My observations of Luo culture

These are some basic facts about the Luo people:

-They are polygamists. Almost all tribes in the country are polygamists. Here, the wives live together generally in harmony.

-They have no culture of circumcision. I don’t know if it’s cultural for them not to circumcise.

-Their last names are related to the time of their birth in the astrological, seasonal sense. Consequently, many people have similar names.

-Their language is Dholuo.

-They are a Nilotic people with a Nilotic language, i.e. of the Nile. They migrated south from Sudan and are presumed to be descendent from the original Egyptians.

-Many Luo also live in Uganda and Tanzania.

-Their people are “rabble rousers” but not violent. Many of the original famous revolutionaries were Luo. Apparently, the shield on the Kenyan flag is a Luo symbol. I haven’t verified that, though.

-They have a unique practice of wife inheritance, in that when one brother dies, the other living brother inherits his wives. This practice perpetuates the HIV epidemic.

-One can marry girls when they are as young as 14 years old. I don’t know if girls can be married at younger ages.

-Women are not allowed to inherit land. Therefore, a family must have a boy survive to adulthood. This prompts the birth of many children.

-Women do ALL the work: cook, clean, bear the children, raise the children, fetch the water, build the houses, etc. Therefore, a family is in very deep trouble when the woman dies.

-Traditional healers were popular, but their popularity has waned over the 20+ years that Lalmba Kenya has existed. However, people still use them. I’m not sure how effective they are, for we always get the failures.

-HIV prevalence here is between 30 and 40%. This region has always had one of the highest prevalence rates in all of Kenya.

-There are Luo in Southern Uganda and Northwestern Tanzania. In fact, we get many Tanzanian patients. It seems that our medical care is superior to that which is available in Tanzania.

-Many people only speak Dholuo knowing very little Kiswahili or English. This particular monolingualism means that these people can go nowhere in the world outside of this area around Lake Victoria.

Some general Kenya facts:

-They gained independence from the British in the 1960’s. After independence, they cooperated with the British to form their government

-Moi was the second president of the country. He was a dictator and disallowed fair elections. People did disappear during his rule, but he was not so violent that everybody feared for his life everyday. The first “fair and free” elections were in 2002.

-Primary school is up to Grade 8. It is supposedly free, but it seems that all of the ancillary costs of books, uniforms, etc. make it very expensive.

-Things are quite expensive in Kenya. In most developing countries, Westerners experience an increased buying power. Not here. Everything costs the same here as it does in the States.

-Kenya has one of the better and more stable governments, economies, and societies in East Africa.

If any of you look up more information about the Luo after reading this entry and want to send me your comments and thoughts so that I can compare them to my experience, I would be happy to receive those e-mails.

A tale of two patients

Earlier this month we had an eventful day that led to some clinical dilemmas. Just as I was going to lunch, a patient arrived being carried by her family members. She didn’t look so hot and Dolith thought it would be a good idea for me to stick around. It was 1:05 pm. Well, it turned out that she had a ruptured ectopic and a surgical abdomen, and so we transferred her to St. Camillus. The road was very bad, and the patient had a rough time getting there as every bump undoubtedly caused her considerable pain. We didn’t have any narcotics to give her. Normally, I don’t go on these ambulance rides, but apparently there were two RCAR (Rescuing Children At Risk. It’s a program that takes care of children who are in dire straits, almost orphaned, gives them education, ensures their diet, etc. They have over 1000 kids in the program.) kids in the hospital and the management wanted to see if I could get them discharged, as they were being treated empirically without any diagnosis on the horizon. One had been there 5 weeks and wasn’t getting better.

When I received the records, the work-up was limited by the facilities and the therapy was driven by a shot-gun approach. Despite the “prettiness” of St. Camillus, their lab is not what I would have expected it to be. As internal medicine docs, tests are our friends and there were none at this hospital. They couldn’t even do blood cultures. When I was reviewing the records, there wasn’t much to go on, and St. Camillus did not have much more to offer, and so I had them discharged with the hope that there would be some way to diagnose the problem and possibly fix it.

