Last day at Fluorspar

Wow, what a week with our Fluorspar family!  I think we all feel that we made big strides in all of our initiatives.  The chronic disease program is progressing nicely with weekly clinics assessing patient’s risk of chronic disease.  We’ve begun the community health care worker program collecting patient data out in the field and sending it via cell phone back to the clinic database.  The vision program also is humming along with the clinic able to provide basic vision care, prescription eyewear and reading glasses.  We were most pleased with the clinic’s enthusiasm with MSK having designated an entire building to provide MSK services to the community.  We’ve donated an assessment table to them and look forward to helping furnish more of the required equipment.

We are also very excited about beginning virtual case review with the clinical officers discussing their complicated cases with Medcan doctors in Toronto.  We’ve donated an iPad to them which they will use to Skype the Medcan Clinic beginning this Friday.  This will allow for continued learning throughout the year during times when we are not there.

We also had a chance to meet with different organizations, including World Spine Care and AMPATH who we may be able to partner with in order to bring the best strategies and resources to the Fluorspar clinic.  We have a lot to learn about working in Kenya and so one of our goals is to speak with as many people/organizations as possible to listen and learn from them.  We see so many opportunities to help and the temptation is to take them all on.  But we believe the more effective strategy is to select just a few areas, take our time, listen to the clinic, listen to other organizations and be happy with hopefully moving them along the spectrum.  Perhaps the impact occurs slowly at the beginning but if we focus our energies the momentum will come and the change will be more indelibly imprinted on the practices of the clinic.

So, next steps!

Our confirmed next trip will be in the Fall.  First and foremost we will continue with the Chronic Disease program and ensure it is running well.  The specialty clinic we’ll run will be centered around women’s health, family planning and children.   They have also requested we bring in a dermatologist as this is the 2nd most common issue at the clinic.  We will also be visiting our other sister clinic Lewa Downs, a conservancy about 250 kms northeast of Nairobi.  It will prove to be a very exciting busy 2 weeks!

So until then, thanks for reading.  Don’t forget to follow us on Instagram, Facebook and Twitter.  And please continue to check in on our website for updates on the program.  

- Stacy

From the journal of Dr. Miners

Working in Kenya as part of the Naweza project has been a fantastic experience.

My first trip (the second Naweza expedition) was full of unknowns and questions.  Dr. James Aw and Stacy Francis approached me and said that the clinics and communities they visited had immense need for basic care in musculoskeletal (MSK) medicine and that they needed my help.  Despite their encouragement and reassurance, I was very unsure and even skeptical. What was the need for musculoskeletal medicine?  Where and how could I help as a sports injury specialist chiropractor?

Well… as you have read from the other postings in the blog, there is a huge need for education and treatment in the field of muscle and joint injury here in Kenya and for that matter throughout Africa.  In fact, the World Health Organization (WHO) as part of the research on the global burden of disease has identified musculoskeletal conditions as one of the growing and largest causes of disability worldwide. Low back pain and other spine related conditions as well as knee osteoarthritis are among the most common causes of this MSK related disability.

This empirical evidence was very much supported during my first expedition, and between the two clinic locations I saw patients into the hundreds.  Cases ranging from the simple and minor up to the complex and strange.  Lots of knee osteoarthritis and low back mechanical pain, but also the rare cases of poorly managed juvenile rheumatoid arthritis and unhealed complete fracture of the humerus (upper arm bone).  The patient cases truly ranged all across the spectrum of MSK injury and disease.  Unfortunately the typical treatment from Kenyan clinicians was only to repetitively provide non-steroidal anti-inflammatory drugs (NSAIDs), no condition education, no self-care management strategies, and no rehabilitation.  Not only does the sustained use of NSAIDs have potential health complications, evidence would suggest that in the vast majority of uncomplicated MSK conditions treatment should be focused on education regarding self-care/management and rehabilitation.

My second trip has been just as interesting as the first and has remained a learning experience.  I have continued to progress on my goal of educating the local nurses and clinical officers on conservative evidence based management of MSK injuries and conditions.  Very exciting is that one of the Fluorspar clinical officers has expressed a strong desire to work personally with me and to learn as much as he can regarding MSK diagnosis, treatment, and rehabilitation.  He has stated that he would like to pursue further education as a physiotherapist or to become a doctor of chiropractic.  He plans to start this road by first taking a nurse clinical officer course in orthopaedics.  He has also asked for medical papers and textbooks on the various aspects of MSK medicine, and the Fluorspar Clinic has proposed a renovation plan for an existing room structure to use solely as an MSK rehabilitation space. 

