Kate’s time in Kenya

Kate Cottenham

Six thousand seven hundred and sixteen miles, and I felt every single one of them away from home. After months of fundraising, packing and planning my feet were finally planted on the burnt orange, equatorial dust that defines the landscape of Northern Kenya. We had finally landed in Marsabit – a town so remote in Northern Kenya that even the locals didn’t consider themselves as Kenyans.

Earlier this year I had successfully applied to represent physiotherapy in Future Health Africa’s Trauma Team, on this year’s trip to Marsabit District General Hospital, Kenya, with the objective of sharing skills and knowledge with the local teams while providing orthopaedic surgery to trauma patients. Our team was made up of the essential people required to run an orthopaedic theatre and clinic – surgeons, anaesthetist, scrub nurses, ODPs, a radiographer, admin staff, a medical student and two physiotherapists, each carrying a suitcase of equipment. We had joined forces across three South West NHS hospitals- Derriford, Truro and Torbay, with one common goal – to do our bit to help Future Health Africa achieve their vision of “sharing skills, transforming lives”.

After an 8 hour flight from a grey, cloud covered Heathrow, we landed in the dusky Nairobi dawn and were immediately plunged into the infamous Nairobi traffic chaos to make our way across town for the next step of the journey. For those of us not brave enough to endure the endless 12 hour drive to Marsabit, we had opted to take a chartered propeller plane, run by the Christian charity MAF (Mission Aviation Fellowship), to take us to our final destination. MAF run a dedicated service of flying parcels, blood test results, local governors and missionaries to remote areas of Kenya, and our experienced pilot soon put us at ease with his simple words of prayer before starting up the engine. Our two hour internal flight was a spectacular one, covering a range of landscapes from arid desert to verdant rain forest and everything in between until we were circling over the lush green (when the rainy season delivers) national park that surrounds the county of Marsabit. Once the runway was clear of the local goats, we bumped our way over the pot holed tarmac and the propellers slowed in the warm midday sunshine, surrounded by casually inquisitive locals, interested to eye today’s cargo.

For someone who had never travelled to Africa before, these first few hours were slightly overwhelming to say the least. Having grown up in the countryside, there was a strange familiarity to the quiet lack of traffic while stood in the dusty field of the runway, the sound of the birds tweeting and goats bleating, the rolling green hills that surrounded us, and at the same time it was like nothing I had ever experienced before. Already the reality of poverty in Marsabit was evident – the make do and mend shoes on the feet of the observing local children, the bony ribs of the local cattle angularly protruding through their wiry skin and the sight of corrugated houses in the distance was my first glimpse of rural Kenya. As we drove half a mile to our hotel, the feeling of uncertainty about what the week had in store rose in my chest, and while everyone else took the opportunity for a quick travellers nap, mine didn’t quite go to plan.

After lunch we made our way to the hospital for our first ward round of the week and received the warmest of welcomes from the CEO and his team, so eager to tell us about the amazing positive changes they had made to the hospital since last year’s visit. Two new theatres and a dedicated orthopaedic ward were among their proud achievements which they had prepared ahead of our trip, staffed with local health care professionals to join in our team efforts. The welcome seemed to continue at every corner that afternoon and throughout the week, where there was a patient, visitor or staff member from 5 to 85 years old, ready to shake our hands and smile warmly that you were welcome in Marsabit. The only locals who weren’t quite so hospitable were the resident baboons that ran amok along the aluminium roof of the walk -ways around the hospital, making me squeal more than once, much to the entertainment of the patients.

Just as I felt I was getting to grips with the constant lump of unidentified emotion that had taken residence in the back of my throat, I’m not sure anything could have quite prepared me for my first steps onto the general medical wards. Each ward, one male and one female, held around 20 beds, although I’m told that it’s not unusual for each bed to be housing two or more patients – people are used to sharing what little resources they have, even if it is in a hospital setting. The terracotta dust from outside seemed to coat every surface in spite of any efforts to clean the floors, and the derelict bathroom to be shared by the whole ward didn’t see much activity due to the lack of running water.

