conversation topics with Kenyans. I bring it up with every new Kenyan I meet – cab drivers, waiters, doctors, nurses, medical students, etcetera. My questions are all the same: who is going to win the election, and do you think tribalism will persist? Although Obama urges the end to ethnic discrimination, and it is clearly to blame for many unnecessary deaths during the post-election violence, every last Kenyan I asked deferred the end of tribalism to a younger generation. For them, it runs too deep. For their children, they hope things will be different. For the sake of their country, I hope they are right.
As for who will win the election… no one is willing to hazard a bet. Most Kikuyu believe Kenyatta has a legitimate chance. America has made it clear they believe electing someone indicted in the ICC, who may or may not be able to rule if elected, would be a very poor choice. Most other tribes believe Odinga is a heavy favorite. But they all agree on one thing: anything can happen.
I have written about a number of Kenyans I met on the wards this month, and some have asked me for updates on their condition. Leah, the young woman with invasive cancer who deeply touched me with her courage and strength, has not returned to the hospital. This in itself is a significant victory. I am hopeful she is able to progress through the latter stages of her terminal illness without discomfort, and with peace.
Samuel, the 26 year-old gentleman with a history of tuberculous pericarditis, presenting with worsening respiratory distress, remains exactly the same four weeks later. His condition has not changed, despite numerous medical therapies. He remains short of breath and appears quite uncomfortable. Impressively he has not required intubation, despite appearing to be in permanent respiratory distress. Occasionally I do see him outside in the sun, without his oxygen on. I have gently reminded him to keep the oxygen on multiple times. But sunshine is its own therapy. I do not know how he will do, but if he does recover, I suspect he has a long ways to go.
The 24 year-old woman with end-stage rheumatic heart disease was sent home to pass away peacefully.
Lillian, whom Joe Mamlin brought to MTRH during my day with him, has recovered impressively on the wards under our care. Despite a CD4 count = 3, she has done quite well. She was discharged approximately a week ago to return to Mosoriot for further care, but could not pay her bill. Her charges are currently tied up in a bureaucratic process that will result in either a family member covering her bill, or her charges being waived. I have fought hard for the latter, with no success. I wish her the best.
The 14 year-old girl at the end of the tuberculosis entry went home with her sister, tocontinue her therapy and rehabilitation. We anticipate she will have a good outcome.
Tony and Mario successfully passed their final exams, despite numerous unforeseen obstacles. We will now refer to them as Tony, MD and Mario, MD. Congratulations dudes.
THE MAMLIN EFFECT
I spent a total of approximately five hours with Joe Mamlin. But my reflections on that time continue to ripple through my cortex. Every Thursday night, the entire IU House community gathers in one living room for a “Fireside chat.” Topics have included ethical conflicts in medicine, maternal and child mortality in Kenya, and Kenyan politics. Last week we discussed the culture of friendship in Kenya. Distinctions were delineated between Western friendship and Kenyan friendship. The principal difference, based on our readings, was that Kenyan friendships appear to be largely assembled through the exchange of material possessions, the indiscriminate opening of one’s home for meals, and the ability for one to depend on another for significant financial support in times of need. In contrast, Western relationships are more traditionally built on a foundation of emotional connection, sharing meals in one’s home is reserved for close relationships, and material gifts are largely of little value. And most importantly for those of us in North America, Financial exchanges are often dependent on conditions of a loan, or with some of sort of anticipated return on investment, planned well in advance of that return.
The interaction of these two cultures in Kenya then occasionally includes a Kenyan request to a “mzungu” (foreigner, usually meaning a white person) for money. Occasionally a significant amount. Discussed around the room during our Fireside Chat, the consensus was that this request, even if it came from someone close to us, would be difficult to grant. First of all, the Western approach to finance management tends to include a significant amount of saving, and budgeting, and planning. A spontaneous request for financial assistance makes us uncomfortable, because it interferes with, and does not acknowledge, this careful process. Yet we all agreed that if the finances came with some sort of advance planning for its end-destination, and the end result was of certain value, we would likely grant the request. One frequently cited example was the financial assistance to support a Kenyan child through basic schooling. Even in primary school, which is “free” to attend, there are significant costs, including uniform, books, and food. Students must bring their own maize and corn to help support meals for the entire school. This was a request the group felt would be reasonable, if the funds were carefully earmarked and budgeted, we had enough advance notice, and could measure the educational benefit in some way.
