The Problem With Some Schools of Manners!

"Primum non nocere", First do no harm.

This is the premise upon which the whole noble profession of medicine is built. The Hippocratic Oath that graduating clinicians take is a solemn vow that affirms a commitment to this philosophy of only making well again and causing absolutely no harm. This is the whole essence of the Oath. The practice of medicine just like the practice of other professions has its toll on the practitioners.  But whatever the case this is the holy ground whose desecration has to be watched against. Do no harm is thus loosely the first law of medicine. In medicine however so much to the contrary has been observed. Left right center you hear of and experience treatment that is quite the opposite of this noble practice. Why? There is a whole load of reasons..

My interactions with both younger and older colleagues has made me appreciate that indeed old is gold. Nearly all of the elder practitioners strictly adhere to the code of ethics of practice. So do a significant number of the millennials. Every generation has its stock of bad eggs though! But we have so many cases of professional malpractice observed in the younger pool. Why? A whole lot of reasons. For instance it is a silent unwritten expectation that colleagues will not charge you for consultation. You observe this more in the older group. This has not prevented them from having brilliant, profitable and fulfilling practices. But now you have recent graduates who are so aloof, arrogant, petty, commercial and strikingly under-read waddling along hospital corridors with a feeling of self importance...one can only observe them as a scientist would observe a recently discovered specimen of existence.
It has to be noted that many do not really grasp what they are signing up for. This coupled with the very persistent hiccups in the health care delivery system can only worsen an already bad situation.

Some day in December I get this call. That one of my uncles is admitted in hospital, gravely ill. Well I know this hospital well and so my anxiety is sort of relieved. It is not that I have a few people over there but that I am in position to go there myself. And so the next day me and two of my cousins jump in a van and when we arrive at the facility I find out that true to what I heard he is in a pretty bad way. But what strikes me as odd is why despite being evidently dyspnoeic he is on no respiratory support. I inquire from the nurses and they direct me to the doctor on call. It happens that I had called a doctor acquaintance of mine who referred me to this very doc.
He comes after  a short wait and goes to the bedside. He requests for space and time to review the patient. We politely give him time to do his work and so wait outside. One hour later we come back. I request him for a little conference. He tells me what they are doing which is alright. However something is bothering me; the lack of oxygen support. When I point this out he tells me they will do something about it. But that is not even my biggest concern. What is causing the breathlessness? I ask him what he thinks and he tells me the patient is on antibiotic cover for what he believes is a bacterial chest infection. In reality this is ducking the question. "Your uncle is very sick", he bluntly tells me that and I try to shut out what this is supposed to mean.
"I can see that doc, I know you have covered him for bacterial pneumonia but don't you think it could be pneumocystic pneumonia or even tuberculosis?" I ask him having absorbed everything.
"I do not think so!".he responds in apparent agitation. But I press further, "You know PCP is a diagnosis by exclusion".
"I know what I am doing my friend and if you think otherwise then you are at liberty to take your patient elsewhere". He snaps and this surprises me. "But I was only trying to point out something doc, I have not come here to discredit you or any one else for that matter, it was just a polite observation".
Then he does two things; requests for a piece of paper to write the transfer letter and then engages my acquaintance in a long phone conversation, proceeding to tell him how he won't be taught biochemistry and pathology again, he already had enough of that in cold, hostile campus lecture halls!
We step outside for a little deliberation with my cousins and they really cannot start to fathom the perils and trouble of a referal to a public facility nearly one hour away. But it is very clear that our patient is far from getting the optimal care and so this little discussion is of mighty weighty significance. I am seething with internal rage but I try to keep my cool lest I jeopardise things. But I am enraged at this treatment and many things are going on in my mind.
When did doctors begin to be so aloof and distant from the people they should be serving? Of course this is not a new observation. People have always been aloof and distant since time immemorial and some are not even improved with time, privilege and education. But when did doctors and other health care workers start to actually believe they are the only people who matter in patient care? And how on earth are they able to get stingy with information about their patients? (this is not a breach in confidentiality) But just how did HCWs start to treat fellow colleagues thus?
We go over the merits of each course of action and we agree to let him stay here because of the nightmarish scenario that relocating a gravely ill patient will present and by this time the patient has been put on respiratory support and this is perhaps the only reason that sways my opinion.
I seek the doctor and try to speak with him.
"Doc I hope you are not offended by my persistent intrusion."
"No, I am not." he responds.
"Well, you must realise that mine and everybody elses' aspirations are the same; we all want the best outcomes for patients who happen to be relatives." I quip.
"But you must give us time to do our work, you know we get overwhelmed with work!" he retorts. I am in no moods to pursue this conversation further and so tell him to consider my opinion on the patient.

My uncle passed on in the night...and the grieving was not only for his passing on but for this disturbing occurence I seen happen pretty often.

Heroes and Villains..

You wake up very early one day.
You go through your usual morning motions and in no time are good to go. There is nothing special about the feel of this particular morning but you somehow know it will be a good day.
Just like most of Nairobi roads are in the morning, you have the very hectic Outering Road and Juja Road traffic jams to beat. In between these there is Kariobangi Roundabout; a deviously brisk place. You have nothing but hard memories for this place...in the morning it's bad, in the evening it's hellish and that's just being very civil. But you conquer jam one, confusion two, jam three and just barely beat the clock.
It is Wednesday, one of the most delicate days of the week; And today it's the monthly pediatric psycho-social support group. Today you are running it.
You check in and engage in a little chit-chat with your colleagues; the usual adult jokes that are the staple of a far-from homogeneous setting. You jest and ridicule and laugh and jest some more. Your sport betting inclined friends' fortunes have taken a nose dive and you take the opportunity to rub it in! This is perhaps the only time you will have today for such vain engagements. For in a short while it shall be raining work-
One by one everybody settles down.

