Parem and Karen are medical students from the University of Ottawa on attachment to TICH for six weeks. They've been in Kisumu for two weeks working at the provincial hospital. Parem is interested in being a surgeon, so he's been hanging out in the surgical ward and Karen is interested in family medicine or pediatrics, so she's been working in the pediatric ward. Parem and Karen generously allow me to visit the hospital with them.
Nyanza General Hospital is the government-run hospital servicing Nyanza province. The cost for a bed in the hospital is 100 shillings per day for adults (about $1.30USD) and 50 shillings for children (about 70 cents US). Seeing the doctor and receiving a diagnosis is free, but treatment may cost the patient. While Parem goes on morning rounds with the head surgeon, Karen and I tour pediatrics with two Kenyan student nurses.
Because there is not enough staff to care for the patients, the hospital requires mothers to stay with their children. Each room holds four or five beds. Sometimes there are two or three children per bed, including their mothers. As we walk through room after room, mothers holding babies look up without smiling. Some mothers are breastfeeding, others are lying, sleeping, next to their dozing baby. Most of the children have malaria while others are dehydrated from diarrhea caused by amoebas. Some have AIDS.
Many children have Burkitt's Lymphoma, a disease rare in North America. Karen and I puzzle over why so many children in Kisumu have this type of cancer. The first sign of the disease is usually a tumor growing along the child's jawline. Then the disease manifests a second tumor on the opposite jaw and, in later stages, causes tumors in the abdomen. It also causes tumors on other parts of the head and face. Many of the children lined up for their treatment have enlarged jaws and necks and distended bellies.
About 10 children are lined up to receive treatment for the cancer. Some sit next to each other on a bed and others sit opposite, on a mattress on the floor. All the children are plugged into IV bags hanging in a row above their heads. Four treatments are administered while the child is an in-patient, then they have follow-up treatment as out-patients. The child's chances of living are good if the disease is caught early enough. Amazingly, not many children die from the cancer. But the treatment is uncomfortable and it's hard to watch as these little ones, between 3- and 10-years-old, take the medicine through needles in the back of their hands.
The nurse giving the treatment goes down the line and shoots a syringe full into each child's IV container. Because the chemical burns as it enters the vein, the usual practice is to insert the syringe into the container and allow the medicine to slowly drip, mixing with the saline solution that will ultimately drip into the child's hand. But not today. The woman squeezes the entire syringe into the container and moves to the next child. Some children cry openly, some sit silently with tears streaming and others just sit quietly, staring straight ahead.
Why so many cases of Burkitt's Lymphoma? The Kenyan nursing students tell us Burkitt's may be a result of malarial infection combined with a strain of Epstein-Barr Virus. Or a malarial virus morphed into EBV. Without a medical background, I'm lost and it doesn't seem clear to Karen, either, how malaria leads to Burkitt's, but it certainly explains why this rare disease is so common in Kenya. Especially in our region of Kenya where malaria is prevalent, killing people every day. Malaria is a tricky illness. Its symptoms are so varied, it can take on the appearance of other sicknesses such as pneumonia, arthritis and flu. People running fevers automatically say it's malaria. People experiencing joint pain automatically say it's malaria. Doctors always test for malaria first. If the test for malarial parasites is negative, then they can treat the real illness.
Parem and Karen have talked to me about some of the cases in the surgical ward, such as a gunshot victim and burn patients, so I prepare mentally as Parem and I climb the stairs. I'm expecting to see some really bad stuff. Parem stands in the hallway and looks toward the first room. He's thinking. “Would you like to see a horrible wound?” he asks. Wanting to say “no,” I say “yes,” with optimism, and we step into the room where a woman sits on the bed next to the door. She's a Mama, perhaps late 50s, and her knee is bent up so her right foot sits flat on the bed. Parem explains she's diabetic and because of lack of circulation, a sore in her foot became a deep tissue infection. It's possible she's also HIV positive, so her body couldn't fight the infection effectively.
Many of the patients have diseases and infections complicated by HIV. Yet, when they come in for treatment, they do not want to be tested for HIV. They would rather not know their status. There is such a stigma around HIV/AIDS, even though campaigns have been launched by the government and NGOs to remove any stigma associated with HIV/AIDS. The patients feel if they are tested and find out they do have the virus, then they wouldn't be able to tell their family and friends. People with the virus are often ostracized or seen as being cursed. It's better for them (they think) if they don't know. But the hospital staff should know. If they're working on a patient who is HIV positive, they should know so they can take personal precautions and so they can treat the patient more effectively. The hospital, however, will not test the patient. Know why? Because the patient won't pay for the the test.