This entire discussion did not sit well with me. For starters, I found it incredibly stereotypical to presume that all Kenyans approached friendship and relationships the same way, distinctly different from those of us in the West. As some astutely mentioned during the discussion, this archetype of Kenyans as heavily materially and financially conscious was likely rooted in poverty, and not only did not necessarily reflect the majority of Kenyans, but seemed much more socioeconomically rather than culturally derived. Passing it off as a cultural difference seemed fraught with risk of being inaccurate and myopic.
And most importantly, my experience with Joe Mamlin rang like an alarm bell in my head. He had built an entire community through generosity, and faith, without preconceived notions about the end result of his contribution. Neither his time nor his frequent donations came with any sort of contract or set of expectations. And yet that faith had been repaid many times over, with the development of a community that has accomplished goals shared by Kenyans and Professor Mamlin alike: the efficacious treatment of the HIV pandemic in Eldoret. While USAID and other financial footholds on which AMPATH and this treatment stand remain a barrier to self-sustenance, it truly felt during my day with Joe that the infrastructure had been erected on solid ground, thanks mostly to the sense of community he had initiated. If he had clung to a Western approach to generosity, none of this would have happened.
My impressions of Kenyans this month have been overwhelmingly positive. When I leave the IU compound every morning, Michael the front gate guard does not hesitate to greet me warmly with a broad smile, shake my hand, and wish me good day, despite multiple family stressors that I know he is dealing with on the inside. When I spend time with the Kenyan medical students in morning report, or during lecture sessions, or on the wards, or at lunch discussing a topic or reading EKG’s, I am always thanked profusely for my time and involvement in their education.
When I speak with patients and families on the wards, no matter the gravity of the situation, Kenyans have been unanimously kind, thoughtful, respectful, and appreciative. When I reach for my stethoscope to examine a patient on the wards, they voluntarily open their shirts and bare their chests, often without concern even for privacy. When I reach my hand to their heart to feel for heaves, prominent P2’s, hyperactive precordiums, and apex beats, I am always reminded of what I have come to believe is a universal truth: the hearts of Kenyans are always warm.
None have ever asked me for financial assistance.
I’m no Joe Mamlin. But I see that he understands this culture at a much deeper level than even other long-term residents here do, and I see that it is much more complex and layered than our Fireside readings might have had us believe. My personal experience this month did not align with those archetypes in the slightest. Even their recent history of terrible violence, which has caused much of the world to shun them, is deeply, deeply rooted in poverty. Without addressing that, which Joe is aggressively attempting to do, any generalizations about Kenyan culture are premature, and any attempts at progress will continue to stall.
MISCELLANEOUS (Part 1)
One of the “registrars” (Kenyans of medical education equivalent to American residents) on our team this month was a very strong, very professional, very tall Kenyan woman who we’ll call Luanne. Meticulously dressed, armed with a steely gaze and a very confidant, very loud high-heeled gait (and very strong opinions) it was clear that under normal circumstances, she usually ran the show on the wards. I’m still not sure whether she resented or appreciated the presence of Andy and I, frequently questioning her medical decision-making and urging for more expedient investigations, but either way we didn’t seem to faze her. The fear she imparted to medical students during presentations at the bedside was tangible.
One day, amidst a particularly grueling rounding session, standing across a patient’s bed from Luanne and me, all of a sudden Andy started dancing. It started as some strange, subtle gallop maneuver. I looked at him, searching for meaning in his eyes. But I found only distant bliss as he gazed into the distance and galloped in place. What in the world was this strange mzungu behavior that was suddenly taking place right in front of me, on the wards, in the middle of a giant group of Kenyan registrars and medical students? Why didn’t I recognize it? Was this a traditional white man dance? Should I be taking part? Was this in the orientation material that my jet-lagged brain largely spaced? Was this the presenting sign of HSV encephalitis?
Then I heard the impetus for these wild spontaneous gesticulations. “Gangnam style” was emanating from somewhere. A Kenyan medical student, mid-presentation, continued reading the history with eyes glued to the chart, oblivious to the surrounding devolving atmosphere. The volume gradually increased as the song continued, encouraging Andy to increase the fine detail of his dance movements, increasing the amplitude of his gallop, and adding hand gestures. Now, certainly, I’m just as fired up as the next guy for a little Gangnam style, but I was too disoriented by the sequence of events, and confusion about where the song was coming from, to join in. Was it break time? Was a Kenyan with a beatbox in the hallway? Was an approaching flash mob in the near vicinity?