There is a very erroneous notion which I hear pretty often; that HIV infected people should not have children let alone enjoy coitus. This must have had its roots in the 90s and early 2000s when efforts to combat HIV were rather clumsy and knowledge about the same rather shaky. It must rank as the golden era of stigmatization. Health care providers must have gone about it with a certain sense of detachment and incidentally perpetuated the ostracization. It is why anyone infected and happening to fall pregnant was frowned upon. Whether this was done subtly or covertly the message was clear.
We have come a long way from those early days. Childbirth and intimacy are universal human rights. Advancements in HIV care have also seen to the possibility of eliminating vertical transmissions. But we still see infections and this is saddening. And so it happens that the infected children and their parents or guardians need an attention that though not strictly special is still special all the same. There are a lot of sensitive issues that have to be scouted when dealing with this group. On this particular Wednesday you are working with the social worker and the other team members to run these activities.

Mathare Valley.

What is an informal settlement? For these people it is very formal. The entire bulk of the city's low wage earners make this and other similar settlements their home. It is all they can afford. It is also very true that the material net worth in some of the shanties will put many a decently employed fellow to shame. It is however an undeniable fact that these people have got so much to contend with. You only need to take a guided (yes guided) walk here to appreciate the dire conditions that nobody is willing or unable to do anything about. This in itself is a catalyst for so many of the social problems observed here. Crime and a complete breakdown of law and order, violence, an open and thriving illicit drug and alcohol market. It is a world unto itself these parts. I am no sociologist nor moralist and so won't wade into this territory.
What is however clear to me is these backyards are deep and with many layers. The physical conditions and low economic status of the majority of the people here make this a truly deserving segment of the urban population. This is where you come in not just augmenting the government efforts but playing a very big role in bringing these social services close to where they are really needed.
It is Wednesday. The preceding Sunday as you go to a medical camp you have organized in one of the locations of the vast settlement you are waylaid by a gang of ruffians and mugged at knife point. It is ten in the morning. You are lucky to come out unscathed with only blows to the head and face. This has come to be accepted as the norm here. Mathare Valley.
Back to this particular Wednesday. The group session goes on well. Then you settle down to the individual consultations and it goes without saying that by lunch time you have had a great deal to handle. If it is not relatives who have no idea what the medicines the young ones under their care are taking then it is parents who have traveled to the rural home and overstayed by a month; effectively missing medicines for the same duration or this sensitive teenager who is shown open dislike and neglect by his current guardians.
It is thus way past the conventional lunch time when you get to sneak out for a quick one.


The after lunch.
You start off right where you left off because nothing has moved. Then your attention is drawn to a disturbance outside. It is just too much to be ignored and so you step outside and up the first floor to investigate. You walk right into cameras and a mass of confusion. A group of street urchins are here with some shocking accusations. That one of them we did a circumcision on died from an unspecified complication, another developed a severe infection and yet another had his glans cut off. Of course all these come as a shocker but what is more shocking is the deep involvement of the media and the police. However an argument that lasts close to two hours ensues. Your day is about to take a dip for the worst.
Do we have an active street children program? No. Do we go out there on the streets rounding up the street children for forced treatments let alone procedures? No. But do we offer services to this same group? Yes. Is this a crime? For they come to us willingly without any coercion or incentive. By this time you are simply stupefied by these ridiculous claims. This cannot possibly be happening. In no time you are being labelled a criminal, a villain. What is your crime? "Let us go to the police station you record a statement". All this time the media guys are bursting at the seams with glee, "Story imeiva, Story Imeiva". You are unceremoniously hounded out of your workplace, your protestations nearly landing you in handcuffs. You are roughed up and led to the media house van. Then to the police station.
When you get here more shock and anguish awaits you. You are held at the holding area or something of the sort, all the while the police officers here making their rude rough jokes about you. They actually think this is a joke.
You are getting agitated by the minute...

What Would Socrates Do?

Perhaps I should come here more often now that it is all sewn up..

Sometimes (most of the time) Fridays are usually very hectic days where I grind the hours at. Then sometimes it loosens up and then a man has to keep himself pretty engaged; maybe reading up a little medicine or his favorite subject; this and that.
Thus was it this particular Friday. The serenity was however shattered when the early afternoon registered an inexplicable bustle of activity. Man, it was like Monday morning all over again. But a man's got to put in hours.
You will meet some of the most strikingly smart people in the most unexpected of places. This is not news; what is news is that in the morning they will be wasting away their immense brain power drinking bitter liquors brewed along open sewer lines. In the afternoon they will sit by the shacks, silently watching the unending wheel of life going on by them. They register all this and mutter some pointed observations about what they see. In the late afternoon they will drink some more and by evening they are laid a complete waste; splattered all over the dirty pavements, unceremoniously locked away by the potent brews of the alleys. Thus ended is one day. Tomorrow is day one all over again. Vicious cycle.
The particular bustling Friday shoves one such fellow my way. Poor fellow is however a new admission to the community of the downtrodden.
He smells like a tramp and he talks animatedly like he is possessed. His one stand out appeal even before I get down to his actual problem is "daktari kindly help me, daktari kindly help me". Of course I am so used to this sort of thing but still alarmed by his stance and insistence noting that he is not drunk then. Sometimes when I meet fellows of his ilk I just let them vent and ventilate out as they give you some very startling perspectives on issues. But you have seemingly intelligent men wasting away their lives in the dungeons of dark and sad alleys overwhelmed by squalor and misery to change a thing about their existence. That is the great tragedy. The ghetto is the social black-hole; once you willingly slide down it's bowels you hardly make it back out whole or alive for that matter.
So I ask him what help he wants. He launches into a tale. His wife of twenty years kicked him out of his home. "But where do I come in?" I curiously ask him after he is done. You can talk to her so that she lets me back in, I am leading a very despicable life now. I have neither bathed nor changed my clothing for five days, I owe my stranger hosts some money, all I do now is survive on drink, left-overs and crumbs and as you might guess they are in very short supply there. It is only the drink that flows freely.
Though you hear gripping tall tales like these with a surprising frequency, this one was somehow believable. His lips are dry and cracked, his eyes sunken and cheek bones beginning to show prominence. I give him a small amount of money and he breaks into innumerable thank yous. He steps out after we are done with the consultation which happened to be rather long. He has a spring in his step and a glow on his face.
Sometimes a total stranger will astonish you with their faith in your ability to solve a pressing problem they have. This must be the special relativity of humanity; problems gravitating towards solutions! And so he comes back after his meal; more convinced that I am the man to crack his complicated domestic situation-
That one man can descend from home owner status to a homeless vagrant beggar is not strange. It happens pretty often. If the man is going to willingly lose the sight of his life mission's compass then something like this might be the outcome. But the reasons are many.
Man had severe bronco-pneumonia; so severe that I was initially convinced it was open tuberculosis. Subsequent tests however ruled out TB and this perhaps saved him from his predicament (his wife had insisted to be told whether it was TB because then there was no way she was taking him back in) So we had given him proper treatment and given him temporary admission. Later a little drama would ensue involving his wife, his mother, his uncle, his aunt and a family pastor friend all who had to be called to arbitrate. Turns out our man was even lucky to be freely roaming the streets. He had caused a grievous injury to his wife after a domestic misunderstanding, then he had bolted.

