FINANCIAL INEQUALITIES AND FRUSTRATIONS IN KENYA HEALTH SECTOR

 FINANCIAL INEQUALITIES AND FRUSTRATIONS IN KENYA HEALTH SECTOR 

I have worked mostly in the public health systems and financial woes amongst clients are real. A little bit of exposure in the private has magnified this gap for me and breaks my heart a lot . When I was an intern , one of my seniors warned me that I risked bankruptcy if I continued paying for things for clients out of mercy. I would always mobilize colleagues to contribute and buy clients drugs and emergency essential equipment such as chest tubes. I gave up with time and accepted things as they were. 

When I started working , I.C.Us were only a luxury of the two main national referral hospitals in the country and a few private facilities in Nairobi; things have changed for the better with devolution . It wasn’t uncommon to baby-sit impending deaths because relatives couldn’t afford the 10s of thousands for public ambulance transfers to Nairobi . It was what it was!! I would always peep in to see if client was still a live or if the bed had a new occupant. Most of the times we would try all manner of manouvers documented and undocumented to atleast keep the clients alive but mostly it didn’t work especially if ICU care was the only modality of care to support breathing. 

In 2013, when I was doing my long weekend call on a public holiday , the then regime announced full free maternity services for all. This eased many burdens , admission files were dumped at the tables and we could admit freely without demanding for a receipt , surgeries could be done freely , ultrasounds were for all , we no longer held clients long after their Caesarean Sections due to lack of pay , neonatal unit drugs equipment and drugs became free . I was demanded to go empty the wards and discharge all who had been held for non-payment. It was a joy . This joy extended when I joined postgraduate training and things like I.C.U and dialysis were fully covered for any pregnancy related issues whether procured from high end private facilities or in the public hospitals. I loved being a Kenyan . I remember one time organizing a brain surgery for a client who had just given birth and this was done freely with confirmed free I.C.U after surgery . This is what I had come home to Kenya to practise ; optimal care for all without a worry about costs and family social status. Many of my colleagues undertook research topics that involved pregnancy because they knew any tests they ordered especially after 28 weeks of pregnancy would be covered , D.V.T in pregnancy stopped being a dilemma ; you would get admitted , get your KSh.30,000 stock of monthly blood thinners  and go home without paying a dime , family planning immediately post delivery was covered . 

Somewhere in between, Free-Maternity changed to a fancy word ‘LINDA-MAMA.’ This came with tons of limitations. Whereas we were used to free services , many things changed. It mostly covered chiefly the costs of maternity and delivery . Most of the other things had to be paid for by the clients from the pocket depending on the level of facility. Ideally Linda Mama scope only includes 4 free antenatal visits, 4 free postnatal visits , normal and Caesarean deliveries . However these are the usual nurse-run M.C.H clinics so any mother requiring high-risk clinics run by Obstetrician-Gyanecologists has to pay for consultation from their pockets even in public facilities . Ultrasounds (not even one) are not covered and any other care such as dialysis/ICU/ambulance transfer has to be borne from the pockets. Essential drugs in pregnancy for some select mothers such as the anti-D injections for clients with Rhesus negative blood groups are not covered and lab works including antenatal tests  have to be paid from the pocket . I have seen mothers go on their knees and beg me to see them for free in the weekly GOPC/HIGH RISK ANC CLINIC for lack of the 300 shillings consultation fee ; which I always do without blinking but they don’t get the luxury of having files opened. Despite the above challenges, I still advise all my clients even those in private to be registered to LINDA-MAMA irregardless of their rich insurance covers ; it could favor a free high-end public service waiver if the worst got to the worst (e.g ICU or dialysis) or at least fully cover delivery of one’s insurance small-print goes against them. 

Financially speaking , it’s very frustrating for me as an obstetrician practising in public . The cheapest ultrasound in public facilities costs 1,200  and clients must pay for it . Drugs are bought out of pocket and surgery needed in between pregnancy such as the Mc-Donald stitch (to prevent 2nd trimester losses in clients with short or incompetent cervix) are paid from the pocket. Of course there is some added relief for NHIF card holders depending on the type of NHIF (with the national cover KShs.500/month scheme users mostly getting a raw deal in outpatient services especially in private facilities). 

I have had crazy experiences . Like a client requiring a Mc-Donald stitch deciding to carry on with the pregnancy without it because of tight finances . The other alternative would be daily vaginal progesterone insert which cost upward of 100-200 shillings per tablet ; a husband once told me that their rent was 2500 per month and they were in arrears so 150 shillings tablet per day would drain them and so they were ready to lose the pregnancy if it came to that . 

I once advised a client that the Shs.5000 Anti-D injection was mandatory for her and she just laughed and brushed it off ; where would she get such an amount if she had to trek to avoid paying the 50 shillings motorcycle transport fee . The effects of lacking the injection can be catastrophic and could lead to an irreversible life long pregnancy losses . 

I still wonder why the government insists on Hepatitis B screening for all pregnant mothers yet the follow-up tests and drugs for those who turn positive are just out of this world to the common citizen in terms of costs yet not available in public facilities . 

