Kenyan Pastoral

"Karibu Sana! Be proud to be here my friend! Karibu Kenya!"

“Being proud” to be in Kenya meant that instead of moving towards a less crowded matatu, we would suck it up and share seats in the already packed Toyota minivan. Usually the matatu conductors try hard to make sure every seat is taken- 4 in the rear, 3 in the middle 3 rows and 4 (including the driver) in the front- but this conductor was exceptional in his ability to squeeze 20 people (not including himself) and at least 2 chickens in.

Dave and I looked at each other and shrugged. He passed me the gallon of water he had been carrying and climbed in the back. I shared my seat with a young woman who was holding a live chicken in her arms. On the other side of me was a younger boy, also with a smaller chicken resting calmly on his lap. I myself was holding my backpack and the gallon of water on my lap.

It was to be their dinner for the evening. We drove the 5 or 6 miles to our home, past rolling hills of sugarcane and millet. When we came to our stop, I motioned to the woman that I needed to get out. She stood and the chicken squawked for the first time.

Karibu sana. We were finally feeling welcome in Kenya.

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Though I have reached a point where I am seeing patients completely on my own, I find the work becoming harder and harder.

An elderly woman came in and I noticed that she was clearly failing her regimen. She had been failing it ever since she started it nearly a year ago and she was recently diagnosed with cryptococcal meningitis. (The diagnosis is never made via lumbar puncture, only by serum cryptococcal antigen which in reality suggests disseminated crypto.) She was on her “intensive (induction) phase” phase of po fluconazole- IV ampho/flucytosine of course is not an option.

I was not the only one to have noticed that she was failing her regimen. One of the clinical officers had assigned her to adherence counseling again, to start ABC/TDF and lopinavir/r. She had faithfully completed the course, but had not yet started the new regimen.

The one thing we were waiting for was the viral load. (Resistance testing is not an option.) I wasn’t sure of the point of testing a viral load, but apparently there have been “1 or 2” cases where the patients who appeared to have immunologic failure to the regimens had undetectable viral loads. And so the protocol was to check the viral load before changing the regimen so as not to waste a second line treatment.

I sighed, frustrated by the situation.

The assistant coordinator and one of the best clinical officers at the site smiled at me ruefully. “I realize that those are isolated cases, but that is the way it is.”

By the time she saw me, the patient’s biggest concern was her left leg. It was exquisitely painful to touch and swollen. The skin looked shiny and felt cool. Her pulses were completely intact and the swelling was not localized to a joint but her entire leg.

Definitely not cellulitis or a septic joint or even gout, though the allodynia was striking. Deep vein thrombosis or a deep abscess, I thought. But why?

I looked her. She was 68, but looked like she was well into her 80s. Thin, wasted. Possibly from her advanced HIV. Possibly from some other occult malignancy which would predispose her to blood clots.

“Is there a place I could send her to get an ultrasound of her leg?” I knew even before I asked what the answer would be.

“There is, but she would have to pay. And it would be in Kisumu.”

When we order chest xrays, the patients travel 30km to obtain them and then bring the plain films back for us to read. I worried that the ultrasound would be the same way, and that was not something I could do with any kind of certainty. Moreover- even if we did find a clot, then what? Start her on coumadin? Or lovenox which has better efficacy in malignancies? Right.

So I wrote her a prescription for Aspirin 325mg, hoping that it was something she could afford, and told her to come back in a week so that we could consider switching her ARV regimen, after the viral load came back.

She lives in Rwanda.

There are no data as far as I know that Aspirin will do anything for her venous thromboembolism.

She will return in a week. Hopefully.

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One of the things I love the most is listening to people talk about their families. I love hearing about road trips with sisters and
Skyping with low-tech mothers and fathers that carve field hockey sticks for their daughters on junior varsity.

And I love watching the interaction between family members. Functional and dysfunctional. A bit voyeuristic? I won’t lie- I think this need “to watch and be a part of” is part of the reason I joined this profession. Or rather, the reason I stuck around.

The human condition. The human stain.

Most of the patients who come to our clinic are women, which was surprising to me given the statistics that women are largely underdiagnosed. Every once in a while I meet a young, loving couple, both HIV positive with their children who are negative because they enrolled early enough to prevent vertical transmission.

You hear of grandmothers taking care of their HIV positive grandchildren all too often, but I saw far more of that in New York and New Haven than I do here. In Kenya, HIV affects all generations, all socioeconomic classes, all tribes and ethnicities. I see as many well-dressed English-speaking daughters who bring their mothers in as I do peasant farmer fathers who bring their daughters in.

It is devastating. But in some weird way it also offers me hope. We created the system we have today largely because of wealthy young politically active gay men who would not wait to die from red tape.

Karibu Kenya. Welcome. Be proud to be here.