Chama cha Mama Toto

Chama cha Mama Toto

It’s been a while since I’ve written, either for myself or to post.  I have been on call this weekend and it’s been busy, but I finally got a chance to sit in my front yard, basking in the hot sun and writing.  I have been busy getting the most out of every second that I am here in Kenya. I am already thinking about coming back to the US (1^st weekend of May!) and therefore already thinking about how I will be able to come back here!

The path today is a little winding but I hope you can follow my though processes here…

I am constantly reminded of all of the concepts and feelings and movements that every human in the world has in common.  I feel that at home too, but somehow I am reminded of it more here. I think because sometimes our first reaction is to see the differences when we look at something; but I don’t think that’s instinctual, I think it’s learned. When you are able to step outside your own boundaries, your own tiny world inside the world, you realize we are really all the same. So much of what binds us are the same needs for our health and care and the same challenges.

I have been on call frequently recently where I do twice walking daily rounds on labour ward.  I love the ritual of greeting every patient- shaking their hand, rubbing their back during a contraction, admiring their newborn baby, congratulating their beaming husband or (much more often here) their mother or sister. “Habari yako, mama?” I ask. They always reply “Mzuri” (good in Kiswahili) or “Fine,” if they speak English. (Finally today a patient said “Not fine!” and we both laughed when I thanked her for her honesty!) It also gives me the opportunity for bedside teaching where we can discuss all of the challenges we face and the best evidence for what we should do to take the best care possible of our patients.  Many of the challenges are the same here and in the US: when to deliver a patient, when to do a cesarean section, how to best educate a woman on her family planning options. Some are much different: how to titrate oxytocin or magnesium in drops per minute (as opposed to just punching it in on the usual IV pumps we have in the US) or what alternative we can get since today the hospital is out of the only oral antihypertensive we have or how much it will cost her family if we have to send them to the pharmacy to get it. 

I am incredibly lucky to have a phenomenal woman as my mentor here in Kenya and in AMPATH. She has lived in Kenya for over 4 years working on improving maternal, newborn, and child health in this area with various initiatives. She has taught me so much in my few short months here and I am excited to be working on so many amazing projects here.  Working with her and in Kenya has made me realize that so many pieces that are difficult to measure are the things that really need to be in place to improve maternal and neonatal outcomes. As she pointed out to me, if every girl in the world had a high school education, we could decrease the risk of preeclampsia and it’s terrible outcomes. Preeclampsia is a disease of pregnancy that disproportionately affects young first-time moms and older women who’ve had many babies.   A high school education alone can empower a woman and provide her with the tools to be able to make her own reproductive choices.

In my last year of residency, midwives and doctors from our high-risk prenatal service were starting a program called Centering. It is a program of group care where women can learn and discuss concerns, challenges, ask questions and be educated about their health. Our group was applying it to women with high risk pregnancies and common challenges, like diabetes. Here in Kenya, my mentor has started a program called Chama cha Mama Toto- Groups for Mothers & Children.  She, in turn, works with a group from Canada who started a similar group care model.  Chama cha Mama Toto combines the traditional type of chamas in Kenya- whereby women join together to pool money to support each other and themselves- with maternal, newborn, and child health care and education. It is amazing how these incredibly simple and intuitive, yet revolutionary, concepts are changing and improving the way we care for women all over the world at the same time.

I had the opportunity last week to travel to Port Victoria, on the edge of Lake Victoria (pictures to come), to meet with the community health workers leading the chamas. It was incredibly inspiring to see the effect a program like this can have on so many communities. They are expanding the number of communities they’re reaching and finding new ways the chamas can be used to improve the health of their communities. The possibilities are endless… One of the most important impacts they have is the ability to connect so many people to resources- both monetarily and personally. This is another difficult-to-measure outcome, which undoubtedly improves maternal and child health.  I love that she begins every presentation about Chama cha Mama Toto with an explanation of the graphic on the front of their educational book used in the group care. It is a beautiful drawing of the steps it takes to get a woman care—connecting her with other women, with a community health care worker and with the leaders in her village to collect money and find transportation to bring her to a healthcare center. I will try to find a picture to post of this painting, but here is a beautiful video created by her wonderful and energetic team (who are becoming my team too!).