I have had to come to terms with a lot in practice and not just to pregnancy related matters . If you suffer from  infertility and you are poor , you are likely doomed if you have an irreversible condition . The tests themselves are exorbitant and procedures such as InVitroFertilization are too expensive unless well covered with a rich insurance cover . 

One night, my covering-nurse on duty called to inform me that the referral facility had rejected a client we had referred because they had no I.C.U space . She was to look for deposit money running into hundreds of thousands and get a slot in one or the neighboring private ICUs. This client  had been brought by good samaritans drunk like a kite from a cheap drinking den ; how on earth was she to afford Kshs. 300,000? We called her relatives and they told us that they didn’t want to be involved because that amount was a dream to them and could be called to collect the body in case she succumbed . In my naivety, I called a senior to try and negotiate for ICU space in private then the government hospital could pay up with Linda Mama ; he duly educated me on the limitations of this scheme and how impossible it was but promised to give my client priority if an ICU bed became available. I remember crying on my drive home and feeling extremely sorry for the client; the Government had failed her , her poverty had failed her. 

On the contrary to above misery , I have seen the wonders of insurance and NHIF-civil-servant-scheme  in offering outpatient facilities in the private sector . Clients freely get seen by specialists and get high end services without paying anything . The same applies to inpatient surgical services all insurance holders including NHIF-national scheme. 

I was a campaigner for NHIF a few years ago and made videos on the same . I reminded my fans to stop limiting themselves to the outpatient challenges but to look at the big picture in case emergency surgeries are needed , in the event of required dialysis or in the unfortunate diagnosis of cancer . I remember commenting how NHIF was only 20 shillings per day if one was to save up for the monthly fees. A few listened and I pray that they keep up at it despite the outpatient frustrations. 

I hear that there are new NHIF terms ; I’m yet to dig in - but I pray that it doesn’t complicate things further for the needy Kenyan Hustler .

HealthCare is costly and I pray that the government gets to widen NHIF scope for national scheme and improves on services available in the public facilities - the usual unavailability falls squarely on the citizenry who are forced to pay cash in private. 

I also hope that we can one day go back to the free-maternity services which had  a wider coverage and benefit to pregnant mothers and under-5-year-old children. 

The government should also consider providing what has been traditionally viewed as rich-private-facility services . For example , our main national and county referral facilities should offer subsidized fertility services such as I.V.F and minimal access surgeries to all; it shouldn’t be limited to the rich only. 

So there goes my frustrations and takes !! 

P.S : Today is Mother’s Day 2023 , I hope our government enhances the free maternity coverage as a gift to motherhood ; women leaders are you listening?

Update in 2025 - I have since changed employment to a government department with a very organized health department  , NHIF has since changed to SHA, the dollar rates changed and some prices quoted above have since almost doubled , Linda Mama no longer exists; my thoughts on the public health sector still apply.

STEREOTYPES AND SOCIAL PREJUDICES IN MY LIFE

 STEREOTYPES AND SOCIAL PREJUDICES IN MY LIFE 

 I enrolled for a competitive Accounting Course at Strathmore University immediately after my KCSE before the results . I used my mock-exam results to get admission and it was a very good exposure for me. I lived alone in a hostel at Nairobi-West , got a different experience from a full life of Machakos region schooling (baby-class to high school) and made amazing lifelong friendships from people who I had misjudged as being too boogie or too rich-looking to speak to me  . One of excellent programs there was being paired with mentors to guide in day to day life and career paths. When KCSE results were announced, I was elated to had scored an A plain and had my name on the newspapers but what my mentor told me exposed me to a new world of stereotyping . We had only two As in the entire Machakos that year - a boy from Machakos School and myself. She told me ‘oh, you got an A ? But you don’t look so bright.’ I wondered whether it was the hijab , the way I dressed or simply that I truthfully didn’t look ‘smart.’

This was the beginning of many of such encounters . I got a full scholarship to study medicine in a South-East Asia country and I took the chance . I filled in my University of Nairobi JAB admission paper-work just in case the scholarship experience didn’t work out and I could always come back to start school here in Kenya -university placement used to be two years after KCSE during my time, so I had two years to try things out ; one year went to Strathmore University and the 2nd year was my 1st year med school experience ‘abroad.’ I met more stereotyping in my new-country of residence . I was the only black in a class of 300 students. I stood out conspicuously but my initial stay was ridden with many myths/presumptions - there was always the assumption that I must have been a reject in my own country who missed out on university space back home ( this was false , I got the scholarship due to excellent performance) and there was the general vibe that I must have been from an extremely needy background and saved by the scholarship( this was also false if you dear reader know my family background; I’m Zuhura’s daughter goddamnit !!). I remember one time a girl complained that the black African girl must have wrongly disposed off sanitary products in the W.C because of her needy background and possible non-exposure to such toilets ; man, it broke me . So I embraced the stereotypes and ignored others; I worked super hard and got distinctions to their surprise, got comfortable with the poor-girl tag ; this eased the pressure of going out for unnecessarily expensive outings and helped me plan my holiday trips back to Kenya without necessarily burdening my parents with too frequent air tickets . I enjoyed the eased pressure yet I never lacked , I had all my medical text books bought brand new, my fridge was always stocked up, my pocket money arrived by 2nd of every month and I comfortably travelled home every 18 months (instead of every 6 months)which was perfect for me and gave me space to do life-changing electives and medical observer-ships during the holidays that I remained back in the hostels. Did I mention that I never failed in any medical school exam? I had excellent exposures and I was an easy to maintain child. 