The new proposed MSK space

From the outside

For me this has been very exciting and rewarding.  Educating the local team is one of two key avenues to making a sustainable and useful change in the local community.   The second avenue is to do community facing educational talks surrounding common MSK conditions.  Targeted information sessions including condition education and self-care strategies on topics such as knee pain and low back pain.  I am hoping in the next two days to train the Fluorspar clinical staff on how they might be able to lead this type of community education session.  

Overall, the Medcan Naweza team has made a noticeable impact on the medical practices here at Fluorspar and I have enjoyed learning and collaborating with both my Naweza colleagues and my Fluorspar colleagues.  Still much to do, but we have made quite the start and the possibilities for future progressions and initiatives are very exciting.

- Andy Miners

Last day at Fluorspar

Our last full day with the Fluorspar team.  And it was a busy one!

It began as usual with rounds at the clinic.  And while we were asleep another mother delivered a baby!  Dr. Michael did the neonatal examination and all went very well.  Mother and baby are perfect!  One observation we’ve made was that the mothers do not have access to diapers.  The baby is swaddled in (I’m not kidding you) 3 or 4 blankets plus the clothing!  Basically the baby soils the clothing and blanket and then the mother must wash all of it!!  We have an idea that we will create a “new baby” kit to give to the mothers before they leave the clinic.  This will include among other things, diaper cloths.  We’re going to buy large rolls of cotton sheets that we’ll cut into squares which they can use as diapers.  Certainly not perfect but at least they will only need to wash the cloth and not blankets and clothing!

We had a patient who came in with chronic anemia and concern of bleeding into his colon and is suspected of having colon cancer.  The clinic staff was educated by Dr. Ed and Dr. Michael on the difference between acute and chronic anemia and bleeding into the gastrointestinal system in an elderly person.

Dr. Sidiqa and Jemima had a chance to distribute more prescription glasses.  And most importantly Dr. Sidiqa had an opportunity to assess Jemima’s ability to accurately determine a patient’s prescription, which in her words was “bang on”!  This is exactly our goal.  That when we leave, Jemima will continue to help her community without our help.  We’ve told her as well that when she decides to leave the clinic to pursue her studies (she’s expressed an interest in becoming an optometrist!), she has the responsibility to train the next person.  To share the knowledge that she now has so that her community will continue to have access to prescription and reading glasses and basic vision care.

We then departed for the outreach and I must admit were a bit anxious to whether the Chief would keep his word and produce patients!  We were especially worried as it is Sunday and not uncommon to go to Church here from 8AM to 7PM.  Thankfully we arrived to many people waiting to be seen.  The outreach is done at the local school in two separate classrooms.  This school is in good condition with clay flooring, lots of windows, brightly lit and good air flow.  The worst part is the tin roof which radiates heat downwards.  But again, this is a nice school and the community very friendly.

Dr. Andy was busy with MSK patients presenting with many different aches, pains, joint issues, etc.  He continued to train Samuel on the types of exercises and strategies to prevent and reduce chronic pain.  Samuel has taken a great interest in MSK and is thinking of becoming a chiropractor or physiotherapist.  Dr. Andy has been kind enough to forward on to him loads of journals and reading material digitally.  It is amazing to think of the potential longterm impact this will have not only on Samuel’s life but the lives of his community if he were to bring this expertise back to Fluorspar.

Dr. Miners and Samuel with a patient

Dr. Michael had an interesting case where he saw a child whose mother complained that her daughter was eating charcoal.  This compulsion, called pica, is in fact a sign of iron deficiency which is common here.  The young girl will come to the clinic tomorrow for a blood test to confirm the diagnosis and will likely be given iron supplements.

Dr. Sidiqa continued to educate Jemima and the community on proper hygiene for the eyes.  The #1 complaint is eye “allergies”.  But in fact it’s not allergies but rather poor eye hygiene and dehydration.  She encourages washing of hands and drinking as much water as possible.  Access to water very much depends on where you live in the region.  This particular area is quite dry.  Water sources can be miles away and even then needs to be purified before drinking.  It is not an easy situation to say the least.  

But the vision team is having a good time today as the locals are having fun doing vision screening on themselves.  Jemima continued to distribute reading glasses and anyone who appears to require prescription glasses is asked to go to Fluorspar clinic for a more thorough exam with the auto refractor.