Long after my colleagues had gone home I was still stuck in a delicate mediation process which mostly involved rebuking our man for he owned up to turning into an moron after he lost his job which was in itself caused by his drink. His uncle had secured him another position but what does he do! He gets into a vicious confrontation with his new supervisor and is cut loose almost immediately. When our man had gone back to his uncle's house for just the chance of a meal he had been sent scampering to safety by his machete wielding uncle. He could not take any more of his grown nephew's bullshit!
Now here we were trying to reconcile the parties each with a bagful of grievances.
Two things had prompted me to meddle in this matter; the condition of his chest and his expressed intention to board on the hospital coaches which he deemed a great deal better than his current lodgings. He had even broached the subject of me taking him in. And I have seen so many cases of hospital abandonment to treat these threats lightly. Privately he had told me that he had seriously contemplated jumping just to end it all. With the little cash I gave him he had debated with himself whether to buy a cyanide laced poison. The only thing that held him back was that his wife was listening to me. However this had not been an easy task. She had been greatly embittered by his guts to even think about calling her. What she had told me was that she would even be very happy to hear a car had fatally knocked him down. He had relatives and they should assist him. My pitch had been plain; he remained her husband and whatever differences they had were best addressed conclusively. But that now he needed help and we had gone over our limit in aiding him.
When uncle had been informed he had said nothing. It was thus a surprise when he showed up and and in tow his wife, a family pastor friend, our man's mother and two other acquaintances. Uncle had to be restrained from delivering a thorough thrashing to our poor fellow. Then wife had also come and I had wondered whether I had thought this through well. I had however given them conference space and they had a bitter family exchange with some very private details that will remain private. My moderation pitch was however singular; they were the people to provide a solution to all this drama. Family was family and I was even out of my mandate to intervene in a matter of this sort.
But after all the tugging and high emotional points it had ended well. Reconciliation had been achieved and the man had been pardoned first by his wife and then by his uncle. Peace had triumphed. "I will not drink again, I will hustle harder, I will stop wasting money and time on trivia", a man will say things like this in a situation like this. His wife had gone with him to his 'benefactors' to settle accounts. What had initially been four hundred was hastily doubled after all the hidden costs like 'loss of business' were laid bare. Lucky happy chap now had one last request for me; he badly needed a job!
Saved from the jaws of pneumonia and the savagery of the harsh cold streets it was kind of hilarious to see him offering to carry his wife's handbag; the complete gentleman! He could not believe this turn of events.

Happy ending hopefully-

A man who is on his death bed already has enough going for him as it were. A soul in peril. The state of his public and private affairs. His private scruples to deal with. It thus would be in the natural order of things to have his burden made light by all those close to him; family and stranger, friend and foe alike.
This man had terminal cancer of the liver. "The man you see lying there was a man indeed", these had been his sisters words to me. We had sat at the nursing station discussing his condition, then the issue of his first wife had come up. The only time she had been to the hospital was when she had first brought him for admission. Then she had disappeared.from the picture.
So this had been partly the subject of our small talk with his sister. What was to be done about it? The confidence that we sometimes get is surprising.

"So it came about that Napoleon frequently would steal out by a little side door at night, with a soft hat pulled over his eyes, and, accompanied by one of his intimates, really betake himself to some fair lady who was expecting him, or else stroll about the great city as of old, passing through streets of the kind which an Emperor hardly sees outside a fairy tale, and breathing the atmosphere of might-have-beens."

How had matters come to this point with our couple here. When the holy flame of marital bliss flickers, cools down and eventually dies out then all that had been is quickly forgotten and what was once the warmest of a felicity turns into the coldest resentment and even hatred. He had been a man of means. Then what had befallen Bonaparte III had come home to him. A complex set of situations had led to him eventually marrying a second wife. Many situations might trigger this tumultuous cascade. His first wife had colluded with her brother (whom he had entrusted with the running of one of his enterprises) to divert a size-able chunk of funds from the same to their own private uses and thus badly compromising the financial position of the business. How do you go on about a situation of this nature? But he had talked fondly of her saying that it was all nothing.
The wife had eventually come after some days and as luck would have it we bumped into each other. I asked to see her briefly. She grudgingly consented and we stepped into an office. "But where have you been ever since that day that your husband was admitted?", "Is that all you want to know?" She had roughly retorted.
"But it's important because in his condition the presence of family counts for much".
"What you are doing is meddling and I strongly warn you to stop it henceforth, I am not in the moods to discuss such a matter with anyone. Do you have any idea what I have been through? Keep to your treatment of him and please excuse me". She had walked out and gone off. I had remained there temporarily rooted to the spot, feeling completely the idiot. But she was right; what business of mine was it? What right had I?

Some months later I happened to meet the sister of the late man and out of interest asked him how it had ended up between the estranged couple. "Badly with a lot of embarrassing drama but we are all trying to forgive and let go".

I believe I have a stronger motivation to keep to my lane. As it is the demands of this job are already too weighty for a soul!  Men and women will always love each other and with the same vigor torment and scorch each other, that is the nature of our existence...but I wonder what Socrates would do..

The Cells That Outgrew Life..

