Submitted by Julie Ronecker
Today we had a chance to visit Kit Mikayi, a local rock within the village that stood for “Rock of the First Wife.” Our tour guide was very passionate and told us a wonderful narrative that introduced us to their culture.
The history behind the rock began during a very dry season without rain. In order to get rain, the people of the village were told to sacrifice 1 goat and 2 chickens. The male village leader would stab a goat onto the rock and blood would be shed on its face, and they would open both chickens and do the same. The goat and chickens would then be eaten as they prayed to their god for rain. The next day, the rain would come and the people of the village would have a plentiful harvest.
We also learned about traditional living arrangements in the village, consisting of one male house at the center. Distributed next to the house were his wives’ houses where the children would also stay. The culture was traditionally polygamous and this is true of several families to this day. Within each house was straw beds, water jugs, rock grinders to grind spices, plates and bowels, and medicinal equipment. One of the most interesting component of their culture was members of their village between the ages of 15-18 would have their bottom 6 teeth removed. The purpose of this was to assist in providing food and nutrients to villagers if they were sick and could not chew. The medicine was ground and dissolved into hot water and swallowed through a large spoon-like device that fit through the gap created from the six missing teeth. To us, this may seem aesthetically unappealing, painful, or unattractive, but the utility of this speaks volumes.
We then spent some time hiking in and around the rock formation. Under the rock was a small space that our tour guide informed us was a place to pray, relax, and offer promises. For the women in the community, they would walk underneath the rock, pray to the altar, dance, and touch the rock. They would promise to stay with their husbands through anything–starvation, sadness, childbirth, and arguments. The underground area was also home to dozens of small bats, and a lot of us were thinking about Histoplasmosis and Rabies because we just took our board exams.
When we climbed to the top, we were able to see a fantastic view of the village–complete with goats relaxing on rocks, villagers lounging below, and a landscape mixed with lakes and greenery. When we got back to the base, a traditional group of village women performed a dance for us and sent us on our way. The song and dance was representative of female empowerment, which a lot of us were happy to see in a male-dominated village.
Our next stop was to the equator line, where we stood at both the southern and northern hemispheres sequentially. We saw that the leaf spun counterclockwise and clockwise in each hemisphere respectively, and we were also able to balance an egg at the equator. If anyone happens to know the science behind this please do share–many of our group members are skeptical.
We have especially enjoyed this weekend and are now more informed medical providers. Part of being a good physician is learning about the area and being culturally-sensitive when providing medical care. For example, knowing that some members of the community believe in polygamy helps us test for multiple partners for sexually transmitted diseases instead of just one wife. Knowing that missing 6 bottom teeth in this village is culturally normal helps us not worry about vitamin C deficiency. Knowing that women carry large basins of water on their heads and babies on their backs gives insight into why joint pain, somatic spinal dysfunctions, and lumbar strains are common chief complaints. And, knowing that animals are sometimes sacrificed gives insight into potential exposure to blood-borne pathogens. On rotations in the United States we are familiar with the culture so the predominant goal of our clerkships is learning the medicine; however, when we come to Kenya, we must learn both the culture and the medicine as both are intrinsically linked in diagnosis, treatment, and management.
Saturday was spent resting and recovering from our week at clinic. Recovery days are important on medical mission trips so that we can return refreshed and rejuvenated to best help our patients. We are expecting to see close to 60-75 patients on Monday after a long weekend. Several of these patients will be follow-ups and the rest new patients. But first, a little recap of Saturday!
We got to experience Kisumu culture today on a relaxing walk through the city. Street artists were selling their clothing, shoes, handmade objects, and art. A lot of us compared it to a mini-version of downtown Kansas City; people were driving, walking, and biking while exchanging quick greetings to each other. We are learning a few greetings in Swahili such as “hamjambo” and “sasa.” It is important to note that Swahili is the main language spoken in Kenya, but each individual village speaks another language. The language in the town that we work in is Lao, and we use translators to translate between patient and physician. Essentially, this means that Kenyans are almost always multilingual–at least a village language, Swahili, and English (due to English being taught in school starting in kindergarten). It really goes a long way and shows respect when visitors try to use greetings.
We had a late lunch at a coffee shop, where some of us ordered more traditional American cuisine like burgers and soup and others ordered quesadillas and beans/rice. Though we are loving the food at the hotel, it’s always nice for a change.
Our evening was spent getting drinks at a hilltop restaurant next to Lake Victoria. Lake Victoria, according to one of our group members, is the second largest freshwater lake in the world. It was home to many creatures–hippos, birds, fish, Naegleria fowleri and other amoebas. We were able to see a hippo lift its head above the water and blow freshwater through its nostrils. It was quite possibly the coolest creature we were able to see, until one of us humans fell in (just kidding!).
Bonyo’s Kenya Mission is collecting backpacks. You can drop off a gently used backpack at Dr. Bonyo’s office at 1569 V. Odom Blvd. during regular office hours. All donated backpacks will be taken to Kenya and donated to children attending a local school near the Mama Pilista Health Centre.
Your gift of a backpack will bring a smile to a child’s face and encourage their pursuit of an education.
Today at clinic we saw a variety of cases that were interesting, and valued the fact that we could send for labs and receive results immediately. For example, one patient was having bloody diarrhea and we sent for a rapid s. typhi test which came back positive, and another patient was having an opportunistic infection and was tested for HIV and found to be positive. The fact that Mama Pilista clinic has a lab with rapid results allows for more specific and successful diagnosis and treatments. On the other hand, one patient and her child who came in with thrush did not want to be tested for HIV. This is a common occurrence because of the stigma and sadness associated with potential positive results. At the end of the day, we must respect the patient’s autonomy. In other cases, physical symptoms outweigh the cost of having to test. A woman came in with pelvic inflammatory disease–pelvic tenderness, green discharge, back pain–and instead of doing a pelvic exam the best approach and standard of care for the village was to simply treat for PID.
