Day 7: See you soon Naweza colleagues! Many 'wins' this trip, and many more to come ...

Jambo! 

It’s our final morning waking up at Ngiri House, our home for the last 7 days.  Rose and her staff have taken such good care of us, providing beautiful meals, doing our laundry, organizing transportation and basically anything else that we need. 

Dr. Sue pointing at the elephants in the background. Earlier Sue and Sidiqa joined me in my regular workout and this is our daily view

daily visitors of monkeys and impalas as we work, eat or exercise

Family of monkeys eating some snacks from our front lawn at Ngiri House

Sidiqa and Sue joined me for our daily circuit workout (thank god for the 7-minute workout app) that we do outside overlooking the plains of Lewa which was full of impala, elephants, zebras, monkeys, warthogs and many more magical creatures to keep us company.  The setting is truly surreal and our sense of gratitude for being there couldn’t be stronger. 

Dr. Michael examining a young patient at yesterday's outreach

A mother and resting child speak to Dr. Michael during yesterday's outreach

During breakfast we had a lovely surprise visit from the clinic staff to come and say one last goodbye.  They have a tradition of guests signing their visitor book.  So each of us wrote a personal message thanking them for a great visit.  Again we had some laughs about the week.  One of my stories involved a mother who had brought her baby in to see Dr. Michael.  Her baby had become fussy during the visit and she was trying to bounce him and hold him in different positions, but to no avail.  He kept crying.  All the while she kept smiling as she discussed the baby’s symptoms with Michael, never losing her composure.  I just marveled at the way she kept calm despite the baby’s obvious displeasure!  She then without missing a beat bent over from the waist, thrust the baby on her back and then threw a type of sarong around the baby and secured it by tying it around her chest.  Although better, he still wasn’t quite settled.  Mind you, she is continuing her discussion with Michael at this point.  And yes, still smiling.  I on the other hand was sweating just watching her, and wanted to help, but realized I was way out of my league.  For her final and decisive move, she slid the baby under her arm and then back up the front so that his little head rested on her chest.  And he finally fell fast asleep.  It was nothing short of masterful.

All of the staff laughed and said how this was quite common.  And John, the ambulance driver then demonstrated how everyone in fact is very good at balancing things on their head while they carry many things in their hands.  So he demonstrated putting his phone on his head and began walking around, bending over, all the while with the phone lying completely still on his head.  All I could think was how is it possible that he do this and I can’t even keep my own phone from falling out of my pocket!

But it was this easy exchange and dynamic that we feel so grateful to have with the staff.  We work hard, have high expectations, challenge them during CME and clinic sessions, constantly putting them on the spot for correct diagnoses and treatment strategies, but always with respect and kindness.  These are nurses who are being forced to be doctors in order to care for their community.  That’s quite a bit of pressure and we know that is not an easy ask.  But their people are relying on them and we want them to know that we are there to help provide the training and knowledge to hopefully close the gap if just a little bit.

Dr. Paul Cohen, a dermatologist at Medcan, pictured here with local children during his first Naweza trip in July 2016. During the February 2018 trip, he supported Medcan Naweza from Toronto via the WhatsApp chat group we created.

One of our new strategies in ensuring a line of communication between us and the clinic is our new WhatsApp chat group.  The clinic will now use the chat group for any complicated cases that they encounter, enabling the Medcan Naweza docs to respond and provide timely guidance.  In fact during our Outreach we had a dermatology question and we sent a photo of a rash to Dr. Paul Cohen who has been on a previous trip.  Within minutes Dr. Paul responded with potential diagnoses, things to check for and recommended treatment strategies.  Technology is going to allow us to have more impact with our programs.  Especially as Kenya continues to improve infrastructure and connectivity, which I have seen over the last 5 years since we began this initiative.  Things are looking bright!

 After the flight we return to the other wild part of Kenya - the Nairobi streets.

We then headed to the airstrip, gave a big hug to our driver Benjamin who has been so patient and attentive to us this past week.  And we boarded our plane to Nairobi, a (very) bumpy 40-minute ride.

Over lunch we discussed next trip dates, hopefully July and Jan/Feb and the steps going forward.  Our main tactical goal will be to operationalize the EMR.  Although the government-issued EMR system that they currently use is quite comprehensive, it does not include most of the data points that we need to properly manage the patients in our Chronic Disease Program.  It is for this reason we were forced to build our own.  In one month we will see the next iteration of it and hopefully it will be ready for a soft launch.  Danet, the builder of the EMR would then go back to Lewa and begin installation, testing and training.  And as any EMR system, it won’t be easy.  But we’ve kept the program purposely simple to help mitigate the inevitable complications, with the long term plan of building onto it and integrating it with the Clinic’s current system.  

So this is it for now.  It has been an incredible journey this week. 

• We’ve made strides in our Chronic Disease Program
• Have buy-in from the CEO of Lewa
• Continued training in women’s health and family planning
• Continued training in optometry and will be doing a vision clinic at a school of 500 providing prescription glasses to those in need, and lastly
• Have increased community engagement by a tremendous amount by conducting interviews of the community and clinic staff as well as talks on health education. 

All round a very fruitful trip, which has left us energized and excited to get on with it and really try to make a difference by equipping this amazing community with the tools it needs to keep its beautiful people healthy.

Once again, thank you for reading.  Please continue to follow us on Instagram https://www.instagram.com/medcannaweza/  

If you'd like to see a sneak preview of some of the footage that you'll see there over the coming months, check out this "trailer"

We’ll keep posting the photos from the trip throughout the year to keep you updated on our progress. 

Until July, with best wishes,

Stacy :)

Lewa's vision clinic: Guest Blogger Naweza's Optometrist Dr. Sidiqa

A young patient is fitted with the refractor. A refraction or vision test is as part of a routine eye examination. This test tells the optometrist exactly what prescription may be needed  (February 2018)

Dr. Sidiqa, Lydia in foreground. Background a local clinical nurse who helped with cataract surgeries in Flurospar

Hello everyone! My name is Dr. Sidiqa and I’m the optometrist working with Naweza. This trip was my 7th one with the team; what an honour to be part of this amazing and dedicated medical team! Stacy has asked me to write a little about the Lewa Vision Clinic ("the vision clinic") — what we have achieved, what we are working on at the moment and what we hope to achieve in the coming year ... and I'm super excited to do, because, well, I love what I do with Naweza as it's my life's passion: helping improve people's lives through the gift of sight.  

Before I get to the updates for the vision clinic from this trip, a quick trip down memory lane to remind us of all that we have achieved already.

Dr. Stephen, a local optometrist who is committed to a regular schedule at Lewa, performing a cataract extraction

Dr. Sidiqa performing post-cataract treatment on patients in 2016 at the Isiolo Hospital

In three years: from Ø vision services at Lewa to the in-house, permanent Lewa Vision Clinic

Over the last three years, we have supported the Lewa Clinic to set up their own in-house vision clinic. We kitted the vision clinic with all the equipment required to carry out a comprehensive eye examination—including an auto refractor, trial frame, trial lenses set and an ophthalmoscope. We also arranged for Stephen—a local optometrist—to visit once a month, in order to service the community’s eye care needs.  He works closely with Lydia, the clinical nurse in charge of vision. In 2016, Naweza partnered with local ophthalmologists at Isiolo Hospital to perform cataract surgeries on 21 elderly patients. This project was a great success and appreciated by many, as cataracts are the leading cause of blindness among the 50+ and so easily treatable.

Lydia with a young patient after he has been outfitted with new glasses for school (February 2018)

Lydia, a clinical nurse who specializes in vision, has gained skills and expertise over the years working with Dr. Sidiqa

Lydia and Dr. Sidiqa: A strong professional relationship

Working with Clinical Nurse Lydia: training and education

During my visits, I work with Lydia on one-to-one training and eye education. We started off with basic eye anatomy and examination. Lydia is now able to take patient history, assess visual acuity and use the ophthalmoscope to examine the front of her patient’s eyes.  Some of the common conditions at Lewa that Lydia faces regularly include conjunctivitis and severe dry eyes (mainly due to the dry, dusty conditions), as well as basic refractive errors and presbyopia (solved easily with reading glasses—age 40+). Occasionally, environmental factors (including tree branches, wild animals, etc) cause ocular trauma.  Such patients are referred on to the nearby hospital for further care.