HIV complicates normal illnesses and we see this in the woman who has a foot sore. After Parem and I talk, he points to her foot and she lifts the piece of gauze. I expect to see redness from exposed veins and capillaries, but instead, her open wound is white with pus. The wound covers the top of her toes, the top of her foot and travels up to her ankle, skirting around her inside ankle bone to the back of the foot. She is missing about 1/4 inch of flesh and her tendons are showing. Instead of being horrified, I'm curious and lean in to get a better look. Parem says, “Don't get too close.” And he's right. When we entered the room, a stench greeted us, like rotting flesh. I couldn't imagine the pain of this huge, open sore, but the mama sits placidly on the bed next to the open door as people file by looking in.
This lack of privacy astonishes me. We are able to walk anywhere we wish, enter any room, as the patients lay fully exposed and vulnerable. Because I am with Parem, who wears a white coat and a stethoscope, most people think I'm a doctor, too. I am amazed at the patient's openness and stoicism. Also in the room with woman who has the foot wound is a mental patient. She sits on a mattress on the floor, naked underneath her dress, which is pulled up around her waist. The tops of her feet have wounds thought by the doctors to have been caused by a car running over them. A stranger brought her to the hospital. As Parem tells me about her, we notice she has defecated on the floor next to her mattress. We leave the room, walking past the woman who has replaced the gauze over her foot. I say, “Asante, Mama,” and her face lights up with a huge smile. Parem says her foot requires a skin graft which costs about 3000 Kshs. (about $35 USD), and if she doesn't have the money, they'll send her home until she can pay for the operation. An orderly passes us, entering the room to clean up the feces.
Hospital bed mattresses are about three inches deep and covered with thick vinyl, dark-green in color. The hospital does not provide sheets or pillows, so patients bring their own. If the patients cannot afford a sheet or pillow, they lie directly on the hard, cold vinyl. Their chart is a piece of beige paper taped to the wall, like the beige construction paper we drew on as children. If the patient has x-rays, they are slid between the mattress and the bed springs.
The next room is labeled “Septic” and contains patients with infections. We enter and a different sort of stench slows us down. There are four beds, filled, and each patient has a family member (or two) standing by his side. Parem brings me to the third bed where a man of 50 years or so reclines with his wife standing next to him. The man has a scrotum infection but didn't seek treatment until he could no longer walk. On the rounds that morning, the head surgeon decided to release the patient. But when Parem asks the patient how he is doing, he says his stomach is paining him a great deal. Parem tells me it's possible the infection has spread to the lining of the man's stomach. He presses on the man's abdomen, eliciting a grimace. “I think I'll say something to the doctor on duty,” Parem says. “If his stomach is infected, he shouldn't go home yet.” Parem then indicates for the man to lift his sheet, which he does without hesitation. If you're a man, you may want to skip ahead to the next paragraph. The patient's legs are spread, to keep from touching his testicles, and his scrotum looks just like the woman's foot wound, skinless and white with a thick layer of pus. The infection hasn't spread to his penis, luckily, but his testicles are slightly enlarged and stand out in their bright whiteness against his dark buttocks. I remind myself not to make faces, just shake my head knowingly as Parem talks to me about his prognosis. Again, this man may be HIV positive, which would account for the extent of the deep tissue infection and the excessive recovery period.
In the next bed is a man who weighs about 65 pounds and is dying from cancer. His ribs show plainly and his face is tight skin over sharp bone. He looks as though he's in the last stages of full-blown AIDS. A large tumor was removed from his abdomen a few days ago and he lays on his side, the sheet falling away as a woman replaces it over his jutting hip. Parem knows very little about this patient, so we don't stop by his bed. But I make eye contact with him and the woman, hoping to convey sympathy, because speaking just doesn't seem appropriate. Another patient in this room has a very good prognosis. He was hit by a bus and then the bus ran over him. He lost his left ear and has a huge gash, down to the skull, on the right side of his head. Luckily, the gash is bandaged. His left shoulder has an open wound smeared with antibacterial cream, but he is ambulatory and should recover nicely.