A boy with a new pair of glasses

Tomorrow we’ll spend the morning at Fluorspar Clinic before departing for Eldoret.  We’ll be meeting AMPATH, a consortium of universities including Indiana, Duke, University of Toronto and Moi University, a medical teaching hospital located in Eldoret.   AMPATH has been very successful in training Western Kenya medical staff on diagnosis and treatment of HIV and cervical cancer.  We’re hoping to listen and learn from them, especially as it pertains to cervical cancer.  We’re planning to launch our womens and children health campaign in November and would like to offer HPV vaccinations to girls aged 9 to 13.  Cervical cancer is a killer of women worldwide and is preventable from the vaccination.

We also plan to begin virtual case review from Kenya to Medcan’s clinic in Toronto.  Every other Friday and on an as needed basis the clinical officers will discuss their most complicated cases with Medcan doctors in Toronto via Skype.  We’ve tested the connection (visual and audio) this week and it worked very well.  We’ll begin the first session on Friday April 17th.  Tomorrow we’ll do one last training session with Julius, the head clinical officer at the clinic.  Telemedicine is an essential part of our sustainable strategy, enabling the staff to continue their learnings virtually.  Our goal is to have them use Medcan doctors on a consultative basis empowering them to offer their community a higher level of care and in turn achieving better health outcomes.

- Stacy Francis

Today, we improvise.

The day started with a visit with the new mother and her absolutely beautiful baby girl.  Dr. Michael was able to perform a neonatal examination on the baby with Julius the head clinician observing.  She was in perfect form and hardly made a peep when he did his examination.

Dr. Hawkes performing a neonatal examination

So off to the outreach we went only to discover that in fact the Chief of the community was having an engagement party for his daughter.  And well, when the Chief has an event everyone (and I mean everyone) goes.  The good news is that they said they’d make an announcement at the event and they expect a full turnout tomorrow.  We learned early on that the ability to adapt and improvise are skills one needs to survive in this environment.  We decided to switch our itinerary we had for Sunday to Saturday.  So we returned to the clinic and had a day of seeing more patients and did more classroom training which included lessons learned from the week.  

A group of children at the outreach site.

We also began to distribute the prescription glasses we ordered for the community from our last trip.  We wanted to be here for the distribution so that Jemima (the clinician who has assumed the optometry duties) would be trained on how to properly fit the glasses and assure the patient has corrected vision.  Fortunately we’ve identified an eyeglass source in Nairobi who has offered deeply discounted glasses which Naweza and Fluorspar fund for the community.  

Boy receiving prescription glasses

We are quite happy to report that Jemima has continued to run Fluorspar’s vision clinic every Thursday at the clinic and at outreaches.  She’s learned how to determine the prescription using an auto refractor which was funded by Naweza.  She then sends us the list and we process the order with the eyewear company.  Today she learned the last part of the process which is to fit the glasses on the patient.  We are very hopeful this practice will continue and the community will have access to vision care on a sustainable basis.

Sadly, a 75 year old man came to the clinic who had suffered a stroke and is now paralyzed on his right side.  After examination it was determined he has atrial fibrillation which commonly causes stroke, especially for an elderly person.  Although not all cases like this one can be prevented, many can be through a proper chronic disease program.  Our plan is to explore purchasing an ECG module which will aid the clinic in diagnosing many types of cardiac conditions.  

A good news story is regarding the woman who came to the outreach yesterday and was diagnosed with diabetes by Dr. Ed.  She actually came to the clinic today to confirm the diagnosis and receive her medication.  One challenge here in Kenya is access to drugs.  Members of communities who are close enough to the Fluorspar clinic are the fortunate ones as they will have access.  Our goal is to empower the team at Fluorspar to identify people at risk of chronic disease so that those people are able to get the necessary treatment and in turn improve their health outcomes. 

Tomorrow, fingers crossed, we’ll have a busy day out our outreach.  The Fluorspar team has contacted the Chief and he assures us everyone will be there!

- Stacy

Outreach at Simit

After a team breakfast we were off to the clinic to do clinic rounds and prepare for the outreach.

First and foremost, update on the mother who was to deliver yesterday.   When we arrived at the clinic she still had not delivered.  So we were all hoping she would give birth before we left not only because we were desperate to see the new baby but more importantly in order for the clinic staff to benefit from feedback from Dr. Michael (our paediatrician) on the post birth protocol.  We’ve found the combination of classroom training with real time patient treatment is the best strategy for training and education.  The clinic here will do about 10 deliveries a month and recently most unfortunately had a death of a baby at birth due to a cord being wrapped around its neck.  This incident was in fact why Dr. Michael did the classroom training with the staff on neonatal resuscitation.  Although rare, these types of incidents happen and our goal is to give them strategies on how to improve the outcomes.   Luckily this mother delivered her baby uneventfully (it was a girl), but unluckily we had left for the outreach before she gave birth!