Stereotypes followed me back to Kenya when I enrolled for internship . I doubt if anyone wanted to be paired with the Swahili girl . I supposed many feared that I would be a lazy burden and that I may not have been well trained ; because I wasn’t trained locally and therefore the very false presumption that I went abroad for possibly not making the cut for university. My first experience with one of my consultants left me wondering if I would ever be given the chance to prove myself ( surprisingly , the said consultant is now a fellow specialist who respects my abilities very much). Ladies and gentlemen , I outdid myself - I was the best intern of my year in the county , had and amazing time, learned so much and left permanent marks in the hearts of many. 

One time during my runnings at Cottolengo Mission Hospital where I had been seconded as a Medical Officer by the first Meru County Government, I had a nasty experience. I was very passionately involved in the care of a patient and so when the relatives demanded my attention for updates , I quickly decided to skip my lunch and gave them all my time . I went straight to the science of things , risks , possibilities and prognosis as professional as I could be . I was shocked the next day to hear that I had been reported to the office of the then Women-Representative and to the County Director  Medical Services  as that ‘rude Swahili girl who said that ABC could happen to the said patient’.  The DMS happens to be one of my mentors and he demanded to know how rude I was because he knew me as a competent and  compassionate dedicated clinician ; the relatives repeated what I had said word to word  and added that ‘you know these Swahili women are just rude.’ I was acquitted because I had shared scientific facts with appropriate wording and my care was noted to be very optimal. The family must have been in denial and decided to heap blame on the HIJAB which sold me out wrongly as being rude and unprofessional even when I wasn’t . Quite unfair if you ask me . 

I could go on and on . Oh one last encounter that happened recently  ; one day I whipped out my phone to open an app that would help me calculate a pregnant client’s E.D.D quick and she asked me ‘daktari are you going to Google like young Doctors do?’ Oh boy !!! I had to show her the app and why it was necessary for me to know her exact gestation as we carried on with our consultation. She went on to say how I looked too young to be a specialist ( and I figured that I may not have looked the part in her eyes). I felt disrespected and misjudged and so I tactfully directed the client to one of my older colleagues to carry on with the rest of her care ; she missed out on excellent services from me . 

So yes , stereotypes and prejudices are in plenty depending on our social-cultural differences. It’s what we do with them that matters ; they are times you fully ignore or other times use them to our advantage . I have swam through postgraduate training and my entire professional career handling and literally ‘lemonading’ stereotypes ( that’s a new word I just came up with to indicate making lemonade out of lemons). Stereotyping affects us all and can happen at any time , whether it’s in traffic when a man abuses and thinks you can’t drive well because you are lady, or in family gatherings , or in the banks or at the airports where it’s common to quickly remove one’s hijab when passing through customs so as to get an easy pass , or even in our churches/mosques and religious interactions . How many akorinos do you know that have been wrongly labeled as illiterate? how many Somalis have been labeled Al-Shabab because of the texture of their hair e.t.c. 

I have learned that I don’t need to explain myself to beat stereotypes because that can only bring unnecessary heightened awareness and self esteem issues ; be you and let your work or ability or character speak for itself!!

Learn to live , expect and ignore stereotyping because sometimes , it’s not in your hands and there is nothing you can do about it !! Stereotypes will always exist as long as we are of different communities, different races, different religions even different genders! 

Have a lovely weekend!! 

LIFE-FAMILY-CAREER BALANCE OF AN OBSGYN WIFE-MUM

 LIFE-FAMILY-CAREER BALANCE OF AN OBSGYN WIFE-MUM

It’s been years and my trend of blogging and vlogging has changed significantly. If you ask me , a girl grew up and got more responsibilities. Those years of daily blogging right after work are long gone ; I was probably doing it to kill boredom or push the night as I always went home to a lonely and very quiet house . My weekends were for blogging and movies ; not any more . 

Well marriage and especially child birth happened . Marriage wasn’t an issue at all , I still vlogged actively when I was married , but a baby changes everything . Your priorities change and you know that you have an innocent human entirely dependent on you in the world . I would say that my marriage and childbearing happened at the right time ; right as I was completing my postgraduate studies . I am a very focused human and I tend to focus on one thing and give it my all ; Masters of Medicine is one of those things I devoted myself into with my heart and soul - a husband and a baby may not have fitted well in that crazy schedule and many hours of quiet studies and strict sleep and study patterns. True , a number of my relatives were worried that I was postponing the marriage subject forever into my mid thirties but it was well worth it and maturity plus financial freedom had set in before I got into the ‘pingu za maisha.’ 