The next room we enter has four beds and four men. Parem tells me about the guy in the bed next to the door. His spinal column has been injured and the young man is paralyzed from his knees down. He looks to be in his early 20s and is laying on his left side, slightly, with his legs bent toward the wall. “I'm going to try to straighten out your legs, okay?” Parem says. The poor guy looks frightened but agrees. He holds the bar over his head while Parem grips his right ankle and presses down above his knee. The leg trembles, the boy's eyes glass over and the knee barely gives. “You must straighten your legs out every day,” Parem coaches, “even if you have to ask someone to do it for you. Every day, okay?” “Okay,” he says. His left leg extends much more easily with Parem's manipulation. The guy is a student from the University of Nairobi who came to Kisumu on an attachment to Standard Charter Bank. He tells me what happened the day he went to the ATM to withdraw funds for his bus ticket back to Nairobi. He then took a boda boda, who obviously saw him get the money from the bank. So the boda boda guy tries to steal his money and when he fights back, he is hit across the back with a large stick, causing the spinal cord damage. “When did it happen?” I ask. “March 28,” he says, “and if I only had a wheelchair I could go back to Nairobi and finish my studies. If I had a wheelchair I could get out of here and get on with my life and graduate.”
Parem and I walk down the hallway and he says, “I think he wants you to buy him a wheelchair.” “Yes,” I say, “that's what he was asking. How much are they?” “The government has made arrangements with a supplier who sells the chairs for about 3000 shillings,” Parem answers. 3000 Kshs is not a lot of money, perhaps $38 USD. Not a lot of money at all if it will get the guy out of the hospital and back to his studies, so he can graduate. He seemed so accepting of the lose of his legs. He's young and healthy otherwise, nice-looking and strong. And stoic. Or perhaps apathetic is a better word.
The next room also has four beds with four patients. The woman nearest the window, who looks to be about 60 years old, is in her fifth day of a diabetic coma. Several family members stand by her bed, one young woman holds her hand, while an orderly empties her catheter bag. Next to the coma patient is a boy who looks to be about 18 or 19. He's from a rural community and burned his hands while tending a fire. The burns were third degree, which damaged the nerves, resulting in no pain. Because he didn't feel pain, he didn't seek treatment. The four fingers on his right hand decayed and fell off. The doctors are trying to save his left hand.
The next patient in the room is a gold miner, 28 years old. His elder brother stands by his bed and tells me what happened. The gold miner went 70 feet down into the mining shaft. A gasoline-powered pump was leaking, so when the gold miner went to light his kerosene lamp, the match ignited the spilled fuel and engulfed him. 80 percent of his body is covered in third degree burns. Without his skin, the young man's face, torso, arms and legs are white. Only the dark skin under his underwear remains intact and unmolested. A semi-circular iron frame covers the length of his body. A sheet covers the frame, but a doctor is inserting an IV into his ankle (because they can find no veins his arms) and the sheet is pulled back, revealing the length of his white and brown body. So young. When I look at the young man's face he looks away. So I take his brother's hand and say, “Pole sana,” (Very sorry), and he bows toward me. It's hard to let go of his hand.
Earlier, Parem told Karen and me about the young man who was shot. The doctors suspect the guy was shot while trying to rob someone, so they weren't as thorough or considerate in their care of him. People here think criminals deserve such punishment and mob justice is common. If a man robs someone on the street and that person yells, “He's robbing me,” people will gather immediately and beat the thief, or they'll stone him, sometimes until he dies. Jackie told me a guy came into the district hospital yesterday who was caught stealing. The crowd stoned him and then set fire to his foot. At least he survived. But doctors and nurses do not like treating “criminals.”
“This guy is nice-looking,” Parem tells us. “He has a nice build but he's probably going to die. And he just looks at you with these pleading eyes.” So we enter the room where the gunshot victim, perhaps 25-years-old, is naked and lying on his right side. He's in respiratory distress, his chest rising and falling rapidly as he struggles to breath. He's looking around the room as he struggles to take in and release air. The area below is heart is slightly sunken where the bullet destroyed the ribs. He has a 6-inch incision with massive black stitches running parallel with his ribs and a tube is going into his skin beside the incision. He also has an 8-inch incision running from his lower abdomen straight up to his chest. This is where they went in to check for damage to his internal organs. Above that incision is a pink spot. Parem and I can only surmise this is where the bullet entered. It is in the exact middle of his chest at the base of his breast bone. Supposedly, he was shot at point blank. A doctor clumsily covers one incision with a folded piece of gauze while the young man breathes rapidly, his eyes moving from face to face. He's dying and his face is pleading, just as Parem described. When his eyes move to mine, I say very quietly, “pole sana,” and it registers somehow on his face, even amongst the distress.
