TROPMEDEX Kenya 2009: highlights of a medical tour

Thanks to HILARY SIMONS* for sharing her journey with us.

1-13 February 2009

I waited a long time for this trip. Originally scheduled for January 2008, fate dictated that it was not to be in that year.

Due to the election process, civil unrest raged in Kenya during December 2007 into January 2008. Opposition supporters accused the ruling party of rigging the vote. Tensions between opposing tribal factions ran high, creating a dangerous and volatile situation. Much of the ensuing violence occurred in Rift Valley cities including Eldoret, Kisumu, Naivasha and Nakuru. Over a thousand Kenyan civilians died in the violence and thousands more were displaced from their homes, particularly in Western Kenya.

Mediation, facilitated by international politicians and the United Nations, resulted in a power share between the two parties and a somewhat uneasy "peace" was restored. During this time, most travellers to Kenya, including myself, heeded the advice of their governments and did not travel.[1]

Like others I had hoped for peace for the Kenyan people and waited for an opportune time to visit. Thus my safari began in late January 2009. The word "safari" is usually associated with the "big five"; this safari was to be somewhat different! Safari is the Kiswahili word for "journey" and my journey was to take me a world away from the long lenses and five star comforts with which I was more familiar.

The itinerary would avoid the tourist route and take me to places where "mzungu" or "wazungu" (white people) were few - apart from a few leathery expats, too long in the sun, and pale young things, just arrived to undertake good work, medical electives or similar. This journey would give me an all too brief taste of the people's Kenya, where access to facilities like education and health care that we take for granted is difficult and life is often tough.

Off the tourist track

TROPMEDEX Kenya 2009[2] offered an exciting itinerary, including visits to a variety of health care facilities (Kenya's health care is delivered on a multi-tier system) and vector prevention and control projects throughout Western and Coastal Kenya. These visits were to be interspersed with lectures on diseases endemic in Kenya, travel medicine issues and the chance to gain practical laboratory experience in the tropics. The tour also promised an opportunity to experience Kenyan culture and to see parts of this great country, not usually visited by tourists.

My travel companions came from all over the world, from various disciplines of medicine and nursing, and included seven doctors (including a microbiologist) and three nurses (myself, a practice nurse from the UK and a public health nurse from Canada).

Our tour leader and mentor was TROPMEDEX Director Dr Kay Schaefer, a consultant in tropical medicine and traveller's health in Germany and in leading medical institutions in East Africa. Dr Schaefer has lived and worked in Africa for over 20 years, speaks Kiswahili and has an enduring respect, passion and understanding of Kenya and her people. He proved an excellent mentor and guide.

On the road

As we left the bustle of Nairobi and took to the open road, the perils of travel by vehicle in a developing country were immediately apparent! Some major roads were well maintained with good surfaces, but this was not the case in more remote areas. Here, roads were rough and pitted with potholes.

It was evident that some Kenyan drivers habitually drive on the wrong side of the road. Not so our expert driver, who dodged the potholes and/or occasional oncoming petrol tankers and people-heavy matatus (mini-buses used as share taxis) with consummate skill. We held onto our seats and to the fact that he had done the run from Uganda to Mombasa, Kenya with heavy freight for years and knew our route well.

On our trip, safety was never compromised, particularly regarding transport. Nevertheless, it is a fact that most deaths and injuries attributed to road traffic accidents each year occur in low- to middle-income countries.[3],[4] For this reason, independent driving by inexperienced tourists in Kenya is definitely not advisable. Seeking out a reputable driver and vehicle is a far safer option.

On the day of our departure from Nairobi, the big news in Kenya was that of an overturned petrol tanker on a major highway near Nakuru. Hundreds were killed as the fuel exploded. The scale of the disaster was such that the story was still in the news two weeks later.