Water: essential for vision health

An important segment of Lydia’s training is educating the patient on small changes in personal habits—resulting in significantly improved eye health. A practical example, is to keep hydrated and drink at least naane (eight in Swahili) cups of water a day! We recently had a patient who complained of red burning eyes with foreign body sensation, who barely managed to drink one cup of water a day!!! Lewa provides free clean drinking water facilities around the community.  This goes to show awareness and education need more attention.

Lydia has now mastered the advice needed to be given to a patient with dry eye syndrome: drink lots of water, wash the eyes regularly with clean water and wear a kofiya (hat) when you’re out in the dusty roads!

Cooking areas and ventilation: area of concern

Another major concern is the lack of ventilation whilst cooking using traditional wood in chimney-less and small-window homes. This results in women and young children bearing red, itchy and burning sensations in the eye. Lydia is constantly reminding mothers to either cook outside (which is not appreciated due to the fear of the animals stealing the food!), or at the least refrain from keeping their young ones with them during this task. We recently found out that Lewa is working with the community in providing them with cooking stoves and chimneys, so we hope this will reduce the occurrence of smoke-related red eyes amongst women and children.

Looking smart with your new specs! On the day after the outreach, three young patients (students) came to Lewa for follow-up treatment and were able to walk away with the right prescription and lenses

Doesn't she look smart?  The spectacles will not only help the children see better, but also protect their eyes from all the dust

Our latest trip: +100 patients seen and treated

During the recent trip, we saw patients at the vision clinic and the outreach (a total of over 100 patients!), and found a few children that required help with their vision. I was able to get them to come to the vision clinic the next day and assess their eyes further. Out of 5 that failed the initial screening, we were able to give glasses to 3 instantly from our stock - wow, the feeling of being able to offer an immediate solution that will lead to better vision (and likely improved education and quality of life) is an indescribable feeling.

The spectacles will not only help the children see better, but also protect their eyes from all the dust! We also gave away almost 25 reading glasses over the last week, something that always makes our elderly patients so happy. They say they will pray for us when they read the Bible at church - just imagining my patients being able to read and live their lives better because of improved vision, made my heart sing.  

Big smiles from a patient after a vision test led to the right prescription and new glasses

A vision clinic at a local school

Dr. Sidiqa and the chalkboard while a young student performs an eye examination

Vision in the community: Lewa Vision Screening at Schools

The project that Naweza is currently working on in partnership with Lewa Health is Vision Screening at Schools. It is found that 80% of a child’s learning is through vision, so Naweza wants to work with local schools to identify those children with vision problems—such as refractive error and amblyopia (lazy eyes)—early on so that each child is able to reach his or her maximum learning and developmental potential.

“Research predicts 4.5% of children screened will require some form of refractive correction to improve their visual acuities.”

Lydia, clinical nurse in charge of vision, demonstrates "Peek", the mobile app vision test, with her own daughters and friends, at Lewa Clinic (February 2018)

The power of "Peek": our mobile app

Lydia has been trained on screening children as young as 4 years old at schools, using a mobile app called Peek Acuity (https://www.peekvision.org/peek-acuity) and recording the results as PASS/FAIL using her mobile on an icloud data collection tool box. The use of mobile technology allows for the screening to be sensitive and specific! I am also able to virtually follow the progress of the screening and give my input.

Any child who ‘fails” to meet the screening requirement is to be referred on to see Dr. Stephen (our local optometrist, coming in on the first Saturday of every month). If the child then requires correction to improve their visual acuity, Naweza has partnered up with a local supplier in Nairobi to provide the child with spectacles at no cost to the child - pricing is a huge obstacle to care for this community, so offering free spectacles makes more children access vision care. 

For this particular project, our supplier has kindly agreed to donate North American-quality frames, ... so Naweza only needs to pay for the lenses! This allows us to help as many children as we can to see better, which in hand improves their opportunities and quality of life.  I am so grateful for the suppliers who joined us in our Naweza mission to support healthier eyes and improved vision!

Vision care starts young. Informed parents can lead to healthier eyes in the whole family

The Naweza Vision Screening aligns well with Medcan’s vision and commitment to prevention medicine as well as the World Health Organization's Vision 2020 initiative (http://www.who.int/blindness/partnerships/vision2020/en/) —to eliminate avoidable blindness in children by 2020, one child at a time, one school at a time!

That is all for me today. Thank you for reading!

And I look forward to sharing more in the future from our next trip.  As always, we’ll keep you in the loop with our daily blog!

One-on-one with Dr. Michael Hawkes: AFYA-chat

Afya, in Swahili means health. This Afya-chat program helps to find and treat people with non-communicable diseases in rural Kenya. Non-communicable diseases are rising as the leading cause of death worldwide. 

You can read about Afya-chat in an article titled "Community-based screening
for cardiovascular risk using a novel mHealth tool in rural Kenya", which will be published in an upcoming issue of the Journal of Innovation in Health Informatics.
 

Day 6: Great meeting with Lewa Conservancy CEO, Final clinical day at Lewa

Jambo!

It’s already our last full day at Lewa.  And as the saying goes, the hours are long but the days are short - so true, especially with Naweza.  We’ve had a very busy week and feel good about the progress we’ve made with the clinic staff as well as working through the strategy of moving ahead the Lewa/Naweza partnership.

Goal: Centre of Excellence on Chronic Disease for the NRT

The day began with a meeting with Mike Watson, CEO of Lewa.  We presented to him our successes to date and the evolution of the Naweza model of building capacity in Lewa’s health care delivery.  The model consists of a community health worker (CHW), a partner clinic (Lewa Clinic at this point) and Naweza.  Naweza will provide education and training to both the CHW and Lewa Clinic on a selected program, with the Chronic Disease Program being our flagship.  Technology will enable us to screen and manage patients, as well as provide credible robust data for research purposes so that we can validate our model with the hope of scaling it with multiple partner clinics.   

He was very receptive and agrees that Lewa has the opportunity to be a Centre of Excellence on Chronic Disease for the NRT, Northern Rangelands Trust, a consortium of 28 conservancies in Kenya.  We look forward to a more collaborative effort in promoting our health programs along with the overall mission of the conservancy. 

Dr. James leading a talk on UTIs and kidney disease

Dr. Michael sharing the importance on treating the "whole child" in order to reduce illness and disability 

Final day of CMEs: UTI / Kidney Diseases, Childhood Illness Pneumonia through IMCI approach

Later in the morning we headed to the clinic and Dr. James led a talk on UTIs/kidney disease and Dr. Michael focused on the integrated management of childhood illness (IMCI) with a focus on pneumonia.  Using the IMCI approach, Dr. Michael's aims to teach an integrated approach to child health (it focuses on the well being of the whole child) in order to reduce illness and disability, and promote improved growth and development among children under five years of age. 

Here I am presenting shirts we had made for the Naweza staff - I hope they wear them with pride

Rosaline - our translator and surveyor extraordinaire!- and Dr. Sidiqa - Dr Sue in the background and a smiling photo-bomber :)  

selfie game is strong

Naweza close-up

The whole group on our final clinical day at Lewa Clinic

We then presented the clinic staff with Naweza t-shirts and tea mugs and thanked them for a productive week.  We took pictures, shared stories, had some laughs and basically made each other feel appreciated.  It is a two-way street and the success of this partnership must be one of mutual respect and collaboration.  I feel we are in a good place and am excited for the potential.

