12/16

I woke up at 4 AM, once again, due to the rooster. I spent my morning packing for my new accommodation, showered, and had a breakfast of toast and marmalade.

Even though I had only been there for a day, it was tough to say goodbye to the generous hosts. They are very nice people who went to great lengths to ensure our comfort, and they had grown on me. Leisel and I were taken my matatu to Jamburi Estate, where we will be staying for the rest of the time here.

I was blown away by this facility. It is a gated community located 10 minutes (by foot) from the slums of Kibera. I was taken to my room in the apartment complex. The apartment I was staying with belongs with Nancy, who has graciously offered me her space for the next few weeks. She works for a financial company and is a graduate of the University of Alabama-Birmingham. It is interesting to live with someone who is a "modern Kenyan," as opposed to a traditional one. It is rude to refuse food, so before I would stay up even when tired to eat with the host family and take food just to be polite. With Nancy, however, I can just be honest! Her apartment is beautifully luxurious. It has a speaker system, western toilet, and a hot water shower. I also have a very spacious room to myself, with plenty of closet/storage space. Liesel is staying in a different apartment downstairs.

I dropped off my suitecase in Nancy's apartmet, and said goodbye to the other volunteers. They will be going to their assignments, and it will be difficult to reconvene. Liesel and I were then taken to Kibera, and the Ushirika Medical Clinic. I was blown away at the stark difference between where I was ten minutes ago, in a gated community, and then later after crossing a set of railroad tracks: in the largest slum in Africa. The slum stretches for about 8 km according to Peter, and he says that although estimates are around 800k inhabitants he thinks there are closer to 1.6 million.

I was quick to get started in Ushirika. The outside appears freshly painted. The main clinic walls are made of wood, whereas additions (maternity ward, VMC--which I'll get to in a inute--, etc. are made of corrugated metal). We were given a tour of the facilities. The pharmacy is well-stocked with ARVs (antiretrovirals, i.e. HIV treatment) and other medication. I was amazed at how complete this was for an impoverished area, and discovered that most of the funding comes from donors. World Bank and Global TB Drug Foundation supply most of the TB medication. PEPVAR, a medical mission set up by George W and Global Health Initiative, set up by Obama, supply most other medications. Additional aid comes from US Aid and IMPACT. As someone who has seen what they are doing for the community first-hand, I highly urge you to donate to these organizations.

I was introduced to the nutritionist, who works closely with the counselor to educate patients on their diet. This is done based on a CBC (complete blood count), which provides vital information about blood chemistry. The laboratory was also well-stocked given the area, but severely malnourished compared to its western counterpart. It is able to do CBCs, glucose, prenancy testing, urinalysis, and stool analysis. CD4 counts (used as an indicator of T cell activity in HIV. 800-1400 is considered normal. <350 requires specific medication, and <200 indicates full-blown AIDS) as well as thyroid/liver/kidney panels must be sent out to other testing facilities. While these are usually available within 24 hours in the US, the results take 3 weeks to get back on average.

Most of the medical care is given by a clinic health officer, who is the equivalent of a PA in the states. A medical doctor is there to oversee the facility, and is in charge of the CCC (Comprehensive Care Clinic), which is exclusively for HIV patients). Keep in mind that although I refer to these centers and departments, it is generally a small room in some area of the overall facility.

The maternity ward has 6 beds and keeps patients for about 2 days after delivery. However, most prefer to give birth at home and bring their child for appropriate immunizations afterward. There is a large amount of counseling given to the mother for appropriate treatment of the child.

After the tour, I became involved with day to day operations. HIPAA guidelines require that persons not directly involved with medical care do not take notes, and I am therefore reciting this information from memory. Therefore, some points may not be accurate and are highly influenced by my perception of events (more than most other things). Everything was observed and conducted with patient permission and under professional supervision. I recognize that HIPAA does not apply outside of the US of A, but I consider it my ethical responsibility here to treat these people with the highest professional standards and utmost respect, and I therefore applied western medical ethics to my work here. With that disclaimer having been said, here we go!

I started the day in the CCC:

Patient 1: 23 y.o male with HIV and TB coinfection. CD4, pregnancy, and liver tests were ordered. Baselines should have been taken, but the blood pressure monitor was broken. Stethescopes are terrible in quality, and heart rhythm abnormalities are therefore hard to detect. There is only one weight machine for the entire facility, so patients have to leave the room in the middle of the exam to get their weight.  There is unfortunately a refusal of treatment of issue--the patient simply would not speak to the doctor. The patient is also forgetting to take medication every day, and has greater issues with taking it on the same time. Counseling instilled in him that missing medication is very bad, and he therefore now just stops taking medicine when he misses a dose due to fears of side effects. The doctor spent over an hour working with him to get him to take his medication on time.

I am amazed at the amount of time spent with each patient. I first thought that the first was an exception due to severe complications, but 45 mins seems to be the standard amount of time. This is a stark contrast to the US, where 15 mins is standard and a maximum of 30 is reserved for rare conditions.