AIDS - the real disaster

Shortly after learning about this disaster, a Kenyan nurse said to me "HIV and AIDS is Africa and Kenya's disaster" and indeed it is, though Kenya seems to be meeting the challenge of this devastating disease and the number of infections appear to be stabilizing.[5] Early diagnosis and treatment provides the best chance for long-term health and testing is encouraged.

Billboards advertising Voluntary Counselling and Testing Centres (VCTs) are common in towns and larger villages. Often staffed by volunteer counsellors, VCTs were available at most health care facilities we visited. Nevertheless, more VCTs and more intensive outreach programmes are required to promote awareness and facilitate testing, particularly in less accessible rural and remote areas.

Anti retroviral drugs (ARVs) are currently provided free of charge by the Kenyan Government (triple therapy with the generic ARVs, stavudine, nivarapine and lemvirudine). In some areas, those with a positive test are entitled to supplementary feeding with maize for themselves and their family, provided by overseas and religious organisations. This is particularly valuable at a time when the past two harvests have failed, leaving people hungry and under-nourished.

Love and hope

In the Rift Valley village of Kampi ya Samaki, a hot remote place with limited medical facilities, we were privileged to be invited to talk to two young HIV infected individuals, who provided us with an insight into how a positive diagnosis of HIV impacts personally, on their family and the community.

With the support of a local American woman, a long term resident of Kenya, these mentally positive, brave and inspirational young people had formed the "Love and Hope Club" with the aim of reducing the stigma of the disease in their community and providing education, support and financial security (by selling eggs) for each other and other members of their group.

In this stunningly beautiful place, close to the shore of Lake Baringo, you could be forgiven for thinking you were in paradise, but all is not as it seems and life here can be harsh. As with elsewhere in Kenya, many parents and extended family have been lost to HIV/AIDS and young children are left to raise their younger siblings.

Improvisation and wound management

In Kampi ya Samaki, Dr Elizabeth Meyerhoff, an American social anthropologist with no formal medical training, runs a clinic where she and a trained nurse provide treatments for the local community.

Many of their patients are very young burn or scald victims, their injuries sustained as a result of falling into fires or coming into contact with boiling water or, often, boiling porridge. Through trial and error and dogged determination, Elizabeth has developed a wound management technique for burns, using tetracycline, petroleum jelly and silver paper (first from cigarette packets and most recently survival blankets).

In an environment where infection is a problem and wounds are slow to heal, she has achieved incredible results, but remains well aware of her limitations. Cases she cannot deal with face a 40 km journey to a local district hospital, which is often logistically and financially out of the question.

The clinic relies on charitable donations of equipment and money. In addition to running the busy clinic, Elizabeth and her husband are committed to the health and wellbeing of the Kenyan people and direct the operations of the Charitable Trust, Rehabilitation of Arid Environments (RAE), from their home in Lake Baringo district.[6]

Good people driven by a desire to care

Marigat is a small rural town in Baringo, Rift Valley Province, with nothing much to distinguish it from all the other small rural towns in Kenya. Busy women walk along the dusty streets, carrying huge loads on their heads supported by neck muscles of iron. Men languish in the shade, doing nothing much. Scabby dogs take their chance and lie in the middle of the road in full sun.

Kenya, it seems, is full of good people driven by a desire to provide the best care possible in difficult conditions with limited resources (not only money, but water, electricity, sanitation and so on). At Marigat Sub-District Hospital, we met such a person. Here a young Maasai woman, proud of her heritage and of her position as a Clinical Officer, was an inspiration.

She told me Maasai women did not often get the chance to be educated to the level she had achieved and she exuded passion for her work and her country. Clinical officers have a Diploma in Clinical Medicine and Surgery, complete an internship for one year after basic training and may go on to do a postgraduate diploma in anaesthesia, paediatrics or other specialities.

After this, many work in health care facilities, such as the hospital in Marigat, undertaking comprehensive medical responsibilities. This is normal for Kenya, where qualified doctors are in short supply. The depth of this young woman's medical knowledge was impressive as she presented each case during ward rounds.