Arriving from an NHS hospital where infection control, hand hygiene and patient isolation were paramount to stop the spread of bacteria, the lack of clean water was probably one of the most shocking revelations. In a country where the rates of communicable disease are constantly being fought by WHO initiatives to reduce mortality, it seemed a fruitless task when you don’t have the most basic form of cleanliness.

The next day was a whirlwind of organised chaos as our clinic began, and the days continued like this for the rest of the week. By 9 o’clock each morning, a less than orderly queue of not only local patients, but those who had travelled hours by bus, motorbike and on foot, would form outside the consulting rooms waiting to be seen by the “Muzungu” doctors. Due to the geography of Marsabit, our patient group was a cultural melting pot of those from the Ethiopian border to the North, the Somalian border to the East and more Southern areas of Kenya, who all arrived with most of their family in tow. Communication skills were put to the test constantly, sometimes translating through two interpreters to be able to triage for surgery, averaging around 10 minutes for each patient if we were to get through the ever growing queue outside.

Our main objective in clinic was to undertake a brief assessment of each patient to determine if their injury was old trauma, new trauma, arthritis or something not orthopaedic at all. This would then guide whether they needed imaging and ultimately were for surgical or conservative management. This would be a challenge in a familiar patient group where everyone spoke the same language, let alone in three different languages and in a place where the types of common conditions is a very different picture to those encountered in an orthopaedic setting at home. As the trip arrives in Marsabit at the same time each year, some patients had been waiting 12 months or more for our return to have surgery, with very high expectations of our ability to fix things.

It is normal practice in Kenya to travel three or four to a motorbike without helmets or protective clothing which as a result guarantees countless cases of complex orthopaedic injuries and deaths on the roads. As well as road traffic accidents, common mechanisms of injury included accidents at work with machinery due to a lack of health and safety regulation, kicks from restless cattle and gunshot wounds. Just the week before we arrived in Marsabit, there had been a tragic multiple shooting of fourteen people caught up in tribal clashes in the county. The changeable nature of the unforgiving elements in Kenya leading to sudden, long periods of drought can often result in cattle theft and rising tensions between local tribes, which along with the rise of availability of firearms can have tragic consequences. There were also a huge number of mal-union and non- union fractures that had been treated, sometimes very successfully, with twigs and rags from the tribal natural healers; and many cases of osteomyelitis from open wounds that understandably had been unable to withstand infection.

Non-orthopaedic conditions were also a common occurrence in clinic – an ankle swelling that was a symptom of Brucellosis, a shoulder pain that was due to a stroke, and several paediatric patients who were brought to the clinic by their parents for an operation for an undiagnosed neurological condition, who would leave disappointed. This was a heart- breaking part of our role in clinic- because of a lack of outpatient or GP services in the remote surrounding area of Marsabit, often you would be the first clinician to assess a patient or give them any sort of diagnosis. This very often applied to children or infants who had been born with a neurological or congenital condition that was not picked up at birth, and only as developmental markers were missed did the family realise there may be a problem, but with no one to tell them what that was. Disability is dealt with very differently to what we are used to at home- families can’t afford to have high tech wheel chairs and disability aids to help their children, there is limited positive drive for social inclusivity or special schools to support their children with their individual needs. It comes heavily laden with stigma, community exile and unimaginable decisions made by parents in order to maintain social acceptance and normality.

One example which was particularly poignant in the trip was a 9 month old baby girl who was brought to clinic by her mother and grandmother who was translating. She explained the baby had something wrong with her neck as she was unable to lift her head and she wanted “the bone doctors to fix her”. Before I’d even placed my hands on the baby it was clear that she had a neurological condition, with a chest that sounded heavy with secretions, eyes that didn’t track her mother and a very low tone posture. After assessing the baby’s movement, my suspicions were confirmed when she had poor head and trunk control miles away from the babbling, crawling infant you would expect at 9 months, and I realised it was my responsibility to explain this to her mother. Breaking bad news is never easy, but as a musculoskeletal physiotherapist I felt totally out of my depth having to be the person to explain her daughter’s condition to her and that ultimately it wasn’t her neck that was the problem and it couldn’t be fixed. I felt so much sorrow for this poor mother with the knowledge of the long term specialist support and education she deserved and required to be able to look after her baby but with no way to access it. One of the most important conversations of her baby’s life discussed through broken translation with ultimately no solution for her. There was an occupational therapist at the hospital that did provide an outpatient service for passive exercise and a form of sensory play for local children, so I referred her into his care feeling it was a small offering but the only one I had to give.