I glanced at Luanne, curious to her reaction. She stared at Andy, without expression, maintaining her usual professionalism. Her face was completely blank. As the medical student finished, Luanne addressed her, clarifying her history. As she continued to talk, Andy continued to dance. Gangnam style continued unabated, in increasing volume. Other medical students in our horde began to look around. My own dance threshold began to lower. The air of professional rounding discourse hung on for dear life as that innate burning inclination we all have to get down, Gangnam style, began to take over.
Luanne continued, entirely unfazed. Her ignorance of the developing situation was almost as distracting as the situation itself. There would have to be resolution soon – we had to find where it was coming from. Finally, mid-sentence, Luanne reached into her white coat and pulled out her cell phone, which was by this point practically blaring. Luanne’s ringtone was Gangnam style. We all erupted in laughter, including Luanne, her steely professionalism temporarily suspended. I have learned this month that Kenyans hate the vibrate function on their cell phones. Regardless of setting or environment, they love their ringtones. Especially Gangnam style.
We were sitting in front of a 73 year-old woman with a history of hypertensive cardiomyopathy and a new diagnosis of atrial fibrillation. Suddenly, amidst the half-completed paperwork that would alter her entire medication regimen, Segut turned to me and asked if I had watched the Super Bowl. He had that expression on his face, like he had just asked me a question out of the blue, that he either expected me to not understand or to dismiss. It was the same expectation he had the first week I had spent his morning cardiology clinic with him, when he asked me if I had heard that Austin Flint murmur. No I didn’t hear the Austin Flint murmur. What the hell is an Austin Flint murmur?
At the time he had laughed his jolly Segut laugh, and taught me to hear Austin Flint murmurs. But now he was speaking my language. Yes, I had watched the Super Bowl. Yes, I had awakened at 4:30 AM to head over to Joe Mamlin’s house, where a small group of us (with the traditional Super Bowl spread of delicious coffee cake) saw the entire debacle unfold on a projector, connected to a laptop, hooked to the local phone landline, tapped into a slingbox in Indiana, which had recorded the Super Bowl from start to finish. I could tell him whatever he wanted to know about the game, the coaches, the players, the surrounding circumstances, the commercials – the spectacle that defines the American sporting year. He lit up like a Christmas tree.
“Did you see Beyonce?”
Segut is a brilliant cardiologist. He is a fellow here, under the watchful guidance of program mastermind John Lawrence, from Duke University. At first glance Segut appears quiet, thoughtful, and considerate. He is patient, and wise. His knowledge base is vast. He carries an air of utmost professionalism, exemplified by his well-kept sweater vests and tidy full Windsor tie knots. But this only partially conceals a youthful jubilance, betrayed by his round cheeks and permanent silent chuckle, the corners of his mouth curved into a smile. There are many brilliant, brilliant cardiology fellows here. But since day one, I have found Segut among the most interesting. Less frequently does he have a case to share at cardiology morning report, but when he does, it has mind-blowing potential. It triggers extensive discussion, followed by that oh-so-familiar feeling of knowledge deficit, culminating in a mandate that we all go home and read about some part of the case so that we can continue to learn from it.
After getting to know him better, I learned about Segut the family man. He has two daughters at home, who often make him late for work. Now Kenyans are always late. Always. In fact there is a special translation we have to do for meeting times, by adding the word “ish” to any scheduled appointment. Morning report is at 7-“ish”, which translates to about 7:15. Rounds start at 9-“ish”, which often means approximately 9:40. Personally, I have found this somewhat freeing, as I’ve always been cursed with that desire to pack a few extra tasks into the last fifteen minutes before I need to be somewhere. I love Kenyan time. But I get the impression that John Lawrence does not, and has done his best to make things start promptly. Being late for work is probably not well tolerated in cardiology.