The ubiquitous malaria

Malaria, malaria, malaria - unsurprisingly the most vulnerable made up the majority of inpatients (babies aged between six and 18 months, pregnant women and AIDS patients). The infective parasite, where identified, was exclusively Plasmodium falciparum and treatment was, in this setting, intravenous (IV) quinine and supportive care.

Accurate diagnosis, effective treatment and follow up are critical for the satisfactory management of malaria (and other diseases). In the facility we visited in Marigat, laboratory facilities were available, but most people were admitted during the night and diagnosis and treatment was usually initiated without the benefit of laboratory blood analysis.

Here in Africa, taking a medical history and performing a thorough physical clinical examination form the cornerstone to accurate diagnosis; the physician often has limited or no access to advanced medical technology.

In Marigat, we were told that those we saw with a diagnosis of malaria who were receiving IV quinine were responding. Most were making a good recovery, but some were, despite treatment, clearly still very sick.

One man had been brought many kilometres and was suffering from cerebral malaria. His convulsions and agitation were proving problematic to treat. Alone and unsupervised he fell crashing to the floor from his bed during our visit. There were just not enough nurses to allow the special individual care that might have been lavished in a European hospital.

Another optical illusion

Climbing out of the great Rift Valley into the lush and fertile highlands of Rift Valley Province, we were struck by how well nourished the people appeared compared to those who were struggling in the heat and drought of the valley below. Again, all was not as it seemed.

We journeyed onward toward the town of Eldoret, at an altitude of 2,100 metres. Perhaps most famous for being the home of Kip Keino and other long distance athletes, we were reminded that it was on the outskirts of this normally peaceful, agricultural town in early 2008, that men, women and children, seeking refuge in a church, perished when their sanctuary was burnt to the ground in one of the most violent events in the aftermath of the 2007 elections.

Reaching the faith-based mission hospital in Kakemega, we were greeted with characteristic politeness and enthusiasm. Our visit was an opportunity for multidisciplinary learning, and nurses and doctors joined us for a lecture given by "Dr. Kay" on haemorrhagic fevers (Marburg, Ebola, Yellow Fever and Rift Valley fever).

Asante sana ... karibu

During the ward round that followed, we were introduced, in a darkened room, to a woman looking much older than her 32 years and clearly weak, subdued and with visual disturbance. She had been "lucky". Crude, but effective laboratory testing of her cerebrospinal fluid (CSF) had enabled a quick identification of cryptococci and a diagnosis of cryptococcal meningitis and cytomegalovirus (CMV) retinitis had been made. Slow infusion of the antifungal drug, Amphotericin B was commenced, the glass bottle infusion and giving set protected by black masking tape to protect the light sensitive drug within.

She had, presumably, yet to come to terms with her newly diagnosed HIV positive status and the cocktail of drugs that would be required to sustain her over the coming years and sat submissively, seemingly oblivious to her predicament, while we discussed her in a foreign tongue. On leaving, I took her hand and thanked her, "asante sana" - "karibu" (you are welcome) she replied, smiling shyly, but not seeing.

Mosquitoes danced lazily in the still air, waiting for their opportunity to feed. At night all the beds here were covered by bright blue mosquito nets, which during the day hung messily from a high hook in the ceiling over each bay.

The price of care

Despite fairly basic equipment, at least by western standards, one got the impression that this hospital was providing a good standard of care. However, the wards were empty, partly because this was dry season (with little malaria, though malaria is omnipresent in Kenya, whatever the season), and partly because the Government hospitals had reduced their charges so patients chose to go there rather than pay the relatively higher costs of the mission hospital.

At a later visit to a large, Government hospital on the coast (40 km south of Mombasa), the state of the Kenyan health system became evident. To my eyes, wards were in a depressing condition. There were often no sheets on the beds, no soap, and equipment was tired and dated. There seemed a general air of dereliction in a surprisingly young building which, on opening, must have been a showpiece hospital.