When my first born ; baby-Q was born , I was thrown off balance . He thankfully came barely a week after my final postgraduate exams . I loved my solid hours of night sleep and day freshness - this disappeared with a new super-breastfeeder Ingoh-omwami baby.  I almost got into postpartum depression and I guess my friends/family couldn’t understand me ; how does a career girl who can more than one nanny if needed and everything she needs get stressed ? Postpartum blues are unique and different for each person due to previous lifestyles . I soon adjusted and snapped into full parenting sacrifice . I learned to take a back seat and delegate . I was a zombie for 6 months due to demanding exclusive breastfeeding. My businesses plummeted and I lost lots of income , my research publishing enthusiasm disappeared(my postgrad professor still awaits my manuscript; I told him to wait till I finish my reproductive cycle), and I stopped focusing on my looks and make-up ; as long as I was clean and with some brain freshness , that was sufficient for me . The new life of having outsiders ‘read maids’ in my house also quite stressed me ; how was I reliant on strangers in my own space ?? My privacy went , my habit of hiding memorabilia disappeared - I no longer cared as long as baby was healthy and fed . 

I started work as a consultant a few months after childbirth . I had outbursts ; I couldn’t understand inefficiencies in the public system especially by fresh men who were not breastfeeding . It was frustrating to adjust . Then came weaning season when baby wouldn’t sleep due to stomach aches and constipation yet I had busy clinics to run and major surgeries on subsequent days . I wondered how I would cope with patient safety in mind. I also live 23Kms from my work place so the idea of driving down with a sleepy head always scared me lots . I used to literally whisper to my baby to sleep well in the night because we were operating on Kajuju or Kawira the next day ; and somehow it worked .  I also did the mistake of hosting in this season ; unadvisable!! The thought of balancing my own sanity , a demanding baby , a busy career and a guest was baaaaaad!! I almost flipped . I remember one day parking my car under a tree and sleeping because the thought of going home to a relative who also expects my attention in my mental fatigue was tiring . So nowadays , I politely decline any unnecessary visits if my schedule is crazy. 

By 9 months , baby was sleeping all night and I had a very reliable nanny . I was fresh and back on my game . It took one senior friend in a related speaciality to introduce me to after-work private practice . He is one colleague who believes in my potential very much and he would always ask me to bounce back from too long a maternity mentality. He even offered me an office space free of charge ; I’m grateful. So I bounced back . I made my first good lump-sum cash  within a week of practice courtesy of him calling me to do a quick major emergency surgery on a client who insisted on a female Muslim Gyanecologist in private; patient paid upfront in cash. That jolted my mind into exploring my potentials and learning to balance . From there it was an upward trend with a fresh mind , a well settled household and a fulfilling clinical practice . I must confess that I probably over-did it sometimes ; it’s like I was paying back for the previously lost few months. There are weeks I would do up to 8 major surgeries in a week far and beyond  and still exceed my public practice expectations. My public clinic became overbooked and my name was spreading fast . I realized that it was possible to be a mother , a wife and Gynaecologist after all. 

I have however have had to create boundaries . I stopped over-doing private work ; I had to drop a few clinics so as to maintain a healthy life balance . I learned that money hunger wasn’t everything , I give my public day job utmost importance , I don’t pick calls after work unless hospital emergencies and I selfishly create some time exclusively for baby and husband. The idea of another baby even popped up( you never know!! check this space ). 

So dear patient , if I insist on surgeries on particular days ; it takes some planning and balance . When I don’t pick any calls post working hours ; it’s because I have designated hours for clients that I have sacrificed away from my family , when I don’t blog/vlog as much it’s because a day only has 24 hours surprisingly, when I don’t entertain coffee dates - it’s because hours are  tight , and when you see in scrubs and rubber shoes mostly - it’s because it’s an easier dress code with no worry on ironing , fashion or discomfort . 

Motherhood made me discover that I’m stronger and versatile that I imagined , I became tough and focused ( if a nanny brings nonsense; they go - I won’t be stressed by work and by an employee), my priorities changed (if you see me with same old car, it’s serving me very well and I’m probably deep into a huge fulfilling investment for my babies), if you see me quiet and somewhat in my own world world, it’s because sometimes I selfishly and unapologetically want space, I don’t work over weekends unless very necessary and I don’t pick unnecessary calls or chats in my family time . For my clients , I would do anything to ensure your safety  and career progression is something I’m passionate about . In the near future expect more babies, more balancing and more school for career progress. 

MY TORONTO ELECTIVE EXPERIENCE

                                                MY TORONTO EXPERIENCE 2019

                                                      DR. KHADIJA MBENEKA ALI

The preparation for electives started way back in January 2019 when we applied; I’m grateful to my referees Dr. Odongo and Dr. Kosgei who wrote my recommendation letters way ahead of the deadlines. I knew that Toronto was my elective choice right from 1st year hence the tag ‘Team-Toronto’ by a section of my classmates; I always took it as a nice little prayer. The group that did the electives in 2017 were full of praises of the program and interacting with Dr. Julie Thorne made me more enthusiastic about an experience in Toronto; she encouraged us all to apply when we sought her opinion and she was ever present to answer any questions regarding expectations in Canada and about the program. 