When we go through the door marked, “E.N.T.” I'm relieved, thinking, “Good. Nothing serious can come of ear, nose or throat infections.” I'm wrong. A boy named Michael is sleeping in the fetal position. He has chronic ear infections. In the West, a child with Michael's persistent ear infections would have tubes placed in his ears so fluid can drain, keeping infection at bay. But not here and not for Michael. His ear infection took hold and moved into his skull next to the ear. Then the infection entered the lining of the brain, then the brain itself, which is extremely painful. “He should not be here,” Parem says, “He should have tubes in his ears, not be lying unconscious in a hospital.” The remedy is to operate, removing the infected portion of the skull. “Michael,” Parem says loudly. “Michael.” His eyes open slightly. They're reddened. He can't open them fully, then he's gone again. Michael is 14-years-old.
Next to Michael, sitting erect against the wall, is a man in his early 20s. The left side of his face is swollen out about three inches above and below his jawline. His eye is swollen and the lower lid is pulled open by the pressure. “He came here two weeks ago with a tooth infection and received antibiotics,” Parem says. “But he wasn't given enough antibiotics. The infection flared back up. He really shouldn't be here. What he needed was to visit a dentist.”
The last room we visit contains patients with broken bones. One young woman, about 15-years-old, sits on her bed as a companion braids extensions into her hair. She has a lovely woven blanket fitted over her mattress. She is in traction for two breaks, one below and one above the knee. Behind this girl, next to the window, is Parem's special patient. He brings her milk every time he comes to the hospital. She is mentally and physically challenged. She cannot talk so they do not know her name. No chart is taped above her bed and no family members sit nearby to care for her. She's all alone. Her left leg is broken and the doctors think she was hit by a car. A kind stranger found her and brought her to the hospital. She is malnourished, weighing maybe 50 pounds. She is naked beneath a filthy, gray, tattered sheet. She lays on the green vinyl facing the wall. When we enter, Parem speaks to her and she turns her face toward us. We open the milk and pour it into Parem's empty Dasani water bottle. He tries to hold it to her mouth, but milk pours onto her face and neck.
“I don't want to move her and risk moving her leg,” Parem says “because she'll cry.” I move behind her head and lift the mattress, to elevate her head so Parem can put the bottle to her mouth. “Be careful of your hands under there,” Parem says. When the bottle is on her mouth, she begins to suck the milk like a baby. The bottle sides are sucked inward. “How old do you think she is,” Parem asks. I look down at her bony arms, her ribs, her breasts which aren't developed. There is a thick scab on her head next to my face, properly an injury from being hit by the car. “I don't know,” I say, “maybe late teens.” Since she's extremely malnourished, she has no typical markings of age. Her hands seem tiny, though, as she holds the bottle herself. There is no air left, so milk does not flow. Parem is afraid to reach for the bottle, however, because she might think he's taking it away. So we wait until her lips tire and weaken their hold. Soon we hear air rush into the bottle and the remaining milk goes into her mouth. I lower the mattress and she lies flat once again. Parem pulls a piece of cotton from a dirty wad and wipes the milk from her mouth and from the depression at the base of her throat. She drank 250 ml of milk very quickly and appears to want more. But Parem worries about over-feeding and vomiting, so he asks the young women in the next bed, who are busy plaiting hair, if they'll make sure she gets the other two containers of milk later. They say yes.
When I step to the side of her bed and look at her, she lifts her hand, open palm toward me, and spreads her fingers. I swear she's waving or saying goodbye. I lift my hand next to hers, imitating the open palm and spread fingers. Her face is beautiful and I picture her with more flesh, with a full face. Maybe she isn't waving, because her eyes simply stare. But, then again, maybe she is. I smile and say, “goodbye,” softly, then “kwaheri,”softly, hoping she understands. Parem says she will die and his milk is the only thing prolonging her life. I think he wonders if he should continue to bring her milk.
Outside, bed sheets hang from lines strung across grassy courtyards. Sheet after sheet after sheet fills the courtyard as the staff cleans hospital laundry. Family members also camp out on the grassy lawns, washing and hanging their laundry, lounging mid-day, some sleeping on pieces of cloth spread over the grass. We pass through to the front yard of the hospital, a dirt, rocky expanse, and move toward the guarded gate, toward the busy, noisy highway just beyond the fence. Because Russians paid to have the hospital built, locals say they're going to Russia when they go to the hospital.
We're leaving Russia. Parem and I part downtown. We say goodbye and start to walk away when he suddenly says, with meaning, “Go wash your clothes.” I feel very much like washing my clothes and washing my body and scrubbing my hands, especially after lifting the mattress and being cautioned about what might be underneath. Part of me wants to scour all the filth and germs and traces of rotting flesh away. And another part thinks wiping it away is like wiping away the young woman's waving hand, palm open and fingers stretched. Nothing, though, can wipe that image away. No amount of hot water or soap, and definitely no amount of time.