The sad, interesting and shocking cases continued throughout the week with infected snake bites, osteomyelitis ridden bones and broken hips that had been walked on for months. It was very apparent that in this part of the world, people just get on with things. If you don’t get up and help yourself, go to work, keep looking after your family, there is no one else to do it for you. There’s no government disability allowance, no carers to visit you at home, no free walking aids or community rehab provided. This had a very positive effect post- operatively, in that once the patient was informed that they could go home, they were, more often than not, up and out of bed with little encouragement, packed bags in hand. The sense of community within the hospital was heart -warming. Whole families sat at bed sides listening diligently with furrowed brows to post op instructions, friends travelling for hours to collect new walking aids or providing transport home (albeit on the back of a motorbike).

Our final night in Marsabit was spent in the hotel conference room surrounded by the majority of the hospital staff who had been invited for an evening presentation and dinner before we said our goodbyes. At the entrance to the hotel we were each greeted with handshakes and cheeks pressed together as everyone arrived in their best dress, almost unrecognisable out of their uniforms. The collection of plastic chairs insufficient to cater for all of our guests, extra seats were brought in, pushed against walls, standing room at the back, the quiet chatter of English and Swahili as we sat intermingled with our new friends. The heads of the table each took their turn to give a speech on what the week had meant to them, to the hospital and to the patients. Much was spoken about development, change and learning as well as words of gratitude and friendship. It was so heartening to hear that the feeling of friendship and togetherness was mutual and to our surprise, we had even been brought gifts as a way of thanks. The locals smiled and laughed as we were each fitted with different coloured hijabs and abayas, and even ghutras for the men in our team, our fair skin incongruous beneath the dark patterned fabric. After a familiar dinner of rice, stewed goat and cabbage, we said our final goodbyes, hugs and kisses surrounded by hopeful promises of returning next year before returning to our rooms to reflect on the week.

The continued professional development gained from the trip was invaluable – nowhere else would you have the opportunity to work so closely with specialist teams sharing ideas and discussing patients with the scope to follow the patient from triage to post op understanding each step of the way so well. Working in Marsabit had undoubtedly allowed development of communication skills both inter-professionally and clinician to patient; forced adaptation of physiotherapy skills with the limited resources and broadened knowledge of orthopaedic and non- orthopaedic disease.

As a physiotherapist who ordinarily only sees the very beginning or very end of the orthopaedic surgery pathway, the opportunity to work side by side with a team, with such a wealth of orthopaedic experience to share, from start to finish was insightful. To both listen and contribute to clinical decision making when selecting a patient for surgery, accompany that patient on the way to the operating theatre, observe the operation stood shoulder to shoulder with the surgical team and then assess the patient afterwards on multiple occasions. It supported a depth of knowledge of anatomy and physiology and brought to life the 2D black and white xrays we are familiar with scrutinizing through a computer screen. The approachable nature of the team promoted inquisitiveness and clinical reasoning with encouragement to ask questions and explore shared ideas- something that at home would require a lot of confidence in the alien environment of an operating theatre. There was a feeling of camaraderie built from keeping each other company on a 10 hour flight, eating dinner together every night and sharing stories about uninvited insects in our bedrooms as well as respecting on another’s clinical ideas and suggestions within the hospital.

This trip was however, far more than an interesting addition to your CV, but an experience to enrich you as a human being. To travel to a part of the world that is so incredibly different to home, to see not only the poverty, the disease and the great need for development, but also the amazing welcome we were given, the smiles and the handshakes – all of the things which remind us that we’re all human and this is just another day for the people who live there. We would leave for another year and this would all continue without us only hopefully with some small positive changes supported by our shared learning experience.

We had gone to Marsabit in hope of changing lives, and yet we had all come away feeling as thought it was our lives that had been changed forever.