Many people back home are hesitant to apply to International Electives due to the fear of being just observers, but I was ready to take it all in and learn the most no matter the nature of the elective. It was very exciting when we knew that CPSO certification was an imminent possibility. It was also great meeting Joseph George (Joe) and Salvo Candela in Kenya and this made the many application emails and communications later on bearable. The whole process can be very overwhelming and CPSO is very thorough to fine details but looking back in retrospect, it was definitely worth it. I feel more internationally acceptable as a medic based on the gruelling CPSO process - it’s a major boost for my C.V. 

My visa work was a nightmare but honestly, visa process could probably be compared to having a child; very painful in the process but you easily forget the pain once everything goes through.

 I missed 2 weeks after my colleague had started but thankfully, I was able to recover the lost time through an extension at the end. Without the help from Dr. Spitzer and Joe, I probably would never have made it to Canada.  Joe became more of a brother, it was not uncommon to do correspondence deep in the night; Toronto time, just to keep ahead with the different time zone in Nairobi. He went far out of his way to make sure I made it for my electives and for that, I will always be grateful. I think the first words that come out of my mouth each time I speak to him are ‘Thank you for everything, as always.’  My Heads of Department back home under Dr. Omenge and later Dr. Itsura were also very supportive and prompt to correspondence, readily sorted the many forms to be filled and they agreed to my two weeks extension at the end. I remember Dr. Itsura readily making quick arrangements for my urgent CPSO-Extension paperwork when he was away on other duties; I don’t take all that for granted.

The pre-elective period in Toronto was quick and fast paced. I remember being whisked from the airport by Joe directly to the university to finish up with administrative work so as to avoid getting CPSO work jammed on a weekend, then going to the bank the same afternoon and getting a whole orientation of the transport / subway train system.

I was tired, confused with timings, dirty, sleepy but timelines had to be met to enable me start as soon as humanly possible. It was a good adrenaline start and I endeavoured to keep that pace throughout. I never got jet-lagged because I was home towards 9pm that evening - I quickly adjusted to the time zone. I spent my first weekend in Toronto going through my POWER-charts, preparing for its test, generally exploring Toronto when I could and spent a lovely Sunday with Dr. Spitzer and family. 

WEEK 1

I started my 1^stweek on a Tuesday because the 14^thOctober was a public holiday; it was a short, fully packed period. This week was a bit of everything including the Tuesday academic afternoon and this enabled me to have a quick look of all the units I was going to rotate in. This helped me to familiarise myself with the different locations of all clinics, systems, individual spectrum of conditions per unit and the colleagues who worked there. Looking back in retrospect, I’m grateful with this calculated allocation that was done because it helped me settle in faster and know what was expected of me all-round. I was also very lucky to have had 2 clinics and an O.R day at Paediatric Gynaecology unit; though as an observer in the first week. The main Fellow in the unit is very lovely, she was understanding from day 1 and understood my role as an observer while making me feel useful and as a team player. (I was initially an observer in Paeds-gynae because there wouldn’t have been any time for my training on the EPIC system). Later-on, I was lucky to get an extension and spend a considerable amount of hands-on time at the unit. The main challenge in this particular week was getting lost in the Sick-Kids O. R – I had wrongly presumed that I would find my way easily and that the Mt. Sinai scrubs access would work in the scrub-machines at Sick-kids. Luckily, I had arrived in the unit much earlier and was able to find my way and sort the scrubs issue before the first case started. Lesson learned was to always get familiar with new places a day prior or to ask a colleague before to clear any wrong assumptions.

WEEK 2-3

My 2^ndand 3^rdweeks were mostly in the Mt. Sinai Fertility Clinic (MSF). I was inducted into seeing patients on my own right on the Monday afternoon after attending to a few cases with the consultant (staff) who was covering the day; this was lovely and exciting for me. The most positive thing about the Fertility Rotation is that we had been given notes to read on a wide spectrum of conditions and procedures in the unit. I got my notes while in Kenya as I waited to pick my visa, and this helped me adjust very fast when I arrived; I went through them back at home and mid-air on my way to Toronto. This week was study-intensive for me and it was thrilling getting to participate in the management of real-time cases than can be investigated fully and managed comprehensively due to a more availability of Fertility-Related resources compared to back in Kenya. The consultants were friendly, ever willing to teach and their different patient-pools and approaches complemented each other enabling me as a student to learn and understand conditions from all different angles. One consultant went out of her way to organize for me to have an IVF Procedure Day and this to me was a very kind gesture. Seeing the different procedures was an unforgettable experience. The staff who took me through that day was very lovely and was very eager to teach me and answer my questions. I got fond of all colleagues in the unit and leaving was difficult. I didn’t have any major challenge in MSF. The eIVF patient system was very easy to learn and straightforward. The fact that my days were build up as a block instead of being distributed between other units helped to build my experience continuously and in a more consistent manner. My colleague Elizabeth had rotated there before I arrived from Kenya and this could have easily contributed to me having a softer landing. Reproductive Endocrinology and Infertility (REI) is top on my list of sub-specialisation choice.

I first got a little glimpse of Fetal Medicine Unit on the Friday of my 2nd week. 