Despite working in seemingly difficult conditions, the doctors, clinical officers and nurses appeared caring and enthusiastic, and up to speed clinically. Diseases peculiar to the tropics filled every bed here: filiariasis, malaria with profound anaemia, spinal tuberculosis with paralysis and HIV/AIDS. All were presented to the visiting medics with utmost professionalism and with consent from the patient.

Nevertheless, of the ubiquitous suggestion box on the wall outside the building (we saw many on our journey!) one of the visitors muttered "we could suggest more doctors, more nurses, more money and a bunch of cleaners for a start!"

Travellers' health

It should be said that Kenya does, however, have some excellent health care facilities. On the coast and in major cities, as a tourist needing medical help, these are the establishments to which you are likely to be referred (gastroenteritis, heart attack and accidents are commonplace). Usually run and funded privately, such clinics and hospitals provide high standards of care and often state of the art facilities (dialysis and ICU), and staff with specialist skills.

Services are offered presuming the patient has the required financial resources to meet the bill, though sometimes exceptions are made. The importance of travel insurance and pre-travel investigation into available medical facilities became crystal clear!

Another valuable service for tourists and Kenyan people alike is the superb African Medical Research Foundation (AMREF).[7] AMREF has an excellent laboratory undertaking research and providing a teaching and diagnosis facility, but is perhaps best known for their long range air rescue and repatriation service. Staffed by expert doctors and nurses, trained in trauma, ICU and anaesthesia, each aircraft and ambulance is kitted out with an impressive range of medical equipment.

In addition the Flying Doctor Outreach service provides expert medical and surgical help to isolated government and mission hospitals in remote Kenya. Funding is by membership (very cheap for tourist travellers) and unused membership supports charity evacuations for the poor.

Beauty and the beast

Returning to the leafy suburbs of Nairobi, I sat in the guest house garden and watched, fascinated, as a beautiful black and white striped Aedes aegypti fed persistently on me, despite the DEET I had meticulously and liberally applied. I reflected on my journey in Kenya, knowing that, even in such a short time I had experienced something special and life changing, and I vowed to return.

Thanks to Dr Kay Schaefer, MD PhD MSc DTM&H, and to Dr Elizabeth Meyerhoff, PhD, and to my colleagues Professor David Hill at NaTHNaC and Dr David Lalloo at LSTM.

Further information: www.tropmedex.com

*Hilary J Simons, RGN RSCN Dip N MSc MFTM RCPSG, is Senior Nurse at the Liverpool School of Tropical Medicine and National Travel Health Network and Centre, London. Email: hilstha@liverpool.ac.uk

References:

(all websites accessed 17 June 2009)

1. The Foreign and Commonwealth Office at: www.fco.gov.uk/en
2. TROPMEDEX: Intensive learning course on Tropical and Travel Medicine for health care professionals in Kenya, Uganda and Tanzania, at: www.tropmedex.com
3. World Health Organization, World report on road traffic injury and prevention at: www.who.int/violence_injury_prevention/publications/road_traffic/world_report/en
4. National Travel Health Network and Centre (NaTHNaC), Personal safety during travel: health information sheet, at: www.nathnac.org/pro/factsheets/personal.htm
5. UNAIDS, Joint United Nations programme on HIV/AIDS: Sub-Saharan Africa, at: www.unaids.org/en/CountryResponses/Regions/SubSaharanAfrica.asp
6. The Rehabilitation of Arid Environments Charitable Trust at: www.raetrust.org
7. AMREF Flying Doctors Service at: www.amref.org

Further reading:

Linking sexual and reproductive health and HIV/AIDS, Gateways to integration: a case study from Kenya, prepared and published by WHO, UNFPA, UNAIDS, IPPF at: http://data.unaids.org/pub/Report/2008/20080923_linkages_kenya_en.pdf