The afternoon was spent seeing patients.  One of the saddest and most difficult cases involved a patient who returned to the clinic after seeing us at yesterday’s Outreach. She was suspected of having juvenile rheumatoid arthritis (Dr. James also wrote about it yesterday and you can see photos here).  The young female patient came into the clinic and had a blood test that confirmed her diagnosis.  If this patient lived in Canada she would require lifelong anti-inflammatory meds and team-based care including occupational therapy in order to train her to do daily activities as her mobility continues to diminish.  But in this resource-limited environment it will be highly unlikely that she’ll receive the treatment that she needs.  The cost of the logistics, let alone the cost of  the treatment is prohibitive.  The mother claims to not have enough money to pay for the necessary trips to the Nairobi hospital, physical therapy and medications.  Her prospects are grim and we are limited in what we can do.

This story illustrates how the doctors who join us on this trip can at times feel a bit demoralized.  And it's totally understandable: they diagnose a patient and know the treatment strategy that’s required and yet the patient won’t be able to receive that treatment.   And in the most serious cases, like the one above, this can result in devastating consequences.  Consequences that we in Canada would never need to endure.  There is no easy solution to this.  And we are forced to accept that we can only do so much.  But still, it is a situation that leaves you full of frustration and sadness and your only choice, coping mechanism really, is focusing on the positive work that we’re doing - and the hope that through our relationship building, education and knowledge sharing our impact will be felt when we aren't here.  We are often reminded that Naweza must choose areas where it can have the most impact. 

A view from inside the clinic yesterday where dozens upon dozens of local residents waited to be seen by Naweza doctors and local nurses

Chronic disease will soon be the leading cause of death in Kenya, overtaking HIV, malaria and other communicable diseases.  It is an up and coming epidemic and Kenya health-care professionals lack the training and education around properly identifying and managing these patients.  Establishing screening and treatment protocols will prepare the Lewa Clinic to care for their patients so that they avoid catastrophic outcomes resulting in a poor quality of life and requiring expensive treatment.  Early intervention is key and through Naweza’s capacity building model overlayed with the SMS technology and EMR patient management tool, we are hopeful that health outcomes will improve for this community.

Tomorrow we will head back to Nairobi and have our debrief meeting before everyone will head back home.  We will have a lot to talk about including planning our next trip, which we are hoping will be in July (!).  We don’t want to lose the momentum that we’ve gained on this trip and are excited to push forward other initiatives that will help Lewa provide a higher level of care to their community.

Until tomorrow, thanks for reading….and lala salama :) 

Stacy

Day 5: Outreach in the community: Touring local homes

Tania Haas is the health and wellness writer at Medcan. She produces the monthly newsletter and the Medcan.com articles found here 

As mentioned in the previous blog, Rosaline and I spent the morning focused on health promotion. The afternoon, we toured a 2KM radius around the clinic and visited with local residents and asked to tour their homes and crops. Some photos and videos below.  

Paul let us tour his sitting area, kitchen and backyard where cows come to drink and rest.

With very little rain this season left the crops small, dry. 

While every home is unique to its inhabitants, we found that there was a common characteristic to their kitchens: poor ventilation. 

Most people are cooking in wooden shacks where the smoke circulates without a vent or a fan and inevitably the ash and smoke will risk affecting vision and respiratory health. This would explain the coughing and itchy eyes that so many of our patients describe. 

We spoke about this later with Drs Hawkes and Sidiqa and they told us about smart clean cooking technologies that cook faster while reducing fuel use, smoke, and toxic emissions. This may be a worthwhile investment for Naweza, or Naweza's supporters to look into. 

This video is a tour of a local home near the Lewa Clinic. As you will see, Rosaline takes us on a tour of local resident Sophia's home -- where we see where she stores her onions and other small scale farming; rabbits; chickens; where the cows sleep and where the water is gathered (it had been a very dry winter so there was very little water collected); and then finally we had a tour of the sitting room and the kitchen. 

This tour is very much in line with other homes we visited around the Meru outreach. We hope to make clean cooking a priority as Naweza moves forward and focuses on health promotion in this community. 

Here's Rosaline and her amazing tour! Rosaline, the next Anderson Cooper! 

~Tania

Day 5: Outreach in the community: Health promotion

Tania Haas is the health and wellness writer at Medcan. She produces the monthly newsletter and the Medcan.com articles found here 

On our February trip, out of the six team members, we were lucky to have four clinicians. Stacy was one of the two non-clinicians, and I was the other. Stacy was very busy working on the business relationships and strategies that make Naweza a sustainable organization. As for me, my role was to be the documenter, interviewer and surveyor of the trip. I was to witness, observe, record and report. You can read my blog from Day 2 here, and see the videos I produced in the previous and following blogs.

But on Day 5, our outreach day, when there were hundreds of people waiting to be seen for hours on end, I really wished I was a clinician so I could help lighten the load and serve more people. Instead, I did the next best thing: health promotion. In the morning, I sat for hours with women, men, teenagers and children. In the afternoon, I toured local homes to document the design and impact of their kitchens so that people back at home could have a better idea of the quality of life of many of the Naweza patients. This is my report. 

Helping people help themselves

The WHO defines health promotion as "the process of enabling people to improve their health through improving control of modifiable risk factors." Health promotion goes far beyond health care. It increases health awareness for the public and policymakers in all sectors and directs them to be aware of potential health consequences of personal choices.

At Medcan, I act as a resource for people who want to live their best life. If they are ill - how can they get better? If they are well, how can they become great? For example attain their health goals through improved sleep, strength or mental resilience?  Over the last three years, I've interviewed physicians, psychologists, chiropractors, researchers, fitness trainers, registered dietitians. Before Medcan, I worked at Mount Sinai and Sick Kids hospitals in Toronto, and so over the years I've collected a lot of health and wellness insights. 

After all the clinicians and nurses were settled in their individual rooms, I surveyed the setting and set up a health promotion station under a tree. 

With a little bit of shade offering us a bit of relief, I led a Q&A session to help pass the time as dozens of patients waited to be seen by a Naweza doctor. I likened it to the webinars we host at Medcan, where I was playing the role of knowledge translator. I told the 30 or so people gathered before me that I was not a nurse nor a doctor, but I could pass on information that I've collected as a journalist. 

Tania leads a dynamic Q&A session while local community members wait to be seen by Naweza doctors and nurses.

With the help of my trusty translator, Rosaline, we went through the A - Zs of health topics I've covered for Medcan.com.  One of the first questions I was asked was related to sleep. "How can they get better sleep? How can I stop my mind from racing when I am trying to sleep?" This is a common question in Canada as well, and I've written numerous articles on it. So I talked about the importance of sleep hygiene, including turning off all phones and televisions a few hours before bed; limiting caffeine intake to before 2pm; reducing stimulating sounds or smells in the bedroom; or starting a bedtime ritual where you journal your thoughts on paper before turning off the light. We discussed the concept of meditation and mono-tasking -- focusing on one task at a time. 

From sleep, the conversation turned to technology. While few sub-Saharan African communities have adequate medical resources, most have a strong mobile signal (96 per cent of the world is connected by a cell phone).  So cell phone addiction is as much as a problem in Kenya as it is in Canada.  We talked about how can you best manage technology so it doesn't manage you, the main point being: Loss of control is the hallmark of an addiction.  We talked about the pros and cons of leaving your cell phone out of the bedroom; of taking "technology breaks" throughout the day, and especially at night. The mothers of the group were especially vocal about their teenagers using cell phones too much -- and so we discussed how a digital device can be much more than just entertainment or education, it can be a window to the outside world.  That being said, you may be using your phones or computers too much if you are noticing slipping grades, hostility, highly sensitivity, strong preoccupation with the phone and not being interested in formerly enjoyed activities. The teens were reminded that true freedom is the ability to choose. 