Life is a good thing.
Make the most of it while it lasts. Well this is easily one of the strongest philosophical impressions that many of us are left with any time that a friend, kin, colleague, partner, patient or acquaintance passes on to the other side.
You can not with certainty design when this happens. In most cases it remains the greatest mystery; this business of going away. Then sometimes it crawls upon us like an unshakable leech! But even when it happens there is always a bad taste in our mouths.
We often hear these things being said on the regular: take plenty of clean water, eat right, exercise frequently, sleep enough, cut out tobacco, do regular checks etc etc. But do we heed a thing? This however is not the object of this post..

The morning was a typical August morning. Sunny, bright, cheery and with a tonne of promise in the air. But later it would perhaps rain. I busied myself in the ward doing an early morning review. I was in no particular rush and so took my time going over the admissions; this to the consternation of my colleagues who wanted to get it done with so they could go take their tea and engage in chit chat! But slowly we had gone on.
In the general female ward as we proceeded it became apparent that some process of putrefaction was going on somewhere. I had been briefed about the case and so was partly aware about what to expect.

Forty two years old, she had been a house help in Nairobi for the better part of her adult life. She had been married briefly at some point but had separated with the husband. This had been over ten years back. She however had an eighteen year old son. She thus led a sort of solitary life, just given to her occupation. Then she had developed this lump in her left breast. She could not even recall with certainty when it first started. All she remembers was that the left breast became progressively big and that's when she went to a neighborhood facility for attention. There she was examined and told something to the effect that some advanced tests needed to be done and for this reason she was sent to Kenyatta National Hospital.
Kenyatta National Hospital she says turned out a real torment on patience. Eventually the test results came out and it was confirmed she had malignant breast cancer. It had spread beyond her left breast and even the other one was now developing the lumps. Already there were nodular swellings in her axilla (armpits) She had to start treatment immediately.
All this time she had not even disclosed to her boss what she was dealing with, bravely going about her duties in a quiet contemplation and resignation. But it became increasingly clear that her health was dipping. Her appointments became more frequent; what with all the systematic setbacks and disappointments. It's how her employer got wind of the situation. Quite understanding and supportive at first, the situation became untenable some months down the line. The time commitment and financial aspects must have seemed overwhelming and this in view of the bleakness of the condition had led to the parties amicably parting ways.
Life in Nairobi became unbearable. All that she had saved was rapidly diminishing and this coupled with the erratic and unreliable KNH system had necessitated her leaving the city. On the advice of a relative she had relocated to Eldoret where she began therapy all over again at The Moi Teaching and Referral Hospital. She had an appointment for January but had not kept it. Now it was August.

We had all listened to her tale with sympathetic patience. It was very clear the condition was terminal. One half of her left breast was literally eaten away. She was in pain and kept appealing for any assistance she could get.
"And just where have you been all this while?" I had asked her a bit hard though.
"I have gone to many places that I can't even tell you." She had answered with a crushing frankness. We had all deduced what she meant by that.
"But why did you not keep the MTRH appointment?"
"Daktari I could not raise the money, I have an outstanding bill of eight thousands from my last admission there, so you can understand why I kept away."
"But this is a serious issue, every day you kept away the cancer grew some more."
"That I know and I regret it highly, now how do you help me?"
"Let me see, as it is there is so little we can do for you here, I would suggest you go back to MTRH..."
"No doctor, what will they tell me now?"
"Remember we need to get you all the meaningful help that we can now."
"But where do I get the money for all that?"
"Keeping off because of an uncleared bill is the worser evil if you asked me."
"Okay, but kindly do something for this pain, ever since I came here nothing much has been done, I have requested for just two tablets of augmentin but no one even cares."
"Augmentin is not a pain medication!"
"For me it greatly works, kindly get me two tablets of augmentin, please I beg..."
"Okay I will do something about it, I want to talk to your relatives when they come to see you."
"Thank you daktari, God bless you so much."

It was three days before her brother came to see her. In the meantime she had been on cover for infection, the wound was also regularly cleansed and we had found for her a stronger narcotic based anaelgesic. The brother had just reiterated her earlier position; the family was totally out of means, they had even approached the M.P and other well-wishers but no much help had been forthcoming and so they had let things take their course.
For six days she had stayed in the ward, alternating between talkertiveness and prolonged periods of pensive silence. We had recommended hospice care and this from the hopelessness of the situation.
"But what difference is a hospice going to make?"
"They are better suited, equipped and focused on these sort of conditions."
"I know that people go to hospices to die." She seemed to be distantly distracted.
"Not necessarily true, it's a recuperative environment sort of."
"Do you believe what you are saying?", she had asked me, intently scrutinizing my face and apparently reviving back to the moment.
"You give it consideration and let me know what you decide by the end of the day."

That day had passed and so had the next. Then she had called for me on the third day after the above conversation.
"Daktari, I want to go home."
"Is that what you have decided?", I had inquired.
"Yes, and I believe it's the best course of action in the circumstances, I do not want to burden anyone any more, let the will of God be done." Then a contemplative silence had ensued, she had come to terms with the eventuality and I found myself regarding the moment with an unexplainable sanctitude..
The next day she went home. We had to find for her a course of augmentin but she declined it. We however pressed and she left us with many thanks. Two weeks later her soul departed this earth.

Life is a good thing while it lasts..

Medicine Meets Something Mediocre.

Loliondo!



Most people with a care for recent history will recall that flash-in-a-pan phenomenon of 2011. For a short while this name took the world by storm. Who will easily forget the long winding lines of caravans from across East and Central Africa making their way to that till-then obscure locality in Northern Tanzania. Who will forget the same masses faithfully gulping down cups upon cups of the cherished cure that went for Tsh 500? Kikombe Cha Babu as it was aptly called was this magical elixir that cured all ailments. So you can only imagine what a sensation it was expected to cause. From the incurable HIV to the very troublesome diabetes and erratic hypertension, Kikombe Cha Babu spared none (sounds familiar?) Not just this but even the apparently well people just had to insure themselves from future incidences of sickness. Heck even Tanzanian MPs were not to be left out on this seemingly once-in-a-lifetime-chance at a cheap remedy gravy train! A Health cabinet minister (a doctor herself) sanctioned it..

A Public Security Agent Drinks From 'The Cup'!