Segut regaled me with a complex and layered tale, of his attempts to gradually implement independence in his daughters by letting them sleep in a little later than usual. Usually, he will “aggressively wake them” and herd them through their morning preparation, so that he can get them to school and get himself to work on time. But once in a while he will allow them to shoulder a bit more of the responsibility. This of course majestically backfires. Hearing about the challenges he faces balancing his competing roles as devout family man and Kenyan cardiologist in high demand, with bottomless lists of consults awaiting his expertise, makes me smile. It resonates.
Getting to know Segut a little better has been one of the great joys of my time here. I am endlessly fascinated by the Kenyans, but specifically two demographics make me more and more curious: the highly professional, like Segut – and Kenyan children.
Missing many developing milestones of my own little guy at home in Portland, and suffering through the layers of withdrawals that have accompanied that distance, I have tempered my Jackson void with a careful analysis of Kenyan children. I have been consistently fascinated by the little Kenyan kiddos. I may or may not be bringing somewhere between seven and thirty-five home with me.
I still have a very difficult time assessing their age accurately, so I have decided to simplify the process and describe them, and their reactions to me, in various stages.
Stage I: Joeys
Kenyan mothers are uniquely adept at fashioning cloth into many varieties of carrying devices. These devices then serve as tightly wound kangaroo pouches, in which to carry the littlest of baby Kenyans. Now these pouches are not usually fashioned in the front, and Kenyan mothers neither hop nor violently kick, but the strength with which the little ones are wound to Mom’s frame is marsupial-esque. They are so firmly fixed in these devices, I often wonder if their breathing is somehow restricted. I have seen many children carried through the streets of Eldoret this way.
These guys are too busy trying to breathe and figure out where they are going and what is going on to pay any attention to me.
Stage II: Walkers
After graduating from the Joey phase, Kenyan kiddos can be seen walking alongside Mom anywhere in Kenya. Usually Mom walks much faster than the little one, and they have to hurry to keep up. They still like to be carried when possible, and occasionally one can be seen attached to Mom’s back like a massive growth. Meanwhile they are fascinated by the world around them, and are always stopping to look at something new.
Reaction: The Death Stare
I was walking home from MTRH the other day and saw one of these little guys hanging out with his Mom next to a family-run fruit stand. They were protected from the sun’s hot rays by an umbrella covering their fruit. The little boy was about two feet tall, in a light blue t-shirt and dark shorts, sitting in a chair beside the table. He watched passersby intently. His eyes glanced back and forth from person to person, taking it all in as his mother sold fruit. As I walked past, just as curious about him as he was about me, I met eyes with him. Suddenly he froze. His eyes locked on to me and did not move, his face became entirely expressionless. He did not blink. I immediately thought of three possibilities: 1. He was attempting to use The Force to make my head explode, 2. He thought I was an alien and wanted to study my every move carefully in the event that he may need to destroy me someday, or 3. He had never seen a mzungu before. His head moved only slightly as I walked past, his dark eyes locked onto mine like a tractor beam. I smiled at him and kept going.
About a block later I glanced back over my shoulder. He was still watching me. I decided that just in case he had any pull with his Mom, I should probably avoid that fruit in the future.
Stage III: Talkers and Wavers
Reaction: Talking and Waving
I see these little guys everywhere. They usually assemble in packs, and approach cars wazungu are riding in as a group. They have thoroughly mastered one specific English phrase, which they looooove to repeat over and over again. As soon as they see a mzungu in a car, they run up as close as they can, and yell at the top of their lungs: “HOW ARE YOU? HOW ARE YOU?” And then in chorus: “Howareyouhowareyouhowareyou?!” over and over again, as growing crowds approach the car.
Some of them don’t approach the cars, and usually these are in isolation or smaller groups. They simply stand on the side of the road, smile, and wave. I’m not sure why wazungu get so many waves, but we do. And I freaking love it. I wave to every kid I see, and they always wave back. It’s endlessly entertaining to me. I can’t get enough of it.
Stage IV: The Street Kids
This is an older version of the Talkers and Walkers, and they are seen primarily in the city, in downtown Eldoret. They are approximately 7-10 years old. They assemble in small groups, and sneak up on me like weird ghosts. I may be walking along, minding my own business, only to realize that I have been suddenly surrounded by the Kenyan version of the Jets and the Sharks. At that point they walk alongside me, ever closer, and I am reminded that I should watch my wallet. They frequently start with “Howareyou,” but it is a tad more ominous. They can be easily distinguished from the Talkers and Wavers because they only say it once.