After technology, there was a question about lower back pain. Many of the women work in the fields in order to have food on their table, and a lot of their tasks require them to bend at the hips. Many of them said they suffered from lower back pain -- much like Canadians who suffer from musculoskeletal injuries. So, here, I took a cue from Andrew Miners, the director of sports and rehabilitation at Medcan, and discussed how movement is medicine. 

I displayed a few exercises and encouraged the audience who gathered to work on their core strength. (I'm also a certified yoga teacher so my teaching core exercises wasn't too much of a strength). My demonstrating the exercises triggered a lot of laughter -- and I hope some consideration to move and strengthen more. 

We covered numerous other topics: constipation and diarrhea; the benefits of fibre and eating greens; how sugar alters the brain and the persuasive powers of soda pop advertising; the importance of drinking enough water; the dangers of cooking in a non-ventilated kitchen; and so on. The desire for health information was very high. Many questions were asked and a lot of discussion ensued. 

I wondered how much health promotion is available in their communities, on their radios or online. I took some notes on how to make the presentations stronger and more effective for next time: include visuals, posters and have more group or partner work. Rosaline was very enthusiastic and maintained the audience's attention throughout. As I've said before, without her, my outreach would not be possible. 

In the afternoon, Rosaline and I left the shade of our narrow trip and ventured out to tour the kitchens and cooking areas of the local homes. 

Videos and photos in the next blog. 

~Tania

Day 5: Outreach Day - Guest Blogger: Dr. James

[James Aw, MD, is the Chief Medical Officer at Medcan with a special interest in adult medicine and global health]

Here I am with Nurse Lydia and Nurse Hagai at the end of the outreach. The day started with lots of people eager to be seen at our outreach in the Meru district.

It was great to be back at Lewa and reunite with the Kenyan clinical team.  Today – the team went on a community outreach and were paired with up with clinical nurses seeing patients in the Meru district.  The Kenyan clinical team also acted as translators for Swahili and the other local tribal dialects.

The physicians (Sue, Michael, me) and optometrist (Sidiqa) focused on medical consults while the rest of the team were busy with training, community health surveys and logistics (including crowd control).

I saw a nice variety of cases today with my Kenyan clinic nurse partner Hagai at the outreach.  A few of them stood out.

The skies were clear and the lines long on this outreach day. While local residents and people who had travelled hours to see us waited at two separate entrances, I was inside treating patients who had been triaged by the local and Naweza nurses

Stacy Francis and the Lewa nurses (at bottom left) upon arrival at the outreach location. Patients wait to be introduced to this outreach's clinicians

Registered Nurse Vanessa is part of the triage process of patients before they reach my door

Case 1: Man with type 1 diabetes

The first case of the day was actually at Lewa Clinic before the community outreach began.  He was a 21-year-old known Type 1 diabetic who had stopped taking his insulin for a few days and was vomiting and dehydrated (he ran out of his insulin). 

His blood sugars were quite elevated and he was dehydrated.  He was vomiting, dizzy, dehydrated and feeling terrible. The team tried to set up some IV lines – but his veins were collapsed and it was very difficult.  After multiple attempts, we were able to secure a couple of IV lines and pushed fluids to get him rehydrated, and normalize his sugars.  We then could reintroduce the insulin while monitoring his potassium levels. 

This case was particularly timely because I had just days before given a couple of talks on high sugar emergencies (hyperglycemia and diabetic ketoacidosis) and diabetes.  However – it also reminded me of the challenges of living with diabetes in remote areas of Kenya. 

“Some locals will dig holes in the ground to store their insulin – but there is no guaranteed temperature control, which can affect the efficacy of the insulin. ”

— James Aw, M.D. on the challenges of living with diabetes in remote areas

Wooden panels and a small chimney made of corrugated steel are typical characteristics of the cooking areas for the residents of Lewa - the set up can lead to respiratory and vision problems, of which we saw a lot among our patients during the outreach

Insulin should be refrigerated – but this is not possible in remote areas. Some locals will dig holes in the ground to store their insulin – but there is no guaranteed temperature control, which can affect the efficacy of the insulin. If a Type 1 diabetic can’t get regular access to insulin – then they will keep falling into these preventable diabetes emergencies.  Also – if patients have poor control of their diabetes then they will have an increased probability of death or end-stage complications.  The supply chain of insulin and storage of insulin in remote communities remains a challenge in Kenya.

(The following video is a quick tour of a local resident's cooking area, and may offer a better understanding of the living conditions of some of my patients.)

Rosaline, Infection Control and Facilities Manager at Lewa, gives Tania Haas, Documenter and Engagement Survey Lead, a quick tour of a local resident's cooking area. The ash and smoke from the open fire leads to widespread respiratory and vision problems among the community.

Case 2: 20-year-old woman with joint pain and muscle wasting 

Another interesting case in the community outreach was a young woman in her 20s who had been suffering for years with joint pains, rigidity, weight loss, fatigue and muscle wasting. She told Hagai and me that she was unable to complete school because of her symptoms. 

Young adult woman visited me with complaints of chronic joint pain and weight loss

When examining her – she had swollen inflamed knee joints, muscle atrophy and rigidity in her upper limb movements.  The chronic inflammation was wearing her down.  It looked like Juvenile Rheumatoid Arthritis (JRA).  I brought in the other clinic nurses and my colleague Dr. Michael to do a case review. 

She reminded us of another case at Lewa Clinic of a young adult who had end stage Juvenile Rheumatoid Arthritis who we assessed on previous trips.  Unfortunately – that patient had more advanced disease and wasn’t a candidate for immuno-suppressive treatment (i.e. methotrexate).

The hope was that early detection of JRA might help this young woman. 

We decided to refer her to a rheumatologist in Nairobi to assess her candidacy for specialty drugs to prevent end-stage complications.  We decided to bring her to the Lewa Clinic and get some baseline blood work on her and start her on some prednisone with follow up to treat her symptoms. 

“This woman reminded me about the importance of early detection, case management and education of the Kenyan clinical team.  Case reviews on past cases helped us to deal with this particular patient.”

Case 3: An elder with a massive foot lesion

An 80-year-old man showed up to the clinic limping with a cane.  He had a massive growth on the sole of his foot that was bleeding.  It didn’t look like an infectious lesion and we ruled out diabetes with a random blood sugar.  He looked cachetic (cachectic [kuh-kek-see-uh] means general ill health with emaciation) and weak – but had managed to live until 80.  He was a resilient man but the foot mass was impacting his quality of life. 

On examination, his foot lesion was a massive growth that looked like a form of foot cancer. (It was likely benign because he was living into his advanced age. That being said, it would have been much easier to treat if it had been caught much earlier in the disease process.)  We decided to refer him to a local hospital to see a surgeon who could hopefully sample the lesion (i.e. make a diagnosis) and debulk the foot mass so that it would improve his quality of life.  We dressed the wound and arranged the referrals.

Case 4: Young woman with bilateral swollen lower legs

Another case that was interesting was a young women who presented with bilateral swollen lower legs.  On examination – the swelling appeared to be of the lymphedema type.  One of the causes of lymphedema in tropical medicine is a condition called filariasis, which is treatable.  The large swelling of the legs from the infection transmitted from a mosquito bite is also known as “elephant-iasm” because the lower legs become so big. 

This case of bilateral swollen lower legs had become so severe that the patient was having trouble walking and was avoiding social interaction

After consulting with the local nurses from the region, however, our position changed. The Kenyan nurses stated that filariasis is more prevalent in coastal Kenya.  With this information, we decided to send her to a local hospital (Isiolo Hospital, which we visited on Day 2) for more advanced testing to determine the diagnosis (either by looking at a sample under the microscope and/or a blood test).  If she is found to have the condition, then it can be treated with medication (i.e. DES), which would drastically improve her quality of life.  It was an interesting case of tropical medicine that required team work on determining the diagnosis and securing the treatment.

