No one will hold your hand here. . .

An IUSM resident and his wife tell of their experiences and the people they met at Kenya's Moi University.

For eleven years the Indiana University School of Medicine has partnered with Moi University in the western highlands of Kenya to offer an exchange experience for medical students and residents at IUSM and Moi. One medical school leads the way in 21st century medicine; the other balances its resources between innovations of the 21st century and rudimentary health care of the early 1900s.

In February Steve Steiner, MD '98, a third-year pediatric resident, and his wife Ellen Gullett, public relations manager for the Indiana Historical Society who had long sought a mission experience, journeyed to Eldoret, Kenya to work in the Moi Teaching and Referral Hospital, part of the Moi University Faculty of Health Sciences. During their work there, they communicated through the Internet with colleagues, friends and family. They have agreed to share some of their observations and reflections with you.

Sent: Monday, February 5, 2001     9:10 pm
From: Ellen

Greetings All! We are safe and sound in Eldoret, Kenya.

Today was our first day "on the job" and Steve and the other residents headed off for the hospital - on foot - a little before 9 a.m. Nothing in Kenya starts before 9. I spent the morning with Sarah Ellen Mamlin going through the seven trunks and two suitcases of supplies that our group brought with us. We then worked on organizing supplies for the daily activity sessions that Sarah Ellen, a former nurse and retired schoolteacher, began last fall on the pediatric ward. Next we went through the tubs of medical supplies that are used when IU team staffs a biweekly clinic at the Boys Rescue Shelter in Eldoret.

In the afternoon, I went with Sarah Ellen and another spouse to the hospital to pass out toys, books, crayons and activity sheets to patients on the pediatric wards. These afternoon sessions are a welcome diversion for patients and their families, who have little to pass the time of day. There are no playrooms or TV lounges at Moi Hospital.

The hospital is just several one-story buildings and every ward is packed with patients - usually two and sometimes even three to a twin bed! The aluminum frame beds are old, the mattresses thin and most beds don't have sheets, although there are blankets. Babies don't wear diapers, other than rags, because no one, including the hospital, can afford them. Actually, diapers are pretty low on the priority list of supplies needed. Staffing is limited too, so clothes and bedding are not changed often. The stench is overwhelming.

Sent: Monday, February 12, 2001    8:35 pm
From: Ellen

Last Tuesday was our first visit to the Boys Rescue Shelter. The shelter takes in boys off the streets (many sniff glue) and provides them lodging, schooling and medical care. The IU team goes every two weeks to run a medical clinic.

Like everything else here, the shelter is not at all what you would find in the States. It's several buildings constructed mostly of wood planks and some aluminum. We noticed many of the boys complained of eye trouble during our visit. If necessary they were referred to an ophthalmologist, but a temporary fix was often sunglasses to protect their eyes from the harsh sun. We later learned that getting sunglasses is a "cool" thing - which might explain the number of eye complaints!

I have started tutoring students in math and English at Lions School, which is within walking distance. In math, they seem to have the same kinds of difficulties as American children. I'm amazed at how well the first and second graders do - they seem to learn some skills sooner than American students.

Our work on the peds ward continues. It's much the same every day - passing out books, toys, crayons and coloring pages. Some days we set up a table in the lobby and do Play-Doh or crafts. The only break the parents/families get from their kids is to do laundry, which they do out back and lay on the ground or over bushes to dry.

Noel and Eli, two abandoned babies who share a bed on the ward, have captured our hearts. Noel was left at the hospital on Christmas and is not doing well. Her prognosis is not good. I've become somewhat attached to Eli. He actually seems quite healthy and was well fed before being left at the hospital. He hardly gets any stimulation, so I try to hold him each time I'm there. He seems to really like being held.

It's amazing that as limited as staff and resources are, the hospital cares for these children. And I often notice other children's mamas checking in on the abandoned babies and even cleaning them up.

Sent: Thursday, February 15, 2001    9:19 pm From: Steve

The work at Moi is both rewarding and frustrating. Every morning, I am not sure who will be sitting up in bed and who will have gone to the morgue. The recovery from cerebral malaria - and its ramifications of coma, high fever, seizures - is still amazing as the patients walk out of the hospital three or four days later. Nearly every patient admitted gets a blood smear for parasites. Reading about malaria and other tropical diseases continues to be fascinating, especially when you see these diseases first hand. I know more about TB than I ever have before. Surprisingly, HIV/AIDS is not talked about on the wards. The prevalence surely must be high, yet it is rare for the Kenyan residents to ask for an "Elisa" or a "P24" which are their codes for HIV testing. I'm still not sure what happens after the diagnosis is made.

Clearly too many children are hospitalized for too long. The diabetics continue to remain in the hospital on BID Lente until their sugars are nearly perfect as no one has glucometers at home, and the Kenyans feel as if the "optimum" sugars and BID Lente regimen should be in place before discharge. With no regard for diet and exercise and the lack of fast-acting insulin use with Lente, it's no wonder the sugars are everywhere, and the patients remain for weeks.

Sent: Tuesday, February 20, 2001    8:10 pm
From: Ellen

I went to Lions School this morning for tutoring and then to the pediatric ward at the hospital in the afternoon. I was sad to learn that baby Noel died last week. Just too ill, too weak, no family to care for her and not enough resources to keep her alive. She fought for a month, but I think it was a real struggle. So Eli now has the bed to himself. I missed him last week when I was sick and was happy to see him today. The nurse came by to give him a shot and said he'd been coughing. I have no idea what's wrong with him. We still don't know if he's HIV positive. Eli always seems hungry, so today we asked for a bottle and I fed him. He drank it so quickly and probably could have finished another one.