I was also shocked that the doctor spent time counseling, in addition to reinforced discussion with the counselor. This may, in part, be due to the place of the doctor in Kenya society. People are willing to listen, and patients rarely ask questions of the medical professional. There is no such thing as a second opinion in this society, and the doctor's word is taken with the highest authority. This is very different from the states, where doctors are frequently mistrusted, and second opinion is commonplace. I personally see the value in questioning every belief that is presented to me, so it is interesting to see this culture.


Chest X-Rays are free at Kenya Medical Institute for TB patients who are referred from the doctor at Ushirika. The bus fare is 20 shillings, but people who can not afford that can walk there from the clinic in about an hour.


As loose as the sense of time is for the Kenyan people, I was fascinated by a method used to encourage attendance. Patients who adhere to their regimen by attending the clinic when they are supposed to and take all medication on time, they are given a longer dosage. To clarify: patients are initially given a two-week supply of ARVs. Later, they are moved to 3 week and 4 week regimens, or even longer with perfect behavior. Reward training and behavioral psychology was cleverly applied in the clinic.


Explaining to the patients the importance of taking medicine at the right time was difficult to do. They come up with every excuse in the book on why they did not take their medication. It is also hard to keep patients. After receiving ARVs, many disappear because they feel better almost instantly. They often return after several months, however, when they realize they need long-term care.


Another patient had been coughing for 3 days (HIV status is positive). The doctor was concerned about a possible TB infection, but the patient was ultimately diagnosed with an upper respiratory tract infection (URTI). Since it is caused by viruses, antibiotics were not given. This is different from the states, where antibiotics are often prescribed anyway to prevent to advance of other opportunistic infections.

It has been very interesting to see that most of the conditions are a more advanced form of disease that is caught early in the US. People here do not go to the clinic until it becomes serious and hardly bearable. Additionally, since there is very little medical technology, doctors must connect to their patients at a deeper level and understand things without expensive tests. When a patient complained of chest pain, the doctor asked a series of questions to rule out serious possibilities such as an infarct; in the US, the patient would have quickly been hooked up to several monitors and EKGs would be conducted. Enough resources simply do not exist, and the doctors have a much tougher job as a result.

The prescriptions were written on specific paper, and it was an eye-opening experience to watch the doctor split up the carbon copy sheet from the original sheet--allowing him to give twice as many prescriptions as he would have been able to if he'd use the paper as directed. The extent to which every resource is used and waste is eliminated amazes me.

Throughout the day, I observed counseling regarding STIs, pregnancy, HIV, and circumcision. Studies have indicated that circumcized males have a much lower risk of contracting and spreading HIV/STIs, and the procedure is done free of charge at Ushirika (the gov't provides funds for this).

At every visit, patients are counseled with specific regards to the incident that brings them to the clinic.

Although TB drugs are free to the patient, we ran into some registration issues. Ushirika's reserves started dwindling, and we therefore had to limit people from the medication. There is a registration system for healthcare where one must register with a particular hospital that one wishes to receive care from (close to where one lives). Many people have moved and not updated this registration, and we therefore had to refuse treatment. They were, however, encouraged to register properly and come back for help. It was disheartening to experience.

Mother-child HIV transmission is carefully monitored. Counseling plays a large role in this, as many mothers are not aware that they can pass it to the child. Others think that there is nothing medicine can do to prevent transmission (the drug HATT is provided to the child after 6 months of age to prevent).

Another issue we faced was that people were not disclosing their HIV status to their partners, and were taking drugs in great secrecy. It is troubling from a public health standpoint, but we work with the counselors to get them to tell their respective spouses.

Documentation is very important here. Many patients transfer out to other hospitals because they move and Ushirika is no longer convenient, and the doctor often makes letters. This takes a lot of the clinic time, and I see the value of EMRs (electronic medical records). While this is quickly becoming a reality in the states (especially with the recent influx of ER scribes), Kenya remains far behind in a standardized place for care. Miscommunication can often result in poor or incomplete care: one woman had been mugged and lost all her medical documentation. HIV and TB tests had to be repeated and she will lose several weeks, as she could not remember for how long she was taking what medications.

While this is small, I noticed that medical doctor's handwriting is very neat here. This could be because he/she is forced to write notes to other clinicians, but it served as a stark contrast from the US, where MDs are notorious for illegible penmanship.

At the end of the day, after seeing approximately 15 patients (keep in mind that these visits are extraordinarily long), we had someone come in with a CD4 count of 28. It had dipped as low as 15 a few months ago.

Stay tuned for more on this patient, the overall work of CHOs (clinical health officers, or PAs), and the VCC (Voluntary Circumcision Center). As you can likely infer from the length of this post, my first day at the clinic was extremely ebusy, eye-opening, shocking, and full of contemplation.