Outreach Feb 2018: another day fascinating day of rural medicine and collaboration

We saw several more cases at the outreach and the lines were very long.  The types of cases that I saw were more focused on general adult medicine, and included a wide range of conditions like cardiovascular disease, diabetes, thyroid disorders, skin tumours, stomach disorders, abdominal pain, prostate diseases and lots of musculoskeletal complaints (osteoarthritis and aches and pains from hard work as farmers and labourers).

It was another fascinating day of rural medicine and collaboration with our Kenyan colleagues. 

Video from Day 3 when Nurse Hagai and Dr. James discuss the highlights of the Continuing Medical Education presentations and the subsequent group learning at the Lewa Clinic

Day 5: Outreach in Meru District - Serving patients until the sunset

Feb 26, 2018 - Meru District. 
Team Naweza drives to the Ntumburi area of Kenya, a few kilometers from Lewa, to set up a medical outreach.

Jambo!  Today is the day of Outreach February 2018, which means Team Naweza will be visiting a village, taking over a local medical clinic building with our staff and resources, and literally see hundred of patients until the sun sets. 

When we are at the Lewa Downs clinic we are able to see fewer patients and take our time with each and every one, which serves as great learning opportunities for the nurses.  However at the outreach, the focus is on seeing and connecting with as many patients as possible.  We want to build a good relationship with the community so that they know we understand all the nature of their most urgent needs. 

Although our main initiative at the moment is chronic disease, the people here are dealing with all sorts of acute issues and other conditions that require referral to a hospital.   Our goal is to establish trust that we are listening to them and here to help them where we can.    It is also an opportunity for us to keep our finger on the pulse of what the community is dealing with on a daily basis so that we can better develop programs.

Feb 25, 2018 - Ntumburi, Meru County. 

Team Naweza (local clinicians and visiting members) introduce themselves to the community with the help of a translator before the medical outreach begins

We arrived at the village to at least 100 people already waiting to see the doctors, with more continually filtering in.  It was very hot with little cloud cover and very few trees to provide shade and a reprieve from the heat.  The tensions grew quite high as people were thirsty, hot and tired of standing.  I couldn’t blame them!  The doctors were trying to go as quickly as possible.  But unfortunately there were several complicated cases as this village appears to be underserved and there are many many sick people; some quite ill.

Dr. Michael speaks Swahili, and so he can connect quite quickly with local residents, here at the beginning of the outreach

Dr. Sue and Phoebe consult with patient

Dr. Michael consults with a patient

The demand for personalized care is high

Dr. Michael is a pediatrician and his expertise is much appreciated by the clients

Before lunch, Tania and Rosaline conducted a health literacy Q & A session under one of the only trees in the area

Inside, Vanessa was conducting a triage (here, she is testing that the scale is working) with local nurses in order to properly direct the patients to the right doctor

Some of the issues we saw included ringworm; juvenile idiopathic arthritis; a large tumour on the outside of a heel; psoriasis; thyroglossal duct cyst; and anxiety disorder.  It's hard to imagine that the nurses here are expected to diagnose and treat all of these conditions with little to no support.  The pressure on the staff here is enormous to perform functions that are way beyond their education and training.

Dr. Sue saw a 17-year-old girl who presented with a large mass in her breast.  She received previous treatment from a local clinic.  They misdiagnosed her with mastitis despite the fact Dr. Sue saw no signs of an infection.  Their treatment strategy included antibiotics and a calcium supplement, which given the symptoms seemed highly insufficient.  She has sent her for follow up and is hopeful it is just benign fibroids as cancer in such a young woman would be highly rare.

Lydia testing the visual acuity app. You can see the health Q&A session in the background

Dr. Sidiqa

We were able to hand out 25 pairs of reading glasses today

One of the highlights was that we’ve introduced a mobile visual acuity app to Lewa whereby Lydia is able to screen and assess a patient’s visual acuity with her phone.  On another app she is able to enter the patient data, which is stored in the cloud and Dr. Sidiqa is able to access and review the results virtually.  The patients who we identify as requiring a prescription are told to come back on Lewa’s designated monthly vision clinic day when our Naweza sponsored optometrist is able to write the prescription.  Naweza has identified a generous supplier of new glasses, which are at a third of the typical cost.  We also continued training on prescriptions for reading glasses and were able to give away 25 of them. 

A patient tests out her new glasses to determine if her vision has improved. Naweza continued training on prescriptions for reading glasses and were able to give away 25 pairs this outreach. 

Tania had an exciting day of visiting the nearby village and meeting farmers and having tours of their homes.   They were very kind to allow us into their homes and chat about their everyday life.  Tania will write about her experience in her own blog.  And I think she has some great videos too!

After lunch, Tania and Rosaline, co-surveyor and translator, walked a 2km radius around the clinic and interviewed local residents about their health concerns and their experience at the clinic. Some residents also gave Tania and Rosaline a tour of their cooking areas, which are often poorly ventilated and the smoke/ash leads to respiratory and vision problems.

Late afternoon at Ntumburi clinic and many patients still wait to be seen by a Naweza clinician. Any patients who were not able to be seen were invited to travel to the Lewa Clinic the next day for care.

We were quite pleased to see the selection of drugs that Lewa brought to the Outreach.  We have been working with them over the years on making sure that when we go on an outreach that we actually bring the drugs that our doctors prescribe.  When we first began 5 years ago the selection of drugs was sparse.    The reason for this was a combination of lack of planning, training as well as limited funding.  Naweza has committed to Lewa to sponsor the outreaches we do when we are here.  This includes everything from the costs of transportation, lunches for the staff and drugs dispersed to the patients.

Naweza clinicians have limited time to see patients. Once the sun goes down, there is not enough light in the building to continue to see people.  Also, patients do not like to travel in the dark, so they must leave before the sun sets to make the journey home by foot or vehicle, often hours away.

Our outreach ended when the sun went down and we no longer had light. Around 7 p.m. were literally in the dark.   It had been a very long day.  Unfortunately we couldn’t get to all of the patients. 

So we told those who hadn’t been seen to come to the Lewa clinic tomorrow if possible.  Our goal is always to see everyone, but because there is no electricity in the buildings that we usually work out of (this building being the local Meru Clinic), we literally are left in the dark. 

Vanessa Churchill, Registered Nurse, and Dr. Sue Wong have big smiles at the end of the outreach

Lydia, Dr. James and Hagai toward the end of the outreach. James' blog on his day is next

We use our iPhone flashlights as long as possible but eventually that is not enough.  It is a reminder that we can’t help everyone and that we can only do what we can do.  It can be very disheartening when you feel like you are letting people down, especially after such a long hard day.  And even though you know that you saw way more patients than you didn’t, you tend to remember the faces of the ones you didn’t.  We hope they come to the clinic tomorrow and they have an opportunity to have their issues addressed.  It was the best we could do.

Tomorrow we will begin our day with a meeting with Mike Watson, CEO of Lewa, in order to discuss the future of the Lewa/Naweza relationship.  Then we have CMEs led by Dr. James and Dr. Michael.  And we finish with clinical consults for the rest of the day.  And hopefully we will see many of those faces that we couldn’t get to today at the Outreach!

That’s all for now.  Thanks for reading!

Stacy :)

Day 4: Medcan Podcast "The60" Special Kenyan Edition featuring the co-founders of Medcan Naweza

Dr. James Aw, Chief Medical Officer and Co-Founder of Medcan Naweza, interviews fellow Co-Founders Stacy Francis and Dr. Michael Hawkes. Recorded at the Lewa Conservancy on Feb 25, 2018. 

Dr. James, Dr. Michael and Stacy on Day 1

The podcast recording session on Feb 25, 2018, Lewa Conservancy.

Day 3: Reproductive health, vision tests, mobile health program and more

Jambo! 

Our second full day began with a beautiful breakfast served by the lovely staff and lots of laughs at the table.  I must say I feel so grateful to be a part of this amazing group.  Smart, funny and passionate about our mission of improving health care for this community.  They work really hard and encounter stressful situations and yet always keep smiling through it all.  It is truly inspirational.