Our next step was to proceed to St. Joseph’s hospital aka Ombo. This hospital has been here for a long time, since even before Matoso Clinic was even started. In fact, the first volunteers worked there for three months to get the feel of taking care of Kenyans before opening the clinic. These initial medical reports are fascinating from a historical perspective and they are all primary sources.

Well, I digress. We took them to the other hospital where I ordered a battery of tests, well, a battery of tests for them. In the end, I got about half of what I wanted. And we had to spend 8 hours at the hospital waiting for the lab techs to process them all. Wow. This is our referral hospital.

As expected, I was only able to narrow the differential diagnosis in these two patients. One had some issue with her gallbladder. Whether it was infected or not, she would need some sort of procedure or CAT scan to determine what to do next. The second one required a repeat ultrasound that we couldn’t get until this week. Regardless, they needed more detailed work-ups at the provincial hospitals – the referral hospitals for the province.

Now, the whole management of resources comes into play. The point of the RCAR program is to maximize the survival potential for the maximum number of kids, not to spend thousands of shillings on a few number of kids. As I was discussing the patients with the Lalmba medical director, we were trying some other therapies in the mean time trying to decide what the definitive course of action should be. Unfortunately, the patient with the gallbladder issue died a few days ago. We were having some issue with transportation and I was informed that she was not doing well. They were able to pick her up and bring her to the clinic. A brief evaluation revealed that she was dying. Thankfully, we were able to get her home so that she could die with her family. I learned that she died later that night.

The other one did get her ultrasound and it looks like she has lymphoma but needs a biopsy in order to confirm or discount this possibility.

The frustrating aspect of these cases is the lack of resources even at the so-called referral hospitals. They don’t even have full chemistries including bicarbonate, something that we use frequently to help determine the acid-base status of the patients. Part of the problem is the expense of automation. All these lab studies have to be processed by hand using special kits. And even then, they don’t necessarily get it right. Furthermore, it is much easier to manage patients when the resources of the patient are very limited. When a patient says, I cannot go to the hospital, then the options for us are fairly limited but straightforward. However, when we are spending thousands of shillings for further evaluation, it is difficult to know when to stop, when is such and such money too much money.

Well, I guess that is the nature of our work here. Sometimes you win some and sometimes you lose some. The wins feel really good and overall the work here is extremely gratifying, and the losses, well, one has to take them in stride. We can’t save the world, but we’ll keep trying one person at a time.

A day in the life of Medical Director Jeevan Sekhar

6:30 am – Roosters start crowing. Then the donkeys start braying. They sound like somebody is killing them. The cows start mooing. I curse them and go back to sleep.

7:20 am – Alarm goes off. I curse it and hit the snooze button. It comes on again. Another whack on the snooze button. Then at 7:45 am, I extricate myself from the warm confines of my bed, emerge from the mosquito net, and stumble out into the wider realm of my bedroom.

7:45 am – I take my malaria prophylaxis and afterwards perform the morning hygenics.

8 am – Morning prayer by the Kenyan staff. Someone starts off in song, the others participate. Then there is an actual prayer done in Dholuo (the language of the Luo people). Despite the different denominations, everybody here is Christian and is happy to praise Jesus for their circumstances.

8:30 am – Go to the PSC (Patient Support Center – just a reiteration for those of you who may have forgotten the acronym explained in the earlier entries), warm up the computer and await the patients.

9 am – Often on a Monday, we are dealing with the critically ill who have stayed away from the clinic until the weekend has passed. I guess they don’t want to inconvenience us during our time off with their acute attempts to die. (We are indeed open at all times for emergencies. Few people avail themselves of those extended hours.) Some we send to the hospital, others we manage on our own and get them from unable to sit to sitting or unable to stand to standing and then they go home. We don’t have inpatient capability.