Reaction: The Complicated High 5
Look, I like a complex handshake just as much as the next guy, but the Street Kid Kenyan version requires a dual degree in international studies and foreign language. Sometimes it is a standard, sensible two-move handshake, but most of the time it devolves into some repetitive, sloppy version of that, and never seems to end. I can’t tell if I’m supposed to conclude with a dap, or a backslap, or just end it unceremoniously and run for my life.
I could never be a pediatrician here. Watching children die would be much too difficult to bear. I have a hard enough time with the teenagers and other young adults we care for on our wards. But outside of the hospital, watching Kenyan kids was pure joy. I’m sure Jackson will get along just great with his new siblings.
MISCELLANEOUS (Part 2)
All of a sudden I heard the Mission Impossible theme song, blaring into the air. We were halfway through yet another lengthy rounding session, with a huge group today, upwards of thirty people. Must be another popular ringtone, I thought. First I looked for Luanne, to see if she had switched away from Gangnam style. Then I remembered she wasn’t even here today. I looked around for the teenager who must be visiting his parents on the wards, who loved Tom Cruise and needed a ringer so loud it could be heard in Tanzania.
Mission Impossible continued to blast, and I continued to search. In fact I didn’t see any young people anywhere, except in beds as patients. Unfortunately, that was the trend today. Finally, up the aisle struggled a short, hunched over woman who appeared to be in her 70’s. As she passed me, she reached into her coat pocket and took out her phone. She slowly brought it to her ear and answered it. Mission Impossible stopped immediately.
I turned back to the patient a medical student was presenting. I looked across the bed at Andy, who looked at me with his head cocked quizzically to the side. He began to smile, and we both suddenly burst out laughing.
Later that day I meant to introduce myself to this woman with the impossible mission, and learn more about it. Unfortunately I could not find her again. But regardless, I was again reminded of a universal truth: Kenyans love their ringtones.
TEACHING THE KENYANS
During my time as a resident here in Eldoret, I have had many assigned responsibilities. At the hospital, these included attending wards rounds daily and contributing in whatever way I could, and coming back in the afternoons as needed to assist with procedures, admissions, and follow-up on plans from earlier in the day. As part of the IU consortium, responsibilities included attending morning report on Tuesdays and Thursdays (and presenting it once), attending afternoon lectures daily, and participating in a variety of additional activities, including physical diagnosis rounds, and giving a talk to the women and children in the Sally Test Center.
Apart from the assigned responsibilities, there are many 4th and 6th year Kenyan medical students who need to learn internal medicine. Their educational process consists of having to prepare their own lectures on over 60 internal medicine topics, present their own morning report without any supervision, presenting their own patients and performing their own physical exams and procedures on the wards. They are left largely to their own devices to accomplish all of this in eight short weeks. They have no regular lecturers, no regular supervision. One 4th-year and one 6th-year student have been elected class leaders, and they are responsible for organizing all of this.
When I first heard about this incredibly chaotic, disorganized way of learning medicine, I was a bit disbelieving. But I quickly realized this was how it was, a consequence of a lack of resources to pay full-time teachers, or even bring in registrars from the wards to teach a session here and there. Geren, the medicine team leader here at IU House, does his best to fill in the gaps in their learning, and regularly provides them with lectures and weekly Jeopardy sessions to hold them partially accountable for their education. But the volume of material they are asked to coordinate and learn on their own is overwhelming.
A few of the residents here at IU House tried to pitch in as well, but had other responsibilities and could not do so on a regular basis. Andy, Dorelan and I began going bright and early to the Kenyan morning report, which began at 7 AM. We quickly realized the Kenyan medical students had no idea how to accomplish case-based learning. In morning report, their format was to have one student present a case, reading it from start to finish. And then they would all get up and leave.
All three of us from PPMC found facilitating morning report very rewarding, and the Kenyans quickly got the hang of it. They learned to appropriately stop at various points in the history and ask clarifying and augmenting questions. They learned to appreciate the value of other parts of the history, including past medical and social history. They began to understand what to look for in their physical exam, as directed from their history, and perform more focused, pertinent exams.