Dr. Sue leads Naweza's longest ever CME to a rapt audience. There were many questions on gestational diabetes, hypertension in pregnancy and contraceptives, STIs and infertility. 

After breakfast, Dr. Sue led her CME on gestational diabetes, hypertension in pregnancy and contraceptives, STIs and infertility.  It was a full house, including Emily, our Community Health Worker, (and how could I not mention little Leon again).  Dr. Sue spoke for 3 hours with no break (a Naweza record).  The staff was especially curious about STIs and infertility asking many questions about their current and past cases.  It was highly interactive and I think very helpful to them.

---

Recorded February 2018

Vanessa, Michael and myself met with Phoebe the clinic manager to review the M-Health Study.  One of our goals on the trip is to ensure the screening process is running properly and that they are enrolling the right patients, prescribing the correct drugs, at the right time, etc.  We’ve identified a couple of areas that need clarification, but for the most part we are pleased with the process.  

The M-Health Study at this point is comprised of two studies, which both screen the community for their risk of a cardiac event caused by chronic disease in the next 10 years.  The first study, Afya Chat 1 (Afya means “health” in Swahili) asks 5 questions about the patient:

• gender
• tobacco use
• age
• blood pressure
• and if you are diabetic. 

The second study, Afya Chat 2, asks the same questions except ...  instead of stating 'Yes' or 'No' if you’re diabetic, Emily (our community health worker) takes their blood sugar level and inputs this number into the software program.  We want to see if the number of patients who are at risk increases if we add this level of accuracy to the data input. 

Emily has screened 672 patients and in order to ensure a valid sample size; our goal is 1192.  We're over halfway there!  

She will finish later this year at which point we will stop the screening process and focus on follow-up and management of those patients through our EMR system.  So far we have identified 13 people or 1.9% of the people screened as requiring treatment.  At this rate we will have just under 30 patients who will be treated for chronic disease who before the screening had no idea that they were at risk.

Dr. James and members of the Lewa clinic consult in between patients

Michael, James and I also had the opportunity to meet with Dr. Butt, the doctor who volunteers at Lewa every 2 weeks.  In fact he has volunteered every two weeks for the last 14 years!  We had met him back in 2013 on our first trip here at the clinic.  Today we learned from him that muscular skeletal and nutrition are two areas that he thought the community could benefit from.  A few years back, professionals in these very fields joined the Medcan Naweza trip --  a chiropractor (read Chiropractor Andy Miners' 2015 blog entry here), a fitness trainer (Rob Turner) and registered dietitian (Alex Friel) and found their contributions to be very well received by the community. Many of the people here do hard farm labour and their tools are not ergonomic, leading to many injuries and strained joints and muscles.  Providing education around exercises and stretches to minimize injury and muscle strain are the best alternative to medication in this resource limited area.  In fact, it’s the best alternative anywhere you might live!

Local residents seek shelter from the rain under the Lewa clinic awning as Medcan Naweza doctors serve patients inside.

After lunch back at Ngiri House we returned to the clinic for an afternoon of seeing patients.  I sat in with Dr. Michael, who saw children.  We had a variety of issues including nephrotic syndrome; pitting edema in a three-month old; and three patients with fungal concerns and various respiratory illnesses.  Dr. Michael again uses an interactive style of teaching with the nurse who is also acting as his translator.  He takes his time with each patient, posing questions and different scenarios to the nurse in order to maximize the learning opportunity.

---

Indoors, Dr. Sidiqa examines patients' eyesight and discusses the Community Health Worker screening program

Dr. Sidiqa saw optometry patients who complained of red and itchy eyes, required reading glasses and prescription glasses.  She worked with Lydia, Lewa’s head of optometry and continued to provide training and education.  Dr. Sidiqa is trying to prepare her for the vision clinics that she will be running at the schools whereby she will screen the student’s visual acuity and will refer them to the clinic if they require glasses.  Naweza will sponsor these clinics and pay for any prescription glasses that are required.

When the rain stops, Lydia leads eye examinations outdoors.  

School children take turns testing their vision with Lydia, Lewa's Head of Optometry

Tomorrow will be a full day of meetings with the team as we prepare our strategy and presentation for when we meet with the CEO of Lewa on Tuesday.  It will be a day of number crunching, modeling and lots of discussion of what we’ve learned and how we believe Naweza can continue to add value to the Lewa Community.

Now it’s time for dinner with the team.  It’s one of our favourite times of the day as we get to share stories and photos of all of the memorable moments.  And there are many as you can’t help but be touched by all of the encounters the day brings you in this beautiful part of the world.

That’s all for now.  Thanks for reading! :)

Stacy

Day 2: Afternoon - We return to Lewa for the first time in 2018, our 8th time since we started

The Lewa clinic

A warm greeting as we walk up the driveway

Rosaline greets familiar faces ... here with Dr. Michael

... all with a hug and reference to former encounters, here with Dr. Sidiqa, Stacy and Rosaline ...

Her enthusiasm is contagious with Stacy

...and she makes even the newest team members feel at home. Rosaline greeting Tania

After a beautiful lunch the team headed to the clinic for the first time on this trip.  We saw many familiar faces and a few new ones.  It was a warm welcome, especially from one of my favourite people, Rosaline, the clinic “go to” person for just about everything.  She came barrelling down the walkway with the biggest smile giving us all big bear hugs.  She even hugged Tania who is new to the team.  So lovely.

Dr. James starts off the CME sessions in a open-air lounge area on the grounds of the Lewa clinic

Attending the session from left: Dr. Sue, Vanessa, Joffrey (nurse), Hagai (nurse), Clarence (lab), Miriam who works in the pharmacy, Eric (lab), Phoebe (clinic manager), Dr. Sidiqa. You can see Stacy in the far back holding Leon. 

Attending the session from left: Dr. Sue, Vanessa, lab tech, Haiga, the nurse from a nearby clinic, lab tech, Miriam who works in the pharmacy, Eric who is also a lab tech, Phoebe, Dr. Sidiqa. You can see Stacy in the far back holding Leon. 

Life imitates art

Is your patient, green, yellow or red?

We quickly got started with Dr. James’ CME regarding Diabetes and Hypertension.  The doctors have found an interactive approach works the best and pose questions and scenarios to the clinic staff.  It is a good strategy and keeps them engaged.  They have many opportunities to use cases they have encountered at the clinic to get the opinions of our doctors in how they would approach the treatment strategies.  It was a rich conversation and I think everyone found it super helpful.

Medcan Naweza's youngest teammate: Leon, Emily's son

Emily, the community health worker, sits with Benard and

Emily our Community Health Worker who is screening the community for chronic disease risk was working with Benard, our research representative.  He is auditing our M-Health study, Afya Chat and ensuring that Emily is adhering to the study guidelines.  Emily is actually a new mother of a 3-month old little baby named Leon.  Absolutely beautiful.  However a bit of a challenge for her when she’s trying to focus with Benard.  So I happily stepped in to hold this little doll while she worked with him.  Honestly the sweetest baby.  And we are so grateful (and impressed!) that Emily has continued to work and meet all of her Naweza responsibilities despite the fact that she is a new mother.  A testament to the strength of character of the Kenyan people.

Miriam sees "green"

Our tech guru Danet leads his session

We wanted the clinic staff to be part of this iterative process of constructing the software so that the final package will meet their needs and wishes.

Dante explains the app that will make it easier for community health workers and clinicians to collect and track data

He will present the second draft in one month and we will again provide more feedback. 

Dr. Michael discusses the M-health app

We are really excited about the prospect of managing these patients and hopefully ensuring more positive health outcomes than if they continued on with no intervention.