10:30 am – Break time!! The Kenyans have chai. I have a Coke and brownies (compliments of Joyce).

11:00 am – Back to work refueled and rejuvenated.

1:00 pm – Lunch time! We usually eat in about 20 minutes. I use the rest of our hour break to have a nice little Siesta. Ha! – you didn’t think there would be much European influence here outside of British colonization did you…?

2:00 pm – More work. The afternoons are generally slower, as the patients tend to cram themselves into the morning. As a result, with the new streamlined approach to patient care that we devised, we can theoretically see 50 patients a day with the current staff we have.

4:30 pm – End of work. I usually do my e-mail at this time or study snippets of Go that I can glean from the net.

6pm-8pm – The time to communicate with my family in the States depending on the day. Done either by chat via internet or phone (assuming the network is working).

8pm – Eat dinner, read.

9pm or so – Evening hygenics.

10 pm – beddy bye…

Kill bugs Vol. 2

For the above, I depend on the spiders, the geckos, and the bats. Unfortunately, the spiders are scary ugly, the geckos relieve themselves in my room, and the bats might carry rabies. Oh well, beggars can't be choosers.

I have received some complementary remarks recently while I’ve been here. Both Moline (the current clinician in PSC) and Jackson had mentioned that it would be nice if I could stay longer. Moline went so far as to recommend that I stay and work here permanently in Kenya. Of course, it would never happen, but it is nice to know that I am appreciated and that people like my work. Perhaps, they say that to everybody. I’ll pretend they don’t.

Last week, we had a tough day. The dreaded ethical decision came up. Not one, but two critically ill patients who up on our doorstep in the morning. One with a septic wound with a blood pressure of 52 systolic (that is very low and I was amazed she could walk), and the other a lady with diarrhea and a BP we couldn’t obtain. Both had no means to pay for the transport to a hospital let alone any subsequent hospital bill.

Initially, I didn’t know what to do. Joseph inquired of Management about what resources we could use for these patients. The goal of Matoso Clinic, as it should be, is to give the basic amount of care to the largest of amount of people – none of this ridiculous ICU stuff that we do in the States. However, similar to the States there are surprisingly legal implications to dropping people off at hospitals. In the case of the first patient, we needed to get her family’s consent to hospitalize her. If we did not and they didn’t want to pay for the hospital bill, apparently it’s their prerogative, and they could shift the responsibility of a multiple thousand or hundred thousand schilling bill to the Lalmba association. Plus, on that day there was a shortage of vehicles. In the end, I made the executive decision that whatever charity funds that Management was going to free up to subsidize the transport and the initial admission fee, we would use to pay for our own resource utilization. We slammed fluids and antibiotics into the patients and then gave them all their medicine free when they left the clinic. Man, what a stressful day. Resource management at its most critical, literally.

Surprisingly, one of the stories has a happy ending. The lady who came in with the septic leg, who we then discharged to walk all the way home after opening the wound so that it would drain, returned on Friday to attend the Q&A session that Joseph holds every month regarding HIV care. Amazing. It’s just a reflection of the hardiness of these Kenyan people.

Over the weekend, I learned how to drive stick shift. Daniel taught me how. Of course, I’m learning on the wrong side of the car, but hopefully I can adapt when I get to the States. The pedals are in the same order with the accelerator on the far right and the clutch on the far left. The gear shift is also in the same order. However, that means that First is furthest away from me with Reverse being closest. On a car driving on the Right side, First will be the closest and Reverse will be the furthest away. Therefore, even though the gears are in the same order conceptually, kinetically it will be the opposite, while the pedals will be the same.

Anyway, I was able to get up to 4^th gear and 60 km/hr. I only stalled out twice. The main challenge was trying to get into Third. For some reason, I kept putting it back into First and we couldn’t accelerate. After we figured out the problem, I could accelerate pretty well. Daniel suggests that when we next have to transport a patient to a hospital, I can learn about what it entails to admit a patient, and then I can practice driving on the way back. I look forward to it.