And so it happened that a remote outpost till then known for some other reasons took the centre stage with the world media shining its full glare on it and thousands upon thousands of hopeful visitors thronging it. At the centre of it was a respectable retired church Minister who claimed to have received a vision about the cure. The substance in question happened to be a local shrub which had other uses before then. Its derivative was actually a lethal poison used to kill lions in the inevitable human wildlife conflict, the area happening to neighbour a national park. And so Reverend Mwasapile aka Babu had gone to work and the world had come to him.
Hospital beds had rapidly been emptied of their occupants and so had many chronic disease and HIV treatment programs.
I was working at Bondo District Hospital then. Before we had grasped the magnitude of the issue so many patients in our care had already made the all important expedition and were already waiting among the frenzied throngs in Loliondo. Then we had made it a point to do a routine talk on the baselessness of the claims. But alas!
A friend of mine who was on follow up had confided to me about his intentions of making the journey. He had quietly listened as I tore through the inaccuracies and laid bare 'facts' surrounding the said concoction (but what did I know about it really?) Alas, poor me! Who was I to stand in the way of a brother who only desired the best for himself? For gone he had, his mind having certainly been made up about the entire business.

Then like all bubbles this one too had burst. It had come in the most tragic but expected of ways. Patients who most likely had been pulled off important lifesaving medicines and secure environments had died awaiting their turn at the cup. Not one, not two, not three but fifty plus two according to the official figures released. Only then had the concerned authorities acted.
But even before this it was easy to see that a disaster in one form or the other was looming large over the village. What was hard to fathom is why authorities looked the other way as matters slowly but surely came to a head. The evident humanitarian crisis alone should have been an indicator to an impending implosion. But such is the way that authorities this side of the world manage important public affairs.

Winding Lines on Their way To Loliondo.

The aftermath of this debacle remains untold but if consideration is taken about the toll of these happenings on the public health system then it becomes clear why healthcare remains one of our biggest challenges.
The drug changes, the worsening morbidities and even mortalities (all of these easily preventable). Name them.

My form two definition of faith remains very clear, "hope for unseen things". Is it what we now have all over the place? Is faith wholesomely dispensable like a prescription? Is the production of a token equal to the manifestation of faith? Many Men of Cloth will have you believe so. For what ends? But only if they went about it with less pomp and more humility. And so it happens that one of the silent thorns in the side of conventional medicine are characters of dubious distinctions who for one reason or the other have been left to operate with unwarranted abandon. Scorning miracle healing is far from my objective but preying on a desperate and thus gullible public to sell their 'wares'? But truth be told, the conundrum that is the public healthcare delivery system is not helping matters either.

I was very young in my practice. Just fresh from internship and very eager to exercise that hard won independence. It is thus to be expected that I saw the world of patient care in only two dimensions; my way and my way. This arose from two weaknesses on my part; the inability to well harmonize theory and actual practice and secondly a shaky grasp of that trifling thing called human nature and conduct. Every new lad in the field goes through the same. So I had seen this middle aged lady with very non specific complaints. My work up had of course included HIV and it turned out positive. Applying tonnes of counselling to the point that I nearly forgot to treat her for the more pressing problems. We had enrolled her in our care unit and I took particular self imposed responsibility for her, she being my first patient to fully deal with right from start. It delighted me that I was now digging my teeth in the otherwise confounding world of HIV care. Scheduled her for sample collection, I gave this business the very best shot and my especial personal touch. Alas!
She did not disappoint at first, dutifully keeping her appointments and seemingly keen on her care. Well till tragedy struck! She met this pastor. And away flew my bird. She defaulted and made it clear that she had found the path to her healing and would keep at it and no other else. I expressed my utter incredulity but nothing could change her mind. Later at the instigation of the very same pastor she had even claimed that we had lumped a wrong status on her; she had never been infected in the first place. The scoundrel. Off she had disappeared in intercessionary schedules and because of many other related reasons we had given up on her.
For some months matters had gone well with her. Well just for some months before she began on a quiet downhill slide. Then the prayer sessions had increased (we maintained a discreet interest in her affairs!) Till it was very late. Then she had died. Case one.

A much beloved high school principal in one of the schools near our facility and whom we had been seeing left us a bitter sad pill. Diabetic and hypertensive it however alarmed us when he started skipping his appointments and going for weeks without his medicines. At first he gave vague reasons for his conduct. That he had seen another physician who had recommended other pills and such like stuff. Of course we trusted that a high school principal must know better so we bothered him no more. It was not before long that word lazily floated on the air that he was actually seeking the intervention of a famed Woman of God not so far from the facility community. Damn!
We have all heard what a deadly combo diabetes and hypertension can make. So here was a man at his prime who had been under good control but who nevertheless thought he had had enough of the daily pills. But for what? He stood no chance. He could for days remain holed up in the lady's premises under her ministrations and word spread that he was on a steady decline. Aloof to the advice of his colleagues it was now in the open that for him it was just a matter of time. He had developed a stroke and one can only imagine what havoc the uncontrolled sugars were playing on his fickle systems. But adamant he remained. He succumbed in this setting and only rushed to hospital when it became apparent he was no more. Prophetess had lost such a high profile and well paying client but you think he would be the last? Case two.

A cup, just one cup will cure it. The rich and poor, elite and unlearned alike all put their faith in a cup of something from one Babu. Any health professional who believes he has seen the last of these miracles cures is deluded. Every day on national TV, radio are these adverts for all sorts of unfounded healing claims. Newer, fancier pastors, herbalists, waganga et al promising heaven only to dispense hell. (Both physical, spiritual and financial). I bet that's how the world operates..

Absurd Rape Related Tales..

One day, in the not so distant past I was seated in The Hallowed Consultation Room just lost in The Muse. The time was around 2030hrs and I was covering the night. Worn out from my daytime activities I was using the downtime to unwind and unclog my mind. And so as I leisurely reclined in my seat painting fantastic mental pictures I heard a knock on the door but even before I could regroup all my faculties back to reality in peeped the night security guard who took the liberty of inviting the two (actually three) fellows behind him in. Well I had to scramble back from wanderland (yes wanderland) and fast!
I went through the preliminary part of the consultation; just confirming the name, age and so forth. It was a very young couple, the man was eighteen (was able to determine that) while the lady was nineteen. They had with them a three year old girl but from the woman's earlier relationship. Married only for a few months, they were now expecting their first fruit of love together, the lady being about two months heavy with child. I had initially thought it was the child who was sick but the card read the mother. Then I had inquired what the problem was. Silence. Fidgeting. More silence.