The second CME was spent presenting a first draft of our EMR software program to the clinic staff by Danet.  The purpose of the EMR is to manage the patients that we identify through our SMS technology as at risk of chronic disease. The EMR will enable us to monitor what drugs are prescribed, compliance and improvement in health indicators.  We wanted the clinic staff to be part of this iterative process of constructing the software so that the final package will meet their needs and wishes.  They had a lot of useful feedback that Danet is going to incorporate into the program. He will present the second draft in 1 month and we will again provide more feedback.  We are really excited about the prospect of managing these patients and hopefully ensuring more positive health outcomes than if they continued on with no intervention.

We ended with an 80-year old man who came in complaining of a severe cough for the last 3 days.  He presented with crackling in his lungs and wasting.   Dr. Michael, a communicable disease specialist, was worried that it was in fact TB and warned everyone to that it would be prudent to leave the room as it is highly contagious.  The patient will be tested tomorrow to rule it out and the diagnostic investigation will continue (Update: a blood test ruled out TB). 

Tomorrow’s agenda includes a meeting with Dr. Butt, Lewa’s doctor who comes to the clinic every 2 weeks.  We met Dr. Butt in 2012 when we were on our first trip here.  So after 7 trips we thought it would be a good idea to visit with him again and review our program and plans going forward.

Dr. Sidiqa will meet with the optometrist that Naweza sponsors to come once a month to hold a vision clinic for the community.  He is able to provide prescriptions for glasses utilizing the autorefractor that Naweza donated last year.  He is also able to provide education and counseling on eye health to both the patients as well as Lydia, the clinical officer who is in charge of optometry at Lewa.  His cost is $50USD per month.  A small investment in the eye health of the community.

We will also have 3 CME’s by Dr. Sue as well as Benard who will present findings from the Chronic Disease Program.  Our thought is to maintain a healthy line of communication with the clinic staff on all of our programs and include them in our discussions.  They have the best insight into their patients and and will be our best tool to ensure we are making the most impact with our initiatives.

I'll leave you with a 20 second video filmed in the clinic's courtyard around dusk today as the doctors were wrapping up their consults. Until tomorrow, thanks for reading and lala salama! :)

Stacy

Day 2: Morning - Our first visit to Isiolo Hospital

[Hello Medcan Naweza blog readers – Stacy asked me to takeover the blog for Day 2 a.m., and I'm excited to do so! I'm Tania Haas, content producer at Medcan. I've been volunteering with Medcan Naweza in Toronto for 2+ years and this is my first time in Kenya. Joining this Naweza group is a dream come true for many reasons given past studies in local and global health equity. Stacy's blog for the afternoon of Day 2. follows. Hope you enjoy, and thank you for reading]

Pace yourself: the journey may not be as expected

Ahead of our trip, Jennifer Mannik, Executive Director of Medcan Naweza, prepared a detailed itinerary and schedule with our days organized down to the minute.  We had to maximize our time here!  What I've learned in my first few days is this: get your sleep and manage the jet lag as soon as possible because once at the base at the Lewa Conservancy/Lewa Downs Clinic, the pace builds and doesn't really stop. Add to that: remember to take your medicine, enjoy the freshness of cold showers because you can't quite figure out the shower knobs, and all the new sounds and buzzes that are animals/not your cell phone. 

We have so much to do in so little time, it helps to be agile, flexible, and ready for a long haul or quick sprint or both in succession. And so with that this is how I remember the day ... 

Open-air workspace: office, dining table and our monkey and impala neighbours graze nearby.

Naweza meets leaders and clinicians at local county hospital 

Over breakfast we had to be on guard for the local monkeys who see food on the table as an invitation to eat. As Grace, one of the workers at Nigiri House said, “monkeys get hungry too.”  Can’t argue with that. And so after a delicious breakfast I worked on my monkey-go-away noises. Soon thereafter Ben arrived with a car for the scheduled trip to Isiolo Hospital – the county hospital where many of Medcan Naweza's patients are referred to for follow-up care.

Ben's car could sit six comfortably and seven legally. Dr. James Aw (Chief Medical Officer, Medcan), Dr. Sue Wong (OB/GYN), Dr. Michael Hawkes (infection control, paediatrician), Danet (EMR technology lead), Hagai (a nurse we've worked with during past trips) and Benard (our ethics and research study advisor) were all set to go. As the car was pulling onto the road, I was called to join. I grabbed my bag of equipment, water bottle and squeezed in the front seat between Hagai and Ben.  Stacy, Vanessa and Sidiqa stayed at Ngiri House for a much-needed planning and communication session to optimize the time we have with our collaborating partners.  And off we drove ... 

Going beyond the conservation grounds to Isiolo Hospital

The hospital is 23 kilometres from Ngiri House. Google Maps says it should take around 21 minutes by car. That prediction did not take into account the careful driving required to navigate motorcyclists swerving on the dirt road and making stops at the roadside, corrugated metal-roofed homes ... or the traffic jam around Isiolo’s city centre where locals were shopping for fruits and vegetables.

Isiolo City Centre

Woman standing by road en route to Isiolo Hospital

As we waited in our van behind other idling cars, we could hear men preaching through a megaphone near a mosque while women shopped for goods wearing hijabs, niqabs, and bright Kenyan patterns. A man on a motorcycle zoomed by flashing his black and white patterned scarf.

This congested and lively urban scene was a direct contrast to the calmness and green-brown vegetation where we are based; and fair depiction of the day-to-day life of the people we strive to serve.

We arrived at Isiolo Hospital in around 45 minutes, enough time to be exposed to a brief view into the daily life of Isiolo residents and those who live near the Lewa Downs Conservancy.  And I arrived to the hospital with many questions ... 

What are the social determinants of health affecting the clients we see at Lewa? 

... like how do the patients who we see at Lewa Downs arrive at Isiolo Hospital when they need urgent or specialized care?  Many of them travel to the Lewa clinic by foot and/or Lewa's shuttle for hours because they don't have regular access to a vehicle. How would they negotiate the additional 25 kilometres when they need urgent or specialized care?  This led to a discussion about what determines health in this part of the world.  

Dr. Sue and I spoke about the social determinants of health. Those are the economic and social conditions, or the health promoting factors, that influence individual and group differences in health status (as opposed to the individual risk factors or genetics).  One study of a region around 200 kilometres from Lewa found the factors that unevenly affected the health of the most vulnerable segments of the population were: water supply, sanitation, solid waste management, food environments, housing, the organization of health care services and transportation.  For the clients at Lewa, that makes me wonder: 

• Food environment: can people access the food that will boost immunity or give them strength? 
• Housing: is the design of the patient's home safe and sanitary? Or does it promote injuries and transmission of infectious diseases?
• Organization of healthcare services: is it easy or difficult to access emergency care? How long must people wait to be seen at clinics they spent hours travelling to? 

These are questions that we hope to answer in our proposed research including the quantitative Community Needs Assessment and the qualitative Community Engagement Survey. (Tomorrow I start the Engagement Survey with my co-surveyor, Rosaline, a Lewa employee and a woman I have yet to meet.)  But I digress ... back to the hospital tour ... 

Hagai (nurse at Manyangalu), Dr. Hawkes, Eric (lab tech at Manyangalu), Benard, Dr. Aw, Dr. Kiluova, Dr. Wong at Isiolo Hospital

Dr. Mark Muriithi, Dr. Magara Marvin, Dr. Kimru Kimathi G, Hagai,

Members of the clinical maternity team and guests at Isiolo Hospital

Touring the maternity ward and paeds rounds with Nurse Faria and Deputy Matron Magdalene

Dr. Wong took an interest in the staff's fetoscope, the tool used to hear the fetus' heartbeat

Dr. Wong in the maternity ward with Clinician Motua Tingos

Hospital tour: with local doctors and nurses

We entered after a brief security review by the armed guards and were introduced to our host Dr. Steven Kiluva, Medical Superintentent, who told us more about his facility.

Drs. Aw, Hawkes and Wong were all very impressed by the size of the facility (Dr. Kiluva said it was 23.52 HA, hectares, but that seems a little too big so I must have misunderstood) and breadth of services offered.