Sent: Friday, February 23, 2001    1:59 am
From: Steve

Jambo! Hard to believe three weeks on the Kenyan wards have already passed. Every day brings many new faces, patients and families as well as students and medical officers. It is a joy to work with the students - they relish any new information or teaching they receive.

Teaching on rounds takes a lot of time. We usually round from 9 to 12:30 or 1. This is usually because the faculty arrives somewhere in the middle and spends 20-30 minutes per patient. When you have to round on 40 patients, it takes a long time. Then there is different staff on different days of the week, and the whole cycle gets repeated - the most frustrating part of the rotation.

The peds ward is divided in half, which means each side admits on alternate days, and the families start lining up outside the ward during rounds. The presence of more IU pediatric faculty would really benefit this program, and we must encourage more faculty to make the trip.

The amount of rheumatic fever and subsequent rheumatic heart disease is incredible. There are unbelievable murmurs here. I have never heard such mitral and aortic valve disease - it affects so many patients I meet here. The hospital has instituted EKGs and ECHOs, and the results we see are truly astonishing. Dr. Mamlin reads all the EKGs done at the hospital, then saves the best three or four every day for the residents to read together. It is a tremendous opportunity for the medicine and med-peds residents, but I am enjoying looking at them as well.

Sent: Sunday, March 18, 2001    8:50 am
From: Ellen

Greetings! It's a beautiful Sunday morning and I have time to write until we go to church with Sarah Ellen at the Africa Inland Church.

I have a little group that I've bonded with. There's Peter (5), Davis (about 6), Nicholas (around 12) and Moses (10). All are cancer patients with Burkitt's lymphoma, a type of cancer that causes visible tumors to grow in the face or abdomen. Steve says it's rarely seen in the U.S. They have been at the hospital since we arrived. Then there's Brenda (maybe 18 months), a little girl abandoned by the side of the road. She's developmentally delayed but seems sharp as a tack. The kids and I have gotten into a routine of getting mandazi (doughnut-type pastries) and soda every day at the kiosk.

Moses' family has apparently abandoned him. He has recurrent Burkitt's lyphoma of the abdomen and also has been severely depressed. The first couple of weeks we were here, a man who was his brother or uncle was with him. But then he left and no one has come to see him for more than a month. Moses doesn't remember any phone numbers from his town, so we can't get in touch with his family to see if they plan to return.

He is skin and bones, hardly ate anything last week, and wouldn't or couldn't get out of bed. He also has become anemic and is receiving blood transfusions, which is frightening as the blood testing for HIV is unreliable here. So, even if he survives his cancer, there's the risk of getting HIV.

As Moses goes downhill, we've all tried to spend more time with him. One afternoon as I was leaving, he asked me to bring him a radio. So, of course, it became my mission to find a radio for Moses. When I arrived the next day with his radio, his whole face lit up. He even got out of bed and bathed! And even better, he wanted to go get a soda with us - something he hadn't done for a week.

So off we went. Nicholas pushed Moses in his wheelchair; Moses held "the Brenda," as he called her, in his lap, and Peter and I walked alongside hand in hand. We moved slowly but we had purpose - to buy soda and mandazi at the kiosk. We all then read books - I read the Lion King to Moses and he read Curious George to me. It was a walk I'll never forget.

Sent: Friday, March 22, 2001    6:45 am
From: Ellen

Steve and I returned yesterday from a relaxing and interesting two-day trip to the coast and were met at the airport by Sarah Ellen. She had bad news; Moses had died on Monday, five hours after we'd left for Lamu.

It's interesting how things turn out. Had Steve and I gone away the previous weekend as planned (we had to cancel because Steve got sick), I wouldn't have spent Moses' last two days with him. And surely Saturday and Sunday are some of the most treasured memories that I will take home with me. I'm amazed at how strong he was over the weekend. Apparently Sunday night, however, he started vomiting blood and went down rapidly from that point.

Sarah Ellen said that Moses' parents arrived at the hospital only moments before he died. I don't know if someone got word to them or if it was intuition, but at least they got to see him. Supposedly Moses raised his head up, saw his Mama, and then took his last breath. I think Moses must have known they would return and simply needed to see them again before he went. I believe I passed judgment too quickly on Moses' family. His father said they were organizing a fundraiser to buy more treatments for Moses. (Patients in Moi get the care they can pay for.) And perhaps they have other children that had to be cared for. It's so hard to know the circumstances these families face.

Sent: Friday, March 23, 2001    9:38 pm
From: Steve

Greetings from our final day in Kenya. I have survived another minor GI illness (which no one should expect to come to Kenya without getting) that delayed our trip to Lamu on the Indian Ocean. We snorkeled, ate seafood, and enjoyed the Muslim history and culture of Lamu town, as well as sailing in a dhow.

As I think I've mentioned before, I want to share experiences to help anyone interested in coming to Moi. At IU House, Joe and Sarah Ellen Mamlin have provided a safe environment that includes food and transportation for residents and spouses. Our time is for the wards and the students, where it is needed most. The learning here is unforgettable, mainly because of the disease seen here. And just as in the States, we remember best from patients not from textbooks.

I want to stress the initiative and effort it takes to have a successful time on the peds side. A resident must be comfortable presenting patients and offering differential diagnoses to the staff, as well as leading a team of 20 on rounds and making treatment decisions for a variety of diseases, learning every night by reading about the things we are so unfamiliar with in the States.

No one will hold your hand here… it is up to you to establish working relationships with the medical team - not to be overbearing but to share knowledge.

Joe Mamlin, MD, professor emeritus of medicine at IUSM and the current IU team leader at Moi, is a founding member of the program. As director of the clinical experience of the IUSM students and residents at Moi Hospital, he and his wife Sarah Ellen manage the IU House, hosting visiting faculty, residents and students.