I was pretty lost on the first day because I didn’t know what was expected of me; so, I tagged along Fellows, Nursing Practitioners and Consultants alike; whoever was available and seeing a patient. There are no residents attached to the unit, so I had to figure my way around. FMU is more radiology-intense so with or without CPSO, residency there is mostly observership by default. I was lucky to find my way quick by the subsequent allocation to the unit. I mainly shadowed one particular Clinical Fellow. I went from being a lost resident to an enthusiastic one about Fetal Medicine thanks to him. I would also join in staff as they analysed interesting cases we had seen or as they cleared out suspicious findings. It was a good learning point seeing normal anomaly scans then occasionally seeing what different conditions and congenital anomalies would appear on sonography and the delineation from normal. Helping and observing procedures such as Amniocentesis and Chorionic Villous Sampling was also very memorable, and it was very nice to see the nurses and Fellows willing to have me assist. I found the nurse practitioners there to be very skilled in sonography, ever willing to teach and answer questions and are the first and by far the most crucial link to FMU. The association of the unit with Genetics and Genetic Counsellors was also very interesting and conditions that would only be suspected in most low-resource settings would be diagnosed through microarrays etc. In the end FMU helped me with my MFM and YPP rotations because I would make orders knowing in my mind the procedures, protocols of the FMU and the reports to expect. 

WEEK 4-5

MFM was mostly on my 4th and 5th weeks.  It was a wonderful experience as expected especially because I had interacted with a few staff from the unit through the new Fellowship programme in Kenya. It was also very hands-on, and I was allowed to see patients on my own right from day one. As I had earlier written, the brief orientation window in my first week helped me step in into the unit smoothly. The clinics and management of medical disorders were very organized. Different days had been allocated different spectrums of conditions and there was collaboration from Obstetric Medicine Physicians specialized in the different conditions on most clinic days. Haematology day on Fridays was very unique to me. I didn’t imagine that I would learn Sickle Cell Anaemia More Comprehensively in a North American setting instead of Africa as would be expected. You see, Toronto is very multinational, and I always joked that comprehensive textbooks were written with this city in mind. I saw things that I only memorized in exams for the sake of passing. There were separate days for Bariatric/Obesity in pregnancy, Mental Health/Infectious Diseases, Hypertension and Endocrine diseases, Cardiac Disease and Neurological/Rheumatological conditions and Friday was Haematology Conditions in Pregnancy. Pregnancy Induced Hypertension remains one of the key antenatal conditions back home; I learned it more comprehensively during my stay here. Prof. Nan Okun’s clinics were always very engaging and she gave me the push to write/dictate comprehensive notes for new patients right from day 1. This was a confident booster by all means and her positive feedback always meant so much to me.  The many round teachings in MFM were always very captivating. Everybody walks and eats lunch fast in the unit - walking to different buildings over lunch for sessions while eating at the same time and quickly getting back to the clinics briskly to continue with work. The Clinical Fellows and Nurse Practitioners in this unit also treated me as one of them and were always available to help when needed.

Pre-conception care, early neonatal diagnosis and Mental Health Care of mothers is huge in Ontario and at an advanced work in progress. If we could go in that direction as Kenya even just a quarter-way, I believe that the impact would be very significant. This stood out for me very much. 

WEEK 5-6

My mid-5th to 6th weeks were mostly spent in Adolescent Gynae. I was to miss these two weeks due to time lost during visa applications but luckily got an extension. I was happy to be back to Sick-Kids this time as any other resident and not as an observer. I was a free bird because all systems were now very familiar, and this felt very good. The consultants there were also very lovely and were happy with our grasp of paeds gynae concepts. It was easy applying the same to patients. There were lots of learning points and positive corrections as always. Paediatrics Gynae is also very organized and if not careful, one can easily be left behind. There were so many early morning revisions, lunch-time Resident Teachings, journal clubs etc. I decided to be arriving an hour earlier always to avoid missing out on anything and to always have lunch in the office just in case a teaching happens as people munch away their lunch. I learned communication skills for the paediatric population and I’m looking forward to being part of the start of a separate Gynae clinic for the paediatric population back home. This is definitely a Unique age group with a different Gynae approach. The Young Pregnant Parents Program was also very mind-opening. The social and mental needs of pregnant adolescents would be addressed in a more tailored environment. It was also fantastic working with our direct supervisor Dr. Spitzer and being a familiar face, made me even more comfortable. 

No elective experience is complete without mentioning the patients. I always feared standing out as a black-person or patients not understanding my accent but those were just fears after-all. All my patients were extremely lovely, they didn’t even notice that I was a visiting resident and when told, they didn’t mind it, I faced no racism at all and everybody seemed to understand my English perfectly. Whenever I couldn’t answer a patient’s question, I would be honest enough to admit that I would run it through my seniors then we discuss together, and they didn’t mind this; if anything, they were happy.  I felt so much at home, I never felt any different and I saw people from many origins and backgrounds, some who needed interpreters. Eliud Kipchoge and the long-distance athletes somewhat helped to be conversation starters in my elective as this would be a common exciting question from patients when they learned that I was from Kenya. Getting the temporary CPSO License was the best part of this journey; if this is not a career highlight, I don’t know what is!