Isiolo Hospital is a typical, full-service hospital with around 40 doctors, including a surgeon, paediatrician and OB/GYN specialist. Fourteen doctors are currently practising to become specialists.  The hospital also hired four pharmacists and two dentists. It has two operating rooms; 150 inpatient beds and an ultrasound machine (but no radiologist).  The most common conditions seen include HIV, respiratory conditions and malaria.

While HIV awareness about prevention has spread throughout the region, adherence to medications remains to be a challenge. The high rate of respiratory conditions in regions like this is linked to poor ventilation in homes where families often live and sleep in cramped quarters near smoke-emitting cooking appliances or open fires.

Deputy Matron Magdalene took us on a tour of the post-natal and maternity wards, where the doctors were briefed on complex cases including two planned caesarean sections later that day.

During the maternity tour, Dr. Sue asked to see the fetoscope, the tool used to hear the in-utero heartbeat (in Canada we use an ultrasound). A common consequence when using this tool, we were told, is that the existence of a twin is often only discovered during the birthing process.

Mother Charity Kajuju and daughter Blessing at 7 months in the post-natal room at Isiolo Hospital.

 With her permission we took this photo and share her story.

Mother Charity Kajuju and daughter Blessing at 7 months in the post-natal room at Isiolo Hospital

Golden opportunity to prevent HIV transmission: Blessing and charity’s story

Dr. Michael pointed out a mother-daughter success story in the corner of one of the maternity rooms: Mother Charity Kajuju and daughter Blessing at 7 months in the post-natal room. With Charity's permission we took this photo and share her story.

Charity is HIV+ and was HIV+ while pregnant. Her daughter is thriving today (as seen with her chubby legs and curious stares), because of her mother’s adherence to medical guidelines during and after the pregnancy. While her child was exposed to HIV, she was not at this time (and will likely not be) infected with HIV.  

Dr. Hawkes explained that Charity likely took all the proper precautions when she learned she was pregnant – taking medication during the pregnancy, breastfeeding (HIV+ mothers in Kenya are encouraged to breastfeed rather than expose the child to the risk of unclean water-->diarrhea if baby formula was to be used) and then weaning the child off breastmilk after three months.  Dr. Hawkes says the balance of risk in Kenya favours breastfeeding.  We met Blessing when she was in the hospital for a check-up on the presence of HIV antibodies that were passed from her mother (and which protect Blessing from contracting HIV). There will be another test at 18 months and then Blessing will officially be considered HIV exposed but uninfected.

Health promotion: vibrant murals and women’s t-shirts

Here are a few photos of the communication signs and health promotion efforts I saw in this hospital. Look carefully at the murals and consider what the messages were intended to be - Benard our research and ethics advisor had some helpful insights. 

Health promotion also comes in clothing: the woman in a yellow vest is Paula, a community health worker who wanted me to photograph the message on her back, which encourages vaccinations. The woman wearing the green shirt, Becky, told me “breast is best” and that’s why she wears this shirt that reads “breastfeeding a key to sustainable development".

Isiolo Hospital operating room

The last stop of the tour was for docs only: Drs. Hawkes, Aw and Wong saw the operating room and theatre, and connected with other doctors and staff available.

After that we rushed back to our car in order to make it back to our group and then Lewa Downs. On our way back to Ngiri House, Dr. Wong and I spoke about the busy and bustling streets of Isiolo and how there are similarities to other highly populated places around the world.  It was hard not to compare the conditions and resources we saw in that hospital to the hospitals and resources we have back at home. But comparisons are not always helpful, and in this case my greatest takeaway was the dedication to care by the community health workers, the commitment to excellence by the nurses and the diligence of the doctors and staff we met to continually work to keep their commitment to heal with care and do no harm.  Also to note was the importance of family: every woman in the post-natal room I toured, had either a sister, husband or friend helping them feed, hold or soothe the newborn as they healed. A universal sign of love and support at the time of a new life. 

Ben, our reliable and talented driver, took a faster route home and we reunited with the rest of Medcan Naweza in time for a late lunch

- Tania

Day 1: Landed safely, got acquainted with our surroundings and prepared for the week ahead

Jambo and greetings from Lewa!  After a full day of meetings yesterday in Nairobi and going into town to buy our Kenyan SIM cards (always an adventure) we flew out of Wilson Airport (had a bird's eye view of Nairobi and the retreat from urban lifestyle) to arrive in the rural plains framed by rolling green hills in beautiful Lewa Downs. 

Waiting for flight at Wilson Airport

Our sturdy chartered flight, expertly piloted by two Kenyan women

Dent, Bernard and Dr. Sue Wong walk to the airplane

All smiles (before turbulence a few mins later)

Classic selfie with Drs. Hawkes, Aw, Rajani and Bernard (some sleepers in the back)

Kiera, largest urban slum in Africa

Kiera (meaning forest or jungle) is a division of Nairobi Area, 6.6 kilometres from the city centre, is thickly-populated region known as the largest urban slum in Africa. The average size of shack in this area is 12ft x 12ft built with mud walls, a corrugated tin roof with a dirt or concrete floor at a minimal cost to rent.  These shacks often house up to 8 or more with many sleeping on the floor.

Agriculture plays an important role in Kenya's economy, followed by tourism

 Over 80% of the population, especially living in rural areas, derive their livelihoods mainly from agricultural related activities.  Agriculture plays an important role in Kenya's economy, accounting for around half of the country's exports. Tea is the main earner, but vegetables, coffee, fruit, cotton and flowers are up there. Anyone know what type of crops are seen here? 

Arriving at Lewa Downs

And it is so good to be back.  At the airstrip, we were greeted by Benjamin our driver and driven to Ngiri House, our home for the next 7 days. 

On our leisurely ride in we came upon a herd of elephants, a large adult rhino and plenty of zebra.  Not bad for an airport transfer! Rose, the property manager was waiting for us at the house with her friendly staff, all shaking our hands and wishing us “Caribou” or “Welcome” in Swahili.

We are super excited to be back here to continue our work with the clinic staff centered around chronic disease, optometry and this time, women’s health.  In addition to the training and education, we’ll also be working on (and hopefully) launching our EMR (Electronic Medical Record), software which will enable us to manage the chronic disease patients we’ve identified through our screening process.

Medcan Naweza Co-Founder Stacy Francis modelling new Naweza t-shirts

Meeting with Phoebe and John

The Team

• Dr. James Aw - Chief Medical Officer, Medcan
• Dr. Michael Hawkes– pediatrician, global infectious disease specialist
• Dr. Sue Wong – ObGyn/surgeon
• Dr. Sidiqa Rajani – Optometrist
• Vanessa Churchill – Registered Nurse, MBA candidate
• Tania Haas – Documenter and surveyor of Community Engagement
• Benard - Research
• Danet – IT developing Naweza’s EMR

We spent the afternoon reviewing the itinerary with Phoebe, the clinic manager and John the Community Engagement officer.  After a few adjustments I think we’ve settled on a solid itinerary, which will enable us to move forward on our initiatives, including interviewing the community on how we can better meet their needs and understanding their perception of the Lewa/Naweza partnership.

Parade of elephants

Naweza always be working

The Feb 2018 group photo

Co-founders having a strategy meeting

The rest of the afternoon was spent on a 2 hour game drive where we were incredibly fortunate to see rhinos (black and white), zebras, elephants, giraffes, baboons, ostriches and unbelievably, the elusive leopard.  In fact we saw 3!  A mother with her 2 babies.  And it was only steps from where we’ll be sleeping tonight.  What a way to start off the week!

Now it is time for bed as we have a big day planned for tomorrow.  Our first morning will be spent visiting the closest triaging hospital to the clinic located in Isiolo, about a 30-minute drive from the Lewa Clinic.  We will be visiting various wards including maternity, female, male, optometry and pediatrics.  Our goal is to make introductions with the staff and become acquainted with Lewa’s primary referral hospital.

Until then, thanks for reading and lala salama!

Stacy