We have been taught never to speak for a patient; a patient has to state his case in his or her own words and it's your duty to figure out with precision what they mean. However you may paraphrase or ask with tact to establish what they have said. So here we were. Checking my demeanor I asked again in the gentlest of tones what it was that had brought them to the facility. Furtive glances and some half attempts at speaking up. Then the man had eventually surmounted the difficulty by imploring the wife to state the issue.
Not able to maintain eye contact at first and fidgeting some more she had eventually explained that the previous night somebody had attempted to rape her. Damn! Where? In their house. What time? Around 0200hrs. How? The intruder had told her he wanted to see her husband and so she had believed he was friends with hubby.
Now the problem was this: the husband was not at home at that time and they being new in the place he expected no night visit from any friend of his. He was doing night duty at his place of work that week. Intruder had however insisted on being admitted saying he had a message for the husband. Well on entering he had cut to the chase and threatened her with a dagger. She had not seen his face for he had moved like the devil himself. This is where it gets twisted. He had not been able to manage intercourse due to a defensive manoeuvre she had adopted and so defeated in his evil designs he had quietly slunk away into the dark night. Real Creepy.
No hair touched, no bruise sustained, no blow given, no alarm raised, nothing but a lone shaken woman at a ghostly hour of the night. Believable? The hubby hardly believed a thing and seemed very riled though he appeared one of those meekly indisposed, gentle characters. It's here that he wanted me to come in. To establish if at all there had been penetration; he had heard that it's possible to examine and know if someone has been raped. Damn, Mungu Baba, saidia hapa!
I went over the details slowly and meticulously. The lady now confident and with a reassuring telling was however adamant that nothing happened, no penetration, no intercourse, no sex, no rape. Nothing. In my own assessment her tale had a ring of honesty to it. The husband however persistent with his hows just could not buy it. I understood his cynicism and so tried to reassure him by pointing out that it made no sense for her having even told him a thing if she was a willing accomplice in the business. She had tried calling him after the scary ordeal but he was apparently sound asleep on duty.
He had never doubted her trust before and nothing so far had occurred that made him have doubts on her fidelity. Same to her. I went through the paces of detailing the post rape protocols and everything that had to be done, explained what risks there were to her and the fetus and that if any intervention needed to be made then we still had time but she stuck to her word. Nothing had happened. At that point I chose to fully believe her.
A private session with the husband and I was able to make him understand that though it was hard for any man to come to terms with anything like that we had to believe her all the same. They had however to report the matter to the police because criminals always left an unmistakable scent or two. Trust Sherlock Holmes to unravel a mystery of this nature and nab the ghost-like, faceless, night time prankster. And who knows, he might have wanted to part hubby's neck from his head. It went like one phantom tale, but true it was. I became more afraid of the dark some more and for some days slept with the lights on..

• 
  

The hilly terrains of Iten and Cherangany and Kapsabet have bequeathed us with generations upon generations of nimble sure footed gifted track athletes, world beaters who have represented us well on the very competitive global stage. It's also true that many of business magnates and captains of industry spent their childhoods braving the morning chill of The Aberdares and Mount Kenya. Now there is in this country one county famed for it's very decent professor-per-village ratio. With many sons of the land well settled in many notable research and academic entities the world over it easily occupies the enviable position as the undisputed hotbed of scholars in the country. It is here that we now go.
Any clinician or nurse or physician or any of the health professional for that matter will tell you they have met some very confounding cases in the course of their work. But it has to be noted that many of these confine themselves to the medical or scientific aspect of things. Any social dimension taking the centre stage in a case and we beat a hasty retreat into our nauseating doctor or nurse cocoons and refer to the counselors, psychologists, pyschiatrists or even the police and the administrators. This state of affairs is however to be understood and the medics are not to be begrudged, they already have much going for them already and almost all training curricula are so deficient in this aspect.