The mode of teaching in Toronto is impressive. Residents are strictly under a consultant(staff); after a resident sees a patient, the staff discusses it with the resident on the side to see what the resident’s plan is and see the patient later as one team. That was very impactful on my learning. I never faced harshness or correction in front of patients. Every case was a learning point at different angles. Students and Consultants also interact in a more friendly but professional manner; no intimidation or threats. Everyone strives to improve knowledge and patient care. It’s not uncommon to see consultants and residents having a group teaching at a coffee place or in between lunch. Students here are also guided step by step especially in surgical skills; they learn the right methodologies no matter the length of time taken.  Academic times for students are also taken very seriously and residents have to leave clinical duties during the specified academic sessions. I also greatly enjoyed the simulation classes at St. Michael’s Li Ka Shing Centre for different obstetric emergencies; I got to learn step by step on how to do different procedures like B-Lynch, Bakri balloon etc all in the correct manner under direct supervision. I participated in different simulations, sometimes as a team-leader and this made me feel so much at home at UoT. I kept wondering if had truly been doing the right things all along for some sessions we had; especially on a teaching we had on 2nd Stage C-Sections. Nobody treated me like I was from a very poor resource setting and everyone seemed to know a lot about Kenya based on the different exchange programs; I was treated as an equal. Theatre (O.R) sessions were also wonderful ; 90% of Gynecological surgeries are laparoscopic .

P.S : I found it very unique that most Clinical Fellows I worked with were younger than me , you see Med school is a continuous process in Canada ; with no breaks between Med-School and Residency and with a direct transition to Fellowship after Residency . I found the finalist class in residency making decisions on Fellowship positions a few months before their final exams. 

Away from academics, Toronto was lovely. I enjoyed fall and winter. The fall colours would be a wonder for me; I would sit in parks after work and just take it all in and take lots of pictures of nature. I became healthier in Toronto due to the daily walks to and from work; a trend I intend to continue in Kenya. I strived to always take a different route home each day if not dark just to see different things and to relax my mind after work. I enjoyed the multicultural nature of the city; I would be amused by all the different accents and languages at the subways or streets. 

I enjoyed P.A.T.H and understood it very well and this was a blessing to me in wet sliding winter. Winter experience was also a first one for me; when everybody was gloomy about it, I was enjoying the serenity. There were lots of fantastic food restaurants and I made many friends at work. We worked so hard over the week and explored harder over the weekends; I’m good with directions so we went to Niagara Falls on our own with just google-Maps on our side and we had a fantastic time. 

We explored several areas in the city like CN Towers, The Ripley’s Aquarium, Wonderland, many exciting random walks in downtown Toronto and the shopping district at Dundas-Yonge-Queens area. We were lucky to experience different special occasions like the Halloween and the annual Christmas Parade which were totally new and exciting .

Our friends and faculty invited us for dinners and interactions with their families and this was very lovely. I was never alone in Toronto; I found Elizabeth and left Chege behind; I never had dinner on my own and having company from home was great. 

We were accommodated comfortably and had a decent stipend; these are things that made our stay so easy. 

We never lacked, and we had decent warm houses in a safe area to go home to. Our health, travel and professional indemnity insurance covers were also well taken care of. Everything was sorted!

Was Toronto experience worth it? More than worth it!! I would come back a million times. Each night before going to bed I would write down new academic concepts and life skills learned in the day and each day was always very fulfilling. 

ADIOS TORONTO. I still look forward to more learning opportunities in the future. Seeing other Kenyans from Eldoret doing Fellowship Programs in Toronto gave us hope towards getting into similar programs back home or in Canada in the near future.

Asante sana! Mungu bariki UoT ! 

ENDOMETRIOSIS – A COMMON CAUSE OF UNEXPLAINED PAIN OR SUBFERTILITY IN WOMEN

         

It was a tuesday morning and I was dropping my mother to the office.  A local Kamba station was playing on the car radio;I guess her driver or car-wash guys had set it to the station the previous day . A morning show was airing and the presenter was discussing about a medical condition; endometriosis .He gave completely wrong information about it and worse still had a very chauvinistic tone in the discussion. He went on and on about it. He addressed the issue of late marriages and late childbearing as the chief cause of endometriosis and in a way blamed the women who suffered from it.This is false. Imagine a chauvinist having such a conversation in the Kamba language. It was so bad and wrong at many levels .

I was angry because I knew that this was going to cause a lot of stigma and psychological trauma to the many women suffering from it. I also knew that this was going to cause unnecessary fears among the many single women of advanced age who were yet to start child bearing . I was annoyed because he also touched on the very sensitive issue of infertility with completely wrong information. The word ‘ngungu’ should be banned from the Kamba vocabulary completely (that word is unfairly used to describe childlessness in Ukambani) . I wondered why the main stream media was allowed to air such without involving professionals yet this particular station belongs to a powerhouse media group with the capacity to do so. Would they take responsibility for depression and God-forbid suicide that could potentially result from this? How would they track the after effects of such carelessness?