Before we left for the outreach we needed to prepare the drug supply we took to the site.  One of our goals is to reduce the unnecessary usage of antibiotics that are prescribed by the staff.  The two reasons being, in order to reduce costs and to educate the staff on the negative impact of overprescribing.  For example, when a child arrives with a cough and cold the nurse automatically gives antibiotic.   In fact if there are no signs of respiratory distress or fast breathing then the child likely has a viral infection and does not require antibiotics.  But the challenge is the mother may have travelled a few hours to get to the clinic or the outreach and if she isn’t given something she is not happy.  Rightfully so!!  Therefore, instead of giving the child antibiotics our doctors are encouraging the nurses to give them micronutrient supplementation for health promotion.  

Dr. Hawkes in the Fluorspar pharmacy

After a 40 minute ride from Fluorspar on let’s just say less than hospitable roads, we arrive at Simit, a remote mountain village.  The doctors are separated into different locations inside and out of one of the houses in the village.  The patients then stand in line to see the appropriate doctor.  It is an amazing sight to see what seems like the entire village encroach on this small house.  They will see a couple hundred patients in about 5 hours.

Dr. Michael saw 50 children and was able to immunize many of them.  The most important case involved a 10 year old boy who was carried in with an abscessed foot caused by him stepping on something (unclear what).  Dr. Ed with the clinic nurse needed to lacerate the foot to drain the infection.  A procedure that anyone of us would be sedated for, this young boy endured lying awake on a table.  He was incredibly brave given the enormous pain I know he felt.   I’m not sure if he very much likes doctors from Canada given what he went through but I’m sure he’ll be thankful tomorrow when his foot finally feels better.  We gave him candy and a pack of gum in a last ditch attempt to win him over before he left with his family.

Boy with abscessed foot

We were able to begin our community healthcare workers program by meeting with Helen, the healthcare worker in Simit.  She has agreed to collect data on members of her community who are age 40+ and submit that data via her cell phone back to the database at the clinic.  She collected data on 10 patients, input the data in her phone, sent the data to the central database at the clinic.  Based on the data she submitted she received via automatic text from the database a risk score.  Basically  simply either green yellow orange red.  We are very hopeful this will result in very good intel which will use to build a more robust chronic disease program.

Jennifer with the community health worker

Dr. Ed examined a patient and after hearing her history and testing her blood sugar she was diagnosed with diabetes. Our hypothesis is that many people in the community are also undiagnosed for diabetes and hypertension.  Through training of the Fluorspar staff we believe that more people will be diagnosed and treated, thereby reduce the incidence of chronic disease.

Tomorrow we’ll begin with rounds and then continue on to the outreach. Looking forward to another productive day with our Fluorspar team!

- Stacy Fracis

Second day at Fluorspar

Another great day with Fluorspar clinic.

It began with morning rounds which included a woman who had gone into labor!  In fact it’s the mother’s 6th delivery so she likely could deliver the baby herself.  3 out of 7 women will deliver at home, but she has elected to come into the clinic to have her baby.  No doubt because of the comfortable accommodation here at Fluorspar Clinic and to perhaps have a little quiet time before having to take care of 6 children!

Dr. Andy gave a classroom training session on back related pain.  Arthritis is Fluorspar’s 3rd most common complaint or condition presented to the clinic each year, behind respiratory and dermatological issues.  The clinic staff seemed super engaged, asking many questions and taking notes.  

Dr. Andy Miners with the clinicians at Fluorspar

Dr. Sidiqa along side Jemima (the clinical officer designated to optometry) conducted the clinic’s Thursday vision program.  The cases included a boy who had suffered a thorn that penetrated his eye and now suffers from a resulting cataract.  Fortunately he should be fine but will require cataract surgery in Eldoret which is a 2 hour car ride.  Usually this might be an impossible task to drive 90 kms away but luckily this mother has the resources and the boy should thankfully regain full eyesight.

Dr. Sidiqa Rajani with the young boy

Dr. Ed and Dr. Michael saw out patients in the clinic.  The cases can be complicated given the challenges with language barriers and incomplete histories.  Putting together a puzzle with missing pieces.  But the good news is we were able to make progress on the Chronic Disease program seeing more patients who will be part of the pilot study we are doing on the Fluorspar employees who are 40 years and older.  Basically, by using the World Health Organization’s guidelines, we designed a questionnaire for patients to determine a risk score for chronic disease.   We’ve been pleased with the results so far and now want to take it out into the field via Community Health Care workers.