Two of our medical students saw their first live vaginal birth. The woman gave birth without pain management and only experienced extreme pain once the episiotomy was placed. These anterolateral cuts help reduce bleeding trauma for the mother and facilitate a smoother labor. When the baby was born, the students remarked how calm the room was but how beautiful the process was. The mom and baby will be kept at least 48 hours for post-partum complications.
One of our members worked on the hostel today–fixing the door frames and working on final changes to the main entryway. The purpose of this hostel will be to house volunteers during medical mission trips and allow for them to be closer to the clinic. This will allow for more time to be spent at the clinic and less time communing from Kisumu. If interested in donating, the approximate cost is $50,000 and can be donated online.
As a group we are all feeling a bit nauseated. We will be taking the day off tomorrow to recover and return on Sunday refreshed and revived!
Clinic today was an eye-opening experience. We started with rounds in the morning where we met a woman who presented overnight with what appeared to be a stroke. She had a right-sided headache and a left-sided facial, lateral palsy, and extremity paralysis that appeared to have worsened overnight. Differentials included hemorrhagic/ischemic stroke, abscess formation, cerebral edema, or an infectious process. In the United States, she most likely would have received a non-contrast CT scan and subsequent tPA if found to be ischemic and within 3-4.5 hours of onset. However, this would cost 10,000 shillings ($100 US dollars) and be of little use based on time-frame for the top differential of stroke. It could help diagnose an infectious process, but the family decided that the distance and cost would be too much of a burden. Additionally in the long run, management and treatment would not change for stroke with or without the CT scan. This patient’s situation was unfortunate, as her breathing, speaking, and swallowing was affected. Long term management would include continued perfusion of the brain, physical and occupational therapy, and palliative care. The second patient on rounds was a young three-year old who was admitted overnight for malaria and UTI. After quinine, dextrose, ceftriaxone, and an overnight stay in the clinic, she appeared like a different child. For other communities, this child would have either had to commute 5-8 hours to a local hospital or wait out the infections at home. However, having the clinic in the local community allowed for rapid recovery and a discharge in less than 24 hours.
The remainder of the day was spent seeing patients in the day clinic. We had a family present with cyclical fevers and chills, decreased appetite, and generalized fatigue. Only the four-year-old in the family of three tested positive with the rapid malaria test; however, it was decided to treat the entire family. When the clinical signs point toward a diagnosis and laboratory tests do not match, it is important to remember sensitivity and specificity. The rapid malaria test is better if found positive, but if found negative, malaria cannot be ruled out. It also only tests for one strand (plasmodium falciparum) so ovale/vivax strains cannot be ruled out. We decided to save the time and resources used for a blood smear and treat the entire family and have them return for follow-up. This is a common occurrence in a low-resource community and a cost-effective strategy toward treatment of malaria. We also treated a woman with herpes zoster, and advised her to stay away from children, sick adults, and those with HIV. The lesion was the typical dermatome pattern and the patient was experiencing extreme pain to palpation. Acyclovir and follow-up was encouraged for her. Finally we were able to see a few simpler cases of cellulitis, otitis media, ringworm, and eczema. It’s always so rewarding seeing how grateful patients are for just a tube of anti-fungal medication or a 5-day antibiotic course. It’s the little things like this that we don’t appreciate as much in the United States and can be grateful for.
Today marks the first day of clinic at Mama Pilista! We started our morning by remembering our purpose for being here. Years ago, Doctor Bonyo Bonyo had the dream to become a physician and eventually return to his community to provide medical care. Our goal is to continue this mission with him by offering comprehensive, quality, culturally-sensitive care. We are also here to strengthen our own history and physical examination skills. During this journey, we will be chronicling our experiences at the clinic.
Together we saw many interesting cases as student doctors and physicians. A woman came in with a large infection of her finger that had been going on for 2 months. The infection appeared to have spread beyond the skin and there was fear of osteomyelitis; however, we were limited as to what imaging studies we could perform and thus decided to treat with antibiotics and hope for resolution at follow-up. We also saw several cases of malaria within the same family–each member presenting very similarly with cyclic fevers and chills. Another interesting case was a woman who was in acute distress, bent at her waist, and clutching her right chest. She had recently had numerous studies done at a local hospital with differentials including pleural effusion, TB, or something more severe like focal cancerous nodules. As a comprehensive clinic that is sustainable and run by the community, the clinic is able to collaborate with other hospitals. For this patient, we will get her studies back from the local hospital first before determining her definitive diagnosis. We also saw a young girl with HIV+ status with a fever of over 104 degrees. At the time she was not taking her ARV medication and appeared extremely depressed. With the risks of developing opportunistic infections and potential death, she was informed about the importance of adhering to her medication management. Bonyo agreed to be her mentor and we ensured that she would follow up at the clinic. The clinic has a fantastic tracking system for HIV and is able to partner with members of the community to keep CD4 count high and viral load down.
The word “harambee” means “all pull together” and we believe that this community does just that. It is evident that when one member of the village is sick, the rest of the village unites and raises them back up. Even after our first day, we believe that this clinic is a unifying force and essential component to the community. We look forward to treating more and learning more over our next few weeks.