http://www.can-mnch.ca/chamas-for-change/

From Port Victoria we traveled to Kapenguria, the southernmost and biggest city in Pokot County, an incredibly rural area on the border with Uganda. They have some of the poorest health outcomes with low rates of education for girls, high teenage marriage and pregnancy rates, high rates of vesicovaginal fistulas, and a vast area over which they have very to spread minimal health resources.  We met with representatives of the Ministry of Health and health leaders within the county to discuss plans for an application for a multi-million dollar grant to improve maternal, newborn & child health within the County. It is an incredibly opportunity to make significant changes in the lives of the women and children of their community (and of course everyone in the community since men benefit from keeping their wives and children being healthy).  We hope to incorporate innovative ideas like Chama cha Mama Toto with more traditional ones, like staffing health facilities, increasing the availability of operative delivery, and comprehensive family planning services.

So all this meandering brings me back to my work today: the 16 year old girl with preeclampsia who just delivered a stillbirth, and the 17 year old girl with eclampsia who had had no prenatal care and hid the pregnancy from her mother, a traditional birth attendant, until she began having seizures. I had to explain to them that her baby probably wouldn’t survive because it was too small and that we would induce her labour so that she wouldn’t have a scarred uterus at the age of 17, setting her up for a lifetime of dangerous pregnancies. The support of her mother and sister who brought her to the hospital and who helped us make this difficult decision ensured that she would survive this pregnancy.  

A picture of the team showing off their famous Pokot honey :)

Cervical Cancer

I have been planning to write about this for a while now, but this past week it really hit home. I recently started working with an organization that works closely with street kids. They currently provide a space for these kids & adolescents to spend time during the day away from the streets with structured activities, a place to stay over night, rehabilitation from glue sniffing (the most common/cheapest drug around), and transition services back to their families or into boarding school or job training programs. They also have healthcare services, especially for HIV positive street kids, and we are working to start a contraception/gynecology clinic. 15% of the girls living on the street are HIV positive. Of the HIV positive girls, almost 70% engage in transactional sex (compared to about over 40% of the HIV negative girls). In talking to the director of the center, she told me about a young woman in her early 20’s who lives on the streets who is HIV positive and died this week of cervical cancer.

Statistically, Kenya has a rate of cervical cancer of 40 per 100,0000 compared to the US rate of 7 per 100,000 and cervical cancer is the number one cause of cancer and cancer deaths in women due to high mortality. Everyone you talk to has a story about a family member with cervical cancer. A few weeks ago I was on the way to one of our outreach clinics for our cervical cancer screening program in which we are training nurses to perform LEEP (a key treatment for cervical dysplasia or pre-cancerous lesions) and I was traveling with one of our recently graduated Gyn Oncology fellows, Dr. Itsura. I am incredibly proud to say that the hospital & organization I work for started the first cervical cancer screening program in Western Kenya and the first Gyn Oncology fellowship in Kenya. They started by training our faculty generalist OBGYNs who had a special interest in Oncology and this year started taking international fellows- one of whom is a wonderful woman from Uganda whose family is still there, so she travels to Kampala every weekend by bus to see her two children and husband. You can only imagine what a phenomenon that is here, in a culture and system that is incredibly sexist and patriarchal. (Perhaps that will be the topic of my next post.) I asked Dr. Itsura why he decided to go into Oncology after having a successful generalist practice. First he said that he had seen the lack of Gyn Oncology to be a huge gap in care. He had so many patients he had seen in practice who had cancer and there was nowhere to send them, no one to take care of them, and due to no comprehensive treatment (the best they could do was sometimes to operate & then send them to a medical oncologist for chemotherapy), the outcomes were incredibly poor.  Then he told me it was also because he watched his mother die of cervical cancer when he was in primary school and she was in her 30’s. He said he always wondered why she was bleeding so much and why she was in so much pain before she died. He said if he could prevent other women and their families from going through what his mother and his family went through then he would have felt he had a successful career.