So, we are especially excited today as we were able to test the new software which the community health care workers will use out in the field when they see patients in their communities.  By collecting 5 simple data points on the patient using a simple cell phone, the healthcare worker will be able to determine the risk score for chronic disease.  Depending on the score, she will recommend the patient go to the clinic for medication or the patient will receive it at the next outreach in their area which is held every 2 weeks.  We are hoping to begin this process tomorrow when we go to our outreach in Simit.  We are quite hopeful this will be of benefit in 2 ways.  One, people who are suffering from chronic disease but are potentially unaware of it will be given early treatment resulting in better health outcomes before the disease progresses.  And two, the data we collect will be used to measure the presence of chronic disease in these communities which will allow the Fluorspar Clinic to better serve them.

Dr. Andy had another busy day seeing patients complaining of body pain.  He worked with 2 clinical officers, Christopher and Samuel, training them as they saw the patients.  One of Dr. Andy’s missions is to drill in the mantra “Exercise is Medicine” or in Swahili “ Mazawezi ni dawa”.   In an area where resources are scarce we are trying to give strategies to reallocate their drug expenditure.  That is, use less on pain medication and more on chronic disease medication!

Dr. Andrew Miners with a patient

Now off to dinner and a good sleep before our outreach tomorrow!  Lala salama!

- Stacy

Arrival at Fluorspar

Arriving off the bush plane from Nairobi on the Fluorspar air strip

Jambo from Kenya!  After 2 days of meetings in Nairobi with potential partners in telemedicine and the World Spine Care Organization, we have finally arrived at our sister clinic Kenya Fluorspar.  

Fluorspar is a mine located in the Kerio Valley 90 kilometers from Eldoret.  It is so good to be back and see all of the bright and motivated staff at the clinic who we worked closely with this past November.  During that mission we began programs on Chronic Disease, Musculoskeletal and Vision.  We were quite happy to see that they have continued to do work in these areas and appear eager to reinforce those learnings on this trip.  

Our day began with clinic rounds involving cases of malaria and a snake bite (potentially by a black cobra) as well as classroom training on neonatal resuscitation and hypertension.  After lunch the team split up: Dr. Andy and Dr. Ed had a meeting with the mine manager and a tour of the mine and refinery to better understand their occupational health issues and costs, Dr. Sidiqa provided visual acuity training and Dr. Michael and Jennifer trained the staff on database development for the Chronic Disease program.  We also had a good discussion on developing Fluorspar’s first Community Health Care Worker Program which we hope to begin on this trip.  These are all official areas that we worked on, but the casual conversations held before and after these sessions are rich with relevant topics such as rabies (which sadly took the life of one of the children in the community) and mental health issues including alcoholism and domestic violence.

Dr. Hawkes with a patient at the Field-Marsham Medical Centre

One of my personal observations is that finally after 3 visits I see the beginnings of a relationship of mutual trust and respect.  One where I hope they feel our respect for the impressive level of care they already provide in the middle of rural Kenya.  And equally one where I sense their trust in consulting with our doctors without fear of judgment.  That in fact we are their partners here to help and provide as much expertise and training as possible.  

A favourite time of the day for me is during clinical rounds which we do first thing in the morning.  The clinical officer (which is equivalent to a nurse and would be the highest level of caregiver at the clinic) gives a proper history on a patient (which was one of the areas of training from the last trip) and our doctors in turn basically quiz them on how they would approach the case.  The doctors will walk them through the thought process for effective diagnosis and treatment strategies.  The style of teaching is effective and the learnings are incredible.  The room is packed with the clinic staff trying to soak in as much knowledge as possible so that they can offer more to their community when we leave, which is of course our goal - to have the health clinic operate at an even higher level when we are not here!

We have one more day in the clinic before heading to outreaches on Friday and Saturday.  Tomorrow, our itinerary includes Dr. Sidiqa overseeing Fluorspar’s weekly vision clinic which they began since our trip in November, as well as Dr. Andy’s training session with the clinic staff on MSK strategies.  We will be holding the session at Fluorspar’s Taekwondo center immediately following one of the community’s Taekwondo classes.  We will also be meeting with a company who supplies software supporting the community healthcare worker program.  The software basically will enable the healthcare worker to assign a risk value to the patient out in the field and quickly determine the course of action for treatment.

Thanks for reading!  And for photos of the day be sure to check us out on Twitter, Instagram and Facebook!

- Stacy Francis