So in the land of scholars one Saturday morning at the OPD/A&E of one of the county referral hospitals, the outpatient crowd sat patiently and orderly waiting in turn at the waiting area. The departments were still very sluggish, what with some of us preoccupied with the usual silly extra-hospital banter and gossip; but the patients and their relatives waited with unbearable patience all the same. Then waves of guilt hit us like the dry heat of The December. Were we really doing justice to whatever it was that paid the bills albeit belatedly? Was this how we repaid back the government after gifting us a hefty extraneous allowance! So one by one we had trooped to our stations and settled down to work. And work we did for in no time the crowd had been conquered!
When you work in the accident and emergency department of any hospital you are always putting out critical situation fires. Serious injuries, shocks, comas, grave complications of all sorts. You are literally in the firing line of things. Speed, sound judgement, experience, patience are all of utmost importance. Then can you hone your competence. But you also get to meet some of the most baffling real life situations that only highlight how deep a well human nature truly is.
And so as we had gone about our work on this particular Saturday morning, a commotion outside had drawn all our attention. A sobbing lady of about twenty two was hustled into the area. She was disheveled and in such a sorry state emotionally and physically. Hot on her heels was the mother, apparently. Also in tow were several relations most likely siblings to the young lady. Mother was fuming, agitated and in no moods to display any etiquette of following the laid down regulations. She headed straight to the nearest consultation room which happened to be mine! They half pulled, half supported the daughter inside and she slumped into the seat. Then the rest of that no nonsense entourage followed, all evidently ruffled and using some of the choicest not-so-nice English words. I let them vent and ventilate for a minute or two before I cracked the whip demanding order and decency. As a condition for anything to proceed I requested they all leave the room except the young lady. The mother insisted on remaining. I grabbed some writing material and dug into it.
"She has been raped" bursts the mother.
I calmly ask to let the lady speak for herself.
"Can't you see how distraught she is?".
I however insist and kindly request the mother to leave the room. Then she beats me to it, rapidly launching into how the suspect waylaid the daughter the previous night and sexually abused her the whole night. She had only been able to make her escape in the wee hours of the morning after the satiated and worn out beast had slumbered off.
I asked the lady to corroborate the narrative but all I got were sobs and more sobs. I sat back and quietly regarded everything. Then out of idle curiosity asked if they knew the suspect. She told me he had been apprehended by the police. However as if on cue another commotion outside revealed that the suspect had been brought to the hospital. Badly beaten, he was bleeding from many scores.
I requested the lady to lie on the couch so I could examine her. She complied and I completed the assessment noting down my findings. After establishing she had not changed her clothing nor had taken a shower I explained to them that we needed to get some samples for lab investigations. It's like the mother had been waiting for this important piece of information. Urging me with uncommon vigor to speedily get done with it. They needed to lock away the unfortunate, worthless and mannerless mongrel.
Then the daughter snapped.
"Mum, why are you doing this to me, how far will you go to achieve your mean objectives? Denounce me but kindly let Kevin go, he is just a poor innocent boy, please mum, I beg you", young lady had hysterically broken down, inviting some alarmed colleagues and even patients into the room.
"You shut up, disgraceful scoundrel, you are a total embarrassment to my person and the entire family. Messing around with poor, pathetic scumbags, is that what is expected of you?".
I was by that time stupefied by the unfolding drama and remained rooted to my feet, I have seen some melodramatic Nigerian movies but only believed them to be sweetened tales. Now here I was!
"Daktari, can you kindly proceed?". the mother roused me from my incomprehension.
I asked to be told what exactly was going on because it looked to me some stinking fishy bit of business.
"Which part of 'she has been raped' don't you understand?".
I inquired from the lady what had then happened. She tells me Kevin was just her boyfriend and she had willingly spent the previous night with him. She was stopped midway by two well aimed slaps from the mother amidst a torrent of unprintables.
That being the case I tried to explain that there really was nothing much to be done here. In fact nothing at all. Wasting valuable daktari and genuine patient's time in this manner was not so cool. Complicated matters of rejected choices were best handled privately and civilly in chief's courts or behind their palatial residences.
"Test her for HIV", barked the mother, evidently smarting from her temporary setback.
The daughter saved me the trouble by flatly declining to have anything to do with a forced HIV test. Out went the mother cursing and wailing and making such a scene that you would certainly believe the greatest calamity had struck home.
Compelling the young lady to compose herself I was itching to get to the bottom of this trifling matter. It turned out to be nothing but a rich girl, poor boy antagonistic family story. She was from a very well-off family from the neighborhood. The mother was a college lecturer, the father a university don. She was herself at the university pursuing a degree in fine arts. Her boyfriend who she confessed to love dearly was in another campus pursuing actuarial science. He was however from an underprivileged background and thus her parents would have none of that social tomfoolery. Only that? Yes. They are despicable egotistical maniacs who have gone to very laughable lengths to achieve their objectives. They have bribed the police and the chief to fabricate and backup this rape story. But they will not succeed. I need to see him daktari.

It would be expected that in any community with a significantly big proportion of well read people would also boast of a corresponding social advancement with scant prejudices and full of understanding and that elusive erudite pity. Wrong.
I can't clearly recall how those Nigerian movies ended. I can't say how this one ended either. The family left the hospital in a huff, young lady remained behind with her boyfriend who was still under police custody though undergoing treatment for his injuries. I asked a police friend of mine how they felt being in such farcical and ridiculous situations and being used thus and he just laughed.

Brothers in the Deep End..

I have in my village a very wealthy decade-shy septuagenarian who has made the bulk of his money selling meat. Now he himself is a vegan. He made the rest of his money supplying cane to one of the moribund sugar factories in the countryside. He takes no sugar also. Life must be one bland tasteless affair for this tycoon then! You would bet so...but such is life.
Then we have all heard about great teachers whose own sons or daughters turned out epic academic failures. Not in that rude sense of below par cerebral abilities but in a more socially humiliating manner; truancy, obstinacy, utter contempt and rejection of the academic life. These sons and daughters of famous teachers have ended up the village vagabonds, well steeped in notoriety and went on to lead pitiable base existences. Well some of them. There was an age when teachers were one of the foremost elite professionals in the neighborhoods. They commanded an unquestionable, unadulterated kind of universal respect that was well earned and merited. This may not be still the case but the reasons for this are not the objective of this post. It is then baffling how some of their sons and daughters turned out to be the complete antithesis to all that these noble souls stood for; the embrace of knowledge and all things knowledge. Little paradoxes that stack together to enrich our existence and make for the colorfulness of everything, but then such is life.

The morning ward round was rather uneventful. Just the usual cases to be encountered in a busy private hospital. Well till we got to the male ward. One of the night admissions was a middle aged morose man. Here is the brief description of the case. Brought in at three in the morning with bruises following an assault at a man's home that also doubled up as a cheap liquor den. The details of the events are embarrassing and tedious and so I wont go there but the long and short of it; well some money owed and some bills unsettled. So he had sustained bruises and lacerations here and there. He being rather weak looking and with a lanky physical disposition it was obvious the opponent or opponents had gotten the better of him and that he had borne the brunt of the altercation. He was as they say dead drunk himself then. And so a few friends who had intervened had brought him to the facility. 
On examination it was discovered he had a lower chest infection in addition to his physical injuries. He was also known to suffer from gastric ulcers. He was started on the appropriate management at admission and this involved reviving him since he had passed out at some point. Enough of the case though, now the man himself.
Forty years old, separated with the wife (a nursing officer practicing in Nairobi), with one known child (daughter in form two) he was a public health officer by profession. He was however now living like a homeless dog in the backstreets of the township. Mr PHO came from a very rich academic and political family. It really is to be believed that some persons are favored with very special powers of the mind, for despite his well known enmity with sobriety he still managed to pull in some decent work. How he managed is still a subject for scrutiny but manage he did.