That same day before Dr. Itsura picked me up for our two-hour trip to the outreach clinic, I was talking with the guard who works at the gate of our compound. When I told him Dr. Itsura was picking me up, he said “Please tell him hello from me, he is a wonderful doctor and a wonderful man.” I figured Eldoret is a pretty small town so maybe they just know each other.  When I gave Dr. Itsura the message, he told me that he had treated the guard's daughter for cervical cancer. She is in her 30s and was diagnosed with stage 3 cervical cancer a few years ago. They had somehow managed to raise the money to send her to Uganda for radiation therapy, since it is not available here, but she had a recurrence and now has no other treatment options.  A few days ago I heard that she is now requiring large amounts of pain medicine and is in hospice care in one of a the few inpatient facilities available in Kenya. 

After going once with Dr. Itsura, I now travel almost every week to one of the outreach clinics. The AMPATH cervical cancer screening program reached over 10,000 women in 2012 with incredible nurses who do all of the screenings themselves, then refer patients who need treatment to the consultant clinic held one day per week. Women travel hours and spend money they can barely scrape together to reach these clinics so we try to limit the number of times they have to come. Training nurses to be able to treat cervical dysplasia is key to this, so I feel incredibly lucky to be able to be a part of training these amazing women in a skill that can help save women’s lives. The nurses are so good at what they do and know many of their patients so well: who comes in with frequent sexually transmitted infections because her husband is sleeping with other women, who has been too busy working to support her family to follow up on her abnormal results, who comes from far and can't afford the travel expenses (so we must do as much as we can in one visit because she may not be able to come again). The stories are endless and often incredibly sad, but you would never know it from the strength, grace, and calm these women project. 

The strides that we have made to develop an effective screening program within this system of many rural health centers and coordinate follow up with patients who often have no way of being contacted is inspiring. But we still have a lot of work to do. In one of my clinics I saw a woman who had had a pap smear done at this clinic over a year ago that showed cancer. The results had somehow gotten lost and the clinic had just received them and called her back. When we did an exam she clearly had a large cervical cancer. We referred her to our Gyn Oncology program and explained that she must start raising the money to pay for the surgery.  If women and their families have the means, they can travel to Nairobi or Kampala for radiation therapy but most can only afford to have surgery, which luckily enough they can have in Eldoret. Another woman had previously been diagnosed with advanced cervical cancer but could not afford radiation therapy and was not a candidate for surgery. She had come with her sister back to the first clinic she had come to for screening because she wanted to “start over.” We tried to figure out what she meant and the nurses realized that she had not yet come to terms with the fact that she had no more treatment options so she wanted to see if there had been a mistake, that she had hope for a cure.  The nurse agreed to do another exam for her. Indeed, she had a large cervical cancer for which no treatment would be possible.  She explained that to the patient who calmly climbed off the table, thanked the nurse, and left holding her sister’s arm.


The door to our CCSP clinic in Webuye, Kenya

Our first year registrars at a recent neonatal resuscitation simulation program

Lessons Learned

After four years as a resident, working an average of 80 hours per week (much more if you’re on labour ward), you tend to think you have seen it all. I have done more vaginal deliveries, cesarean sections, and vacuum-assisted vaginal deliveries than I can count; managed more non-reassuring fetal heart rate tracings, shoulder dystocias, diabetics, and hypertensives than I can remember. It becomes second nature. It becomes your sixth sense. You develop your intuition and you learn to trust it. You develop your skills in using all of your available tools and you trust them. But throughout that you have the reassurance of back-up. If your intuition, skills and tools do not give you the answer, you call your attending. Even when you are completely sure of your decisions, you still call them. But when you begin to practice independently, you don’t have anyone else to call. You have to make immediate, life-altering decisions.

