STORIES FROM THE FIELD

Patient Care Ethics and Ramifications of Post-Election Violence in Kenya: a Medical Student’s Experience - Part 2 (of 2)

Note from the Editor – Part 1 was presented in the Fall Issue of the IH Section Newsletter (2008).

An elementary school in the border town of Busia, Uganda housed the 2,000 refugees with each packed classroom inevitably creating a ripe environment for disease.  In addition, the threat of violence was still present due to the proximity to the border and the similar tribal demographics in comparison to that of western Kenya. The Red Cross refugee site was located just 1.5 km from the local public clinic.  Thus, without any medical infrastructure, Red Cross personnel were sending all refugees with health needs to the clinic.  As you could imagine, the Red Cross staff was pleased to learn of my medical background and immediately gave me all clinical and public health responsibilities.  I gave health education presentations (sanitation, personal and community hygiene, etc.) and continued to make referrals, in which I would write a brief history and physical description to assist the overwhelmed clinic.  Additionally, I initiated a patient record system.  As a medical student, it is easier to feel competent when the safety net of your attending is always in place, and this scenario was no different.  However, that was all about to change.

I have always pictured the Red Cross to be a medical relief organization with large stocks of food, medical supplies, and other basic necessities in times of crisis.  While I can only speak for the Uganda chapter, the real power of the Red Cross was not the direct supply of resources.  The food stock needed to be carefully rationed per family based upon number of adults and children, and medical equipment and personnel was non-existent.  Our food stock nearly ran dry in just a few days.  Despite a lack of a surplus of supplies from the Red Cross, we were still able to maintain an adequate level of provisions by establishing something far more critical: a collaborative network of NGOs.  I was impressed by the intricately organized effort centered around the Red Cross.  Nine different organizations, including the United Nations, MSF (Doctors without Borders), Ugandan Ministry of Health, and World Vision made diagnostic visits in assessing the needs, and would return a few days later with critical resources. 

Medically, my scrap piece of paper with scribbles, also known as the patient record system, became incredibly vital in allowing me to make specific recommendations to the various NGOs, regarding much needed supplies.  Anti-malarials, mosquito nets, bronchodilators, blankets, rehydration salts, antibiotics, analgesics…and a doctor?   By the end of my first week, a tent and a few medications were available.  This immediate access to medications was invaluable due to the fact that many patients were incapable of walking 1.5 km due to an assortment of lower extremity and back injuries.  Additionally, several clinicians of the nearby clinic had begun turning away refugees due to the overwhelming patient load and possible tribalism.  The arrival of medications and no doctors meant that I would have to be the “daktari.”  My work in Kenya revolved around logistics and programming of patient care projects regarding tuberculosis.  While I absolutely enjoyed the work, I admittedly had no need to pick up a stethoscope.  For the first three days in Busia, I would not even have a stethoscope.  Even more problematic: no safety net. 

Notable challenges included an epileptic boy who fell into a grand mal seizure directly in front of me.  With no anti-epilepsy medications available, he would be sent to a Kenyan hospital just across the border.  He remained stable and returned two days later.  Another challenge stemmed from the TB and HIV patients being reluctant to identify themselves due to stigma despite running out of medications.  MSF was instrumental in desensitization campaigns to identify such patients.  Other chronic patients (diabetes, hypertension, etc.) would run out of medications by the end of my two week stay.  We requested appropriate medications to be sent as soon as possible, and so my temporary treatment plan would be limited to treatment of symptoms and lifestyle changes.  Lastly, one of the MDR-TB patients in Eldoret, Kenya, who was to be among the first patients enrolled into the nearly established treatment program, persistently called me due to his rapidly deteriorating condition.  With limited incoming cargo, closed roads, and my attending in Eldoret not permitting my return, I could only tell him to wait it out and hope for a quick end to the political crisis so that the second line TB medications could arrive and I could continue working to help establish the MDR-TB program.

The biggest clinical challenge by far was the anxiety and other psychiatric issues related to the horrors of the post-election violence.  With no psychiatric medications available, psychosocial counseling and anxiety-reducing lifestyle modifications were all I had to offer.  Each heart-wrenching story made me feel useless.  These were families who were burned out of their homes and attacked with machetes by their neighbors.  Beyond the traumatizing escape, they now had virtually no hope for a peaceful return home.  Many said that they would never trust their neighbors again.  I can only hope that listening to their stories provided at least a grain of comfort in their lives.

Excerpts from e-mails:

I keep waking up in the middle of the night, and I can feel my heart beating so hard, so fast....I'm so worried and anxious about my "daktari" role.  I think I'm doing fine, but still....These refugees deserve the best clinical care available…I'm just physically and mentally exhausted....

These kids have no toys or anything (a soccer ball is coming tomorrow), and they've obviously been through a lot (one child told me that he never wants to go back to Kenya, many came with no parents, and several witnessed their parents murdered).  Today I taught them “duck, duck, goose,” and then we played some Kenyan games....they loved it and so did I.  In college, "crowd control" with the kids was my specialty on medical trips...but I've forgotten its significance since gaining more medical experience.  But today, being able to put a smile on these children's faces was probably the most useful thing I could've done, especially given recent events in their lives...and it didn't require a single pill. 

That first week, a Ugandan doctor from Friends of Christ Revival Missionaries (FOC-Rev) made a brief visit and gave me advice on diagnosing malaria amongst other regional illnesses.  Thankfully, he would return in the second week as a daily clinician at the refugee site.  Together, we would see almost 500 patients.  He also brought an extra stethoscope.

After two weeks at the refugee site in Busia, the violence in Kenya had subsided, although tension remained high.  The camp was to be re-located further interior into Uganda due to constant threats of violence infiltrating into the camps.  Meanwhile, my attending in Eldoret had decided to permit my return.  With plenty of patient care responsibilities and rebuilding needed in Kenya, I eagerly returned.  The trip back to Eldoret was like driving through a bizarre battlefield: burned cars and stores, but civilians going about their daily business as usual.  I could only think of how the vast majority of an entire tribe of people no longer lived in these lands.  Instead they were living at a refugee camp full of helpless despair.

Just last week, we were able to start treatment for that patient with MDR-TB; however, time will tell if his condition has already deteriorated beyond recovery.  I can only wonder what would have been if there were no political violence and we were consequently able to start treatment one month earlier, along with so many other “what if’s” for other patients.  While my experience provided many valuable lessons, tools, and experiences that have been permanently scarred into my mind, for me the most significant principle has been the reinforcement of the idea that we should never underestimate the impact of the ramifications of our choices.  Whether it is imperializing and fabricating national borders while teaching divide and conquer politics for self-gain or pushing a friend to reassess his utility, a single choice can ultimately create a seemingly endless cycle of violence, destabilize an entire health care infrastructure, or provide comfort to refugees entrenched in pain and suffering.

--Paul H. Park Indiana University School of Medicine, park.paul.h@gmail.com