I won't be the one to judge any one who waddles through life the way he chooses to in the name of living it. And so I won't criticize Mr PHO for having sort of a very open social life; sleeping wherever a door was open to him and only going back to his resident hostess (a cheap liquor vendor herself) for maybe a change of clothing. Needless to say, he enjoyed very dire financial circumstances perennially. He was the object of ridicule and derision in the community.
So we had seen him in that ward round, run some tests and recommended others and retained him for continuation of treatment. Many hours later he requested to see me privately. Says he, "doc I am required at the office for some work related reasons."
Me; but you are sick, I mean you are sick, what is so urgent over there that your illness has to be suspended?
He replies; I know that but I can handle it, I just have to be there myself.
Me; can I talk to your boss myself and maybe make him understand or rather believe that you are unwell?
He; oh no, I would not bother you with that, let me just then explain to him the situation.
Me; doc, now that we are here I think it's important I point out something that I meant to talk to you about. It has to do with your drinking and smoking. You well grasp what a precarious place the two have led you to. You are not any ignorant fool out there...you have been on this road long enough to understand its perilous destination. you understand the effects on your health.
He; I understand everything perfectly well, though you must realize how hard it is on me.
Me; I appreciate how difficult it is and that brings me to my point. You need help, serious professional help.
He; oh doc just do what you can do the rest will come in time..
Me; now this is equally important just like anything else that we will do for you. Your recovery is of top priority now and I think this is best addressed now rather than later.
He; doc let me be frank with you for once. I have tried many remedies and gone through many extreme paces to reform but only met with disappointment after disappointment. As you see me now I am just resigned to fate; let be what will be. You know this thing runs in our blood. I won't be the first nor the last to go down this way.
Me; (after some brief pause) you really need to encourage yourself, you are still very young, at your prime, why would you throw away such a productive life at the price of a penny?
He; no one would mind. In the whole wide world no one would miss me, because no one cares and that is my only consolation.
Me; now is there any particular way that we or I could be of help?
He: yes, we could start with an immediate discharge from the ward now...the rest will come later.
Me; huh!

I ended this conversation on that unpromising and resigned note. A cloud of defeat had never hung any heavier than it did around our consultation room. 
The precursor to this conversation had been a visit I had received earlier that day from an acquaintance of our friend. She had urged me to do anything within my power to insist on his rehabilitation as a key factor in his treatment. We had briefly discussed it and she had given me a number to call; our patient's father. Many life situations will come our way. In facing them options are always open to us. Sometimes too many options. Sometimes just one or the other. Choosing one over the other may make all the difference. Extracting just a tiny fraction of learning from the myriad possibilities is an awkward preoccupation of mine. And so I had called our PHO's old man who was himself a retired nurse but then engaged in private business.

After the usual introductions and niceties had been gotten out of the way our conversation took this turn;
Me; he needs help now more than ever.
Old Man; (after a momentary pause) he should himself realize that first. Then we can only come in to facilitate. We have in the past been the initiators of many a process and all our good intentions and noble efforts have always come to naught. As it is we are all resigned to fate.
Me; a one last grand effort; a concerted effort bringing together his family, his friends, his colleagues maybe?
Old Man; huh! I would never be the one to waste another man's time in vain pursuits and endeavors. Do you even believe he has friends? Or any friends who would care for his well-being for that matter? Let me ask you something young man.
Me; Yes?
Old Man; how old are you?
Me; thirty something.
Old Man; and how old is your patient who happens to be my son?
Me; forty.
Old Man; a man of forty should be very embarrassed with himself for leading his life like a homeless dog (I was stupefied by him for expressing my very own sentiments in the exact same words), he went on; I feel the humiliation very acutely myself but I have tried all the known tricks in the book. Nothing has permanently worked. I will be very honest with you; I have even consulted witch doctors just in case you know how our people are, just in case his addictions are the product of some malicious underhand efforts. All I have got was more and more disappointments to add on my expenses.
Me; sorry to learn about that, it really must be heartrending but all the more the reason for a last grand effort at rehabilitation. As we speak now I believe even a visit from his relatives may do him some good since he feels abandoned and neglected.
Old Man; but I can not drive all the way from Eldoret just to come and see him, and above all he has brought all of that on himself. In reality I can't summon the strength to realize that all I can do for him can't go any further than mere pity. As it is I am resigned to whatever designs that both fate and the devil may have on him. 
Me; don't you believe that that very effort from you might make a positive impression on him? Or anyone you know who may be of help here, his wife maybe?
Old Man; I am positively persuaded that it may have no impact whatsoever. It would thus be very pointless of me to hazard the ramble. I can not speak for his wife either, i can't bother her even. As I told you already we have left all to the will of fate.Till then we still pray for him and as for now daktari do whatever you can do for him.

Thus had we ended our little discussion and then I had grasped the depth of the hopelessness of the situation. So I had intended to speak to Mr PHO myself and as he had happened to bring himself my way so had our chat passed as earlier described.

Thus passed he the day rolling up and down the hospital grounds, but what happened in the night was one of those occurrences that really torments a man's patience and rudely fries a man's cool. Not being able to hold out any more and finding his getaway efforts thwarted at every turn Mr PHO had played a smart one by having the liquor brought to him instead of he going to the liquor. And so in a discreet corner had he treated himself to his toxic cocktails. A patient ending up dead drunk in the ward was a sight that really worked me up and did so to the point that it was the only incident in a very long time that the flat of my palm had the opportunity of encountering the ill prepared cheek of another man (not the patient though).

The following morning I had gone about my business in a rather quiet and self absorbing manner. I spend a little time turning over in my head how to handle this obstinate hopeless colleague with a bad habit. He saved me the trouble himself. As I sat at the nursing station in the pediatric ward just observing the children get well along comes he seeking my indulgence. I grant him audience out of sheer curiosity and in admiration of his nerve. So the first thing he does is apologize profusely about the events of the previous night. He goes on and on beseeching me to the point of disgust and so I cut him short and ask what he wants.
Doc just give me twenty minutes I sort out an issue at the office, don't even bother to remove the canular. This is a humble request.
And so out of an ember of professional respect I give him twenty minutes to sort out an issue at the office. He never came back.

Brothers in the know, 
Battling petty and gigantic addictions.
But shall we let them go?
However the swell of their afflictions,
Shall we lose them our sight?
Seeing a brother in the know in his woes
Fills one with morbid fright..
However undoing a pact with the devil's claws
Only the brother in the know can do.