I talked to my mama about the condition in detail and she encouraged me to look for the presenter and correct him. My mother believes that we should use our skills and knowledge for the betterment of society no matter how low in the ladder we feel we are in our respective professions. Once I dropped her to the office, I quickly googled the contacts of the vernacular station and demanded to speak to the said presenter. I also made sure that I dropped a few posts on Facebook and Twitter just to make sure the information reached the right people in the company. When I called, he was still live on air so they took down my number and promised that he would call me back immediately. I’m still waiting for the call ; *I’m tempted to type his name.*

I know a friend of a friend who was divorced by her husband because she had severe dysperunia (painful sex). She was being investigated for endometriosis and was yet to start treatment. She was a young mother of one in her early twenties and was divorced because of a condition she had nil control over. Her very religious Muslim husband could not bear having a wife who couldn’t engage in the ‘procreation exercise.’ What happened to ‘for better, for worse’ in marriage vows?. I remembered the many patients who came in terrified because they were ‘menstruating’ from the umbilicus ,were reassured after learning about endometriosis and subsequently treated successfully. I also remembered Njambi Koikai our strong-girl who has battled pleural endometriosis with a lot of zeal.

Endometriosis is a condition in which normal endometrial tissue (stroma and glands) is implanted in other areas other than the inner cavity of the uterus. (endometrium is the inner wall of the uterus). It is commonly a painful condition and may be a cause of sub-fertility. >>>>>> it’s basically like having many small wombs/uteruses in the wrong areas that swell and bleed during menses and are potentially painful when touched. Imagine concurrently menstruating into the lungs or through the umblicus during normal menses? I hope this paints a clear picture of what really endometriosis is.

The common sites of implantation of this endometrial tissue is the pelvic walls (pelvis is the hollow cavity that holds inner reproductive organs). Other sites include the ovaries, the fallopian tubes, the pelvic wall ligaments , the umbilicus, and in rare cases it can involve bowels, surgical scars, the urinary system, pleura (covering of lungs), the pericardium (covering of the heart ) and even brain.

The prevalence is around 6-10% in asymptomatic women,40-50% in women having pelvic pains and in 20-50% of women with subfertility. The condition has been reported in all age groups including teenagers.

Common symptoms of endometriosis include any of the following symptoms,

1.                      Mostly asymptomatic
2.                   Chronic pain which could present as;  severe pelvic pain during menstruation, severe pain during sex, pain when passing stool, pain during urination and generally recurrent abdominal pains.
3.                  . Subfertility  commonly caused by impaired oocyte pick-up and possibly fallopian tube blockage due to swelling and adhesions caused by severe endometriosis lesions. Impaired ovulation (egg production) can also occur due to endometriosis of the ovaries.     Inferility is a consequence and not a cause of endometriosis unlike what was being propagated by that radio station.
4.    Cyclical bleeding through the anus(may or may not be mixed with stool) and through urination especially during menses  . This may be accompanied by severe pain and discomfort during urination/defecation
5.       Cyclical bleeding through umbilical lesions or surgical scars during menses
6.   Other symptoms – cyclical breathlessness and severe chest pains, severe headaches and even convulsions during menses

So what causes endometriosis?????? The main cause of endometriosis is largely unknown but there are many theories to its cause.  

• 1.       Retrograde menstruation – this is backflow of menstrual blood through the fallopian tubes that can possibly carry with it some endometrial tissues that can be deposited in the abdominal and pelvic cavity. These implants subsequently develop blood supply and thrive where they are deposited.
• 2.       Abberant lymphatic or vascular spread . This where some endometrial tissue is deposited through blood vessels and lymphatic system into other areas
• 3.       Coelomic Metaplasia theory. This is basically where normal tissue in other organs converts to look and act like endometrial lining. This is the common cause of ovarian endometriosis especially in young girls who are yet to start menses.
• 4.       Mullerian remnants differentiation theory.  During the normal formation or development of a girl before birth, what would make male reproductive organs usually disappear so that a girl is born with female organs and vice versa . Sometimes these remnants of the opposite sex can remain in the pelvis and form abnormal tissue resembling the inner lining of the uterus.
• 5.       Post surgical propagation – I have not seen this in the major Gyanecology books that I read but my undergraduate professor always insisted that surgeries involving the uterus such as Caeserian Sections can lead to ‘seeding’ of some endometrial tissue outside the uterus.

There is a large genetic or hereditary predisposition in all the above theories. History of above symptoms in close family members is an important indicator of possible endometriosis.

The diagnosis of this condition is done by

1)      Physical examination – maroon/blue painful lesions may be seen in visible areas such as the outer female organs , anus, scars or the umbilicus etc

2)      Firm hard lesions can be felt on vaginal, anal  and abdominal examinations

3)      Imaging such as ultrasound or CT-scan of the respective locations

4)      Laparascopy – this is the gold-standard of diagnosis and is available in major hospitals including K.N.H and Moi Teaching and Referral Hospitals.

Treatment depends on the symptoms, the extent of the lesions and desired fertility. Pain management can be done using regular pain-medications but definitive treatment of the lesions is by hormonal treatment or surgical excision.

It’s important to see a Gynaecologist for investigation and treatment if having any of the symptoms explained above. This condition is a major nuisance but it should be remembered that nobody does anything to cause it upon themselves. It is very important for correct information to be passed around to minimize the stigma associated with the condition.

Spread the word. I will continue looking for that Kamba Radio presenter so that he gets informed and corrects the false information and mentality.