And finally, with much trial and error, they began to understand the importance of a differential diagnosis. Quite often they would finish their history and physical exam, and jump right to an impression that had nothing to do with their findings. For example, they may present a case of clear-cut rheumatic heart disease exacerbation, and conclude with “Impression: glomerulonephritis.” This happened on the wards regularly. When asked for a differential diagnosis, or at least some shred of evidence to support their nonsensical conclusion, they would stare back at us blankly like we had just asked them to sing “We Didn’t Start the Fire” in Kiswahili.
So we helped them learn the ways of case-based learning, and conduct morning report. We also all took the 4th and 6th year students from our teams to lunch at Cool Stream, a local Kenyan restaurant situated along the banks of a stream, at least twice a week. The cost to be the cool American taking an entire team of Kenyan medical students to lunch? Around a whopping $15. Topics included physical exam skills, heart failure, antibiotics, acute kidney injury, TB, and how to read chest x-rays and ECG’s. It was a great way to simultaneously get to know each other, teach, eat, and build rapport.
In addition to morning report and lunches, frequently after rounds we would gather our medical students and examine a patient with notable exam findings. At times we would spend hours with the 4th-years, teaching them the most basic components of physical exam. Despite three prior years of medical education, this was their first interaction with real patients, and most of them had very little ability to appropriately examine a patient.
And finally, there were the lectures. So many topics that they had to learn, in the short period of eight weeks, with no supervisor to organize, coordinate, or teach. So they came to us. In addition to morning report, this quickly became my most enjoyable contribution. A student would prepare a basic outline on a topic, say pneumonia, and come prepared with a basic powerpoint presentation to present from. Frequently there would be significant inaccuracies or omissions, and we would have to provide adequate context. And often diagnosis or management would be derived from an American textbook and have very little to do with how things were done at MTRH here in Eldoret. Contributing to these lectures required me to do a significant amount of preparation, learning about diagnostic and treatment options here in Eldoret, and adding literature context to each topic.
And sometimes the presenter simply wouldn’t show up. Or the projector would break. Or the computer wouldn't work. And then I was on the spot, to provide the chalk talk. It was important to always be prepared for that, because it happened often.
Of all the sessions we did, I had a clear favorite. It was a session on rheumatic heart disease, which I ran in the hospital. It started with a bedside exam of a very ill gentleman with end-stage disease, who would pass away from the disease two days later. After examining him in great detail, we moved to the classroom. Two hours later, we were still deep in discussion about this patient’s findings and the classic presentation and management of rheumatic heart disease. There were ECG’s and echocardiograms to interpret, which they initially did quite poorly. And when we finally got to management, it quickly became clear they had never been taught anything about how to treat most of the conditions they were seeing on the wards. They were so responsive, and appreciative, and engaged – I’ve never experienced anything like it as an educator.
Working with the students was the best part of my month. I enjoyed the morning reports and the teaching, but most rewarding of all was the relationships we all forged with the students. It created a learning environment on the wards that was collegial, educational, and a lot of fun. Yesterday, aware our month was coming to an end, the 6th-years presented Andy, Dorelan and I each with beautiful framed Kenyan art, saying thank you for our time this month. They wanted to say goodbye “in the African way,” which ultimately meant they wanted to take a lot of group pictures. I will cherish the memories I have from working with them forever.
When I first heard an opportunity might exist for me to go to Kenya this year, I wasn’t interested. The time frame was short and involved a lot of preparation over the holidays amidst other busy rotations, I was hesitant to leave Steph and Jackson, I was unsure of how safe it was, and I didn’t know if I would get much out of it.
Thanks to a lot of encouragement from Steph and Mark Rosenberg, I decided to come. It was one of the most memorable and powerful experiences of my life. I can’t say enough thank you’s to Providence Portland, IU, MTRH, and my family for creating the space for me to do this. I feel I am returning to Portland a more knowledgeable, compassionate, and understanding physician, with immense appreciation for (and skepticism of the necessity of) the resources we are afforded to practice medicine in a major U.S. hospital. My international experience and global health appreciation has gone from 0 to 1, and I can certainly envision returning to Kenya in a different capacity in the future, if not broadening my involvement to other developing nations. Thank you again!
And thank you to everyone for being such a supportive audience as I have shared my reflections. It has been very therapeutic. I hope all is well with all of you.
Read more: http://blog.travelpod.com/travel-blog-entries/rilesmd/1/1360387706/tpod.html#ixzz2NSat8mpB
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