What if you don’t have your usual tools? Then on what do you base your decisions? Intuition can fail you. If you’re interested in this concept, read the book Blink: The Power of Thinking Without Thinking by Malcolm Gladwell. It is eye-opening and riveting. We are constantly taught to second-guess ourselves. We are told “don’t judge a book by its cover” and “think before you act” etc etc… When you begin to think and overthink your intuition, you think of many ways in which to break down your initial judgment. Every argument has a counter argument and you begin finding every piece of evidence that shows you why your intuition is wrong. But there is a reason something is made clear to you by your intuition.

You must learn to trust yourself. I often get compliments about my confidence and I think of it as one of my stronger personality traits. Of course, like everything else in the world there are pros and cons to confidence. I can come off as over-confident, smug, superior, etc. But when confidence is honed by learning, hard work, practice, experience, and hardship, it can be your most important skill. It helps others believe in you, allowing you to be a good leader. It allows you to remain calm and elicit calm from others in difficult situations.

Here, the registrars (residents) do not have back-up. On labour ward they are lucky if they have a consultant (attending) who comes in once or twice a day to round on the patients and make plans. Then they are left to carry out those plans, whether or not they have been taught what to do or how to do it. I am constantly reminding them to call their consultants for help- for their own safety and for the patients. In turn, they constantly remind me that any time they call for help the response is “Why are you calling me? Can’t you deal with it yourself?” (If not worse.) They are often put in situations where they do not have the tools and have not been taught the skills that will give them the right answer. The hierarchical system is such that if there is a bad outcome they will be berated and reprimanded for what they have failed to do correctly before they have ever even learned what the correct thing is. When this is the only system you know, it is difficult to find your own intuition. It is difficult to become confident in your skills and in yourself.

This is an interesting point of distinction from the modern American system of education and medicine. I have asked people here where it comes from and they have told me from the UK system, the system in which everyone here is trained. In the US we have worked so hard over the past 10 or 20 years to dissolve that system, though I don’t know about the modern UK system. As medical students and residents now (or recently) we see the last vestiges of it in certain “old-school” attendings, but for the most part it has been systematically broken down by consciously and actively changing the way in which we interact with each other and our patients. We take classes in ethics and discuss how rigid hierarchical systems in medicine hurt everyone involved, including our patients and ourselves. We are taught that there is a better way to do it and we strive to embody that in our practice. 

These are some of my abstract thoughts at the end of a long day in response to a very difficult clinical situation. The details are not important and I am still struggling to understand and believe them myself. Suffice it to say, I am reminded to always trust my intuition, because my tools and skills may fail me.  When the line between right and wrong is so blurred and when the situation can be so unclear, as it often seems to be here, your intuition and confidence in your ability to be a leader, as well as a team member, are all that will carry you through.  Every day I am trying to teach these skills to the registrars and although the outcome today was bad, I believe the lessons they (and I) have learned from this will make them (and me) better physicians.

The first two pictures are the courtyard in the hospital- it is always filled with people enjoying the sun and fresh air. It is my favorite place to see interesting faces and beautiful children who love to shout "hello!" to catch your attention then grin & giggle & dash away.  The last picture is the beautiful Hindu Temple that I walk past on the way to the hospital every day. 

The Reward

This week was long & exhausting, but it was one of those weeks where I get to remember why I do what I do.

One of the patients I have been taking care of for 2 weeks was incredibly sick. She is 21 years old & came in at 34 weeks pregnant in respiratory distress. Her chest x-ray was horrible & we started treating her for pneumonia while awaiting her tuberculosis testing (I naively thought it would be negative since she is HIV negative). She was so sick & dehydrated we were concerned that the baby wasn’t doing well, so I spent half an hour doing an ultrasound to try to make sure it was safe to continue her pregnancy. She clearly was in no shape to go through labor as she couldn’t maintain her own oxygenation, and being intubated for a cesarean section (all of our C-sections are done under general anesthesia) wouldn’t be safe either.  The entire time I did the ultrasound she was having trouble breathing and coughing in the poorly ventilated room where I do ultrasound & fetal monitoring. She had low fluid but her baby was ok for the meantime. Later that day her TB test came back positive. She had been in a room with 5 other high-risk pregnant women, so they were quickly moved out and we began her TB treatment. But she didn’t get better. In fact, she became worse including being confused and pulling out her IV. We did a lumbar puncture and found she had meningeal tuberculosis as well. Over the next few days of treatment she began to improve but the fetal status deteriorated. On the next ultrasound there was no fluid around the baby and by the next day we decided we needed to deliver the baby as soon as possible by cesarean section. I left that day assuming she was “next in line” for the theatre, but came back the next day to find that the anesthesiologist didn’t think it was safe to put her under general anesthesia, and there were no beds in the ICU in case that she couldn’t be extubated. By the next day her respiratory and overall status had improved enough that they agreed and she underwent a cesarean section. I wasn’t there for it, but the following day I went looking for her to find out how she and the baby were. She looked better than before, no longer required oxygen, but said she hadn’t been able to see her baby yet. Can you imagine, after going through all of that & not even seeing your newborn baby?? She was still very weak so I supported her arm as we walked down the stairs from the postpartum ward, through the labour ward & into the newborn unit. She had to wear a mask, but they let us in for a moment to see him. I will never forget the look in her eyes when she first saw him, put her finger in his little hand, caressed his little foot & wondered at his five little toes. He was the most amazing thing she had ever seen. The nurses quickly shooed us out, and we walked upstairs in silence together.

Today I saw her smiling for the first time, practically running through labour ward on her way to the newborn unit to see him and my heart was bursting with pride that I had helped care for her and her baby, that she had gotten through her terrible illness, that they were both alive and healthy.

My other long-term sick patient was transferred from another hospital a week after delivering twins. They sent her overnight with preeclampsia and when she got here they gave her blood pressure medication that precipitously dropped her blood pressure. When I saw her that morning she was practically unconscious. We resuscitated her with IV fluids and quickly sent her for a CT scan of her head. She had had a large ischemic stroke. The next day she was still curled in bed in the fetal position, unable to say much. But over the next few days she began to improve and I realized she spoke English very well and had the greatest sense of humor. Trying to explain what had happened to her and her family was incredibly challenging. She said she didn't understand why the scar on her belly where she had had a c-section was healing, but the thing that was wrong in her head wasn't healing. I explained that it was healing, but that it would just take more time; that while she could see the scar on her belly healing she couldn't see this scar, but that her moving every day was showing us it was healing. 

The first thing I heard her say, and every day after that, was “when can I go home?” I would tell her when she can walk out the door she can go home. The laughs of her and her family egged me on, wanting to get more laughs out of them. I said, “you can leave when you can walk out the door, down the sidewalk and get in a matatu with your babies.” They all doubled over laughing, hearing this muzungu doctor talking about matatus (those dangerous taxi vans stuffed to the brim with passengers). She would grab both my hands in hers to lift herself up in bed (she weighs all of 100 pounds) and attempt to swing her legs to the side of the bed to show me she could walk out the door. At first this didn’t work at all as her one leg was too weak to move. But slowly, over the course of the past week, she has gotten to the point where she is now walking out the door (of her room, anyway). In the course of our testing we have found out she has atrial fibrillation and had a blood clot in her heart that caused the stroke. Now she can’t leave the hospital until she is fully anticoagulated so this doesn’t happen again.

Through this all her family has been with her every single time I’ve gone to see her. Her sister stays overnight with her & helps her take care of the twins, who sleep in baskets on the counter in the room. Keep in mind she is in a room with 5 other high-risk postpartum women with all of their babies (and some women who have lost their babies).  Today I went to see her and she was lying down, breastfeeding her baby boy while her sister had the baby girl bundled up. I admired them both and told her how lucky she was to have two beautiful, healthy babies. She asked me, “where’s your baby?” and I smiled and told her “next year.” She laughed and said, “you can have one of mine.” Her amazing smile, sense of humor, and generosity in the face of such an unfair, nearly deadly, condition that she will have to deal with for the rest of her life is inspiring and humbling.