A Mission for Medicine
For 24 Detroit-area health care providers, a trip to Kenya revealed their limitations — and renewed their calling to help others
For three days the patients lined up by the hundreds. Some with malaria. Some with AIDS-related diseases. Some with goiters, or enlargements of the thyroid gland, which are typical in countries where people's diets are deficient in essential nutrients and must be surgically removed. Few patients could document their medical history. Many were scared of their health problems. All of them needed help. Isaac, who was 11 years old and accompanied by his uncle, was one of them.
"There's something wrong with his arm," the interpreter said to Dr. Marlene Roth, a pediatrician with a private practice in Birmingham.
It was early morning and the air was chilly from the onset of fall. Isaac took off his hooded coat, then a sweatshirt, then a blue bandanna covering his upper right arm. If Roth was shocked by what she saw, the soft-spoken doctor didn't show it. Isaac's humerus, the long arm bone that runs from the shoulder to the elbow, was broken at the center with half of it protruding through his muscle and skin. It was cracked and dry and massively infected. Perhaps numb to the pain, Isaac showed no emotion either. Roth asked the interpreter how long his arm had been that way.
"One year," she said.
Roth briefly turned around to conceal her reaction. "I think I'm going to cry," she whispered. "I don't know how this kid is still alive."
A DANGEROUS DISPARITY
About two weeks later, Steve James, a certified registered nurse anesthetist and the founder of Kenya Relief, walked into the Imperial in Ferndale to meet me for lunch. For almost five years, a group of Detroit health care providers, led by Elizabeth Studley, who is also a certified registered nurse anesthetist with Henry Ford Health System and C.S. Mott Children's Hospital, have been supporting James' cause. After traveling with Studley, Roth, and the rest of the team to Kenya to document their work, I wanted to talk to James about the changes he's seen in the decade since he established his nonprofit health care initiative.
But something else briefly dominated the conversation. At that exact moment a massacre was unfolding in James' adopted country. Somali militants had invaded the fancy Westgate Mall in Nairobi. They would ultimately kill more than 60 people and wound close to 200 more, motivated by a dizzyingly complex set of political and cultural reasons unknowable to outsiders.
"What's changed? Unfortunately, not a lot," said James, a native of Alabama who speaks with a genteel Southern accent.
James wasn't talking about the violence. Kenya, after all, is no exception in its vulnerability to single acts of terror. What the Westgate Mall tragedy seemed to magnify for James instead was an insidious undercurrent plaguing the continent in which he says life remains fragile and supremely unpredictable. Africa may be on its way to joining the rest of the world in terms of capital investment and the rise of the middle class in cities like Nairobi. That's evident in Western-style malls like Westgate, where the most successful people shop for designer clothes and see movies. But the vast majority of inhabitants in Kenya and other sub-Saharan countries still live in abject poverty while shouldering a massive burden of diseases.
It's a dangerous disparity in quality of life, James said, perpetuated by health care environments like the one in Kenya that is equally poor and unable to pay for working medical infrastructure or the training that specialists would need to treat complex health issues in meaningful ways. As a result, there's an extreme shortage of doctors in Kenya (just one for every 10,000 people compared with 26 per 10,000 in the U.S.) as well as a shortage of fully functioning hospitals.
Compounding the issue is that more than 50 percent of doctors in Kenya work in Nairobi where only 3 million of the country's 43 million residents live, leaving most of the population with no practical options for emergency care. If people are lucky enough to make it to a hospital, usually they can't pay the $400 or more for a typical surgery. There is no comprehensive health insurance, so hospitals have been known to keep patients captive until they come up with the money. These patients end up getting sicker - and their health problems never really go away.
Some if not all of these aspects of health care in Kenya have a way of dovetailing in chaotic fashion, said James, who remembers being "blown out of the water" during his first experience in an operating room at a private hospital near Migori. "Clinic" would probably be a more accurate term to describe it, as these health care facilities in rural Kenya are typically small and ill-equipped, lacking basic medications, tools like X-ray machines, or even a blood supply in the case that a patient might need a transfusion during surgery.
This particular operating room where James was assisting had an anesthesia machine "that must have been 40 years old." It had a leak in it and had contributed to the death of at least one patient on the operating table. Still, the Kenyan doctor continued using it because it was the only one the hospital had. He was not the anesthesiologist but the surgeon, and he was not trained in how to keep patients safe and pain-free during surgeries. He had access to one narcotic drug, but didn't know how to use it. He performed the surgery anyway - the birth of a baby by cesarean section.
"Doctors resort to archaic, primitive methods of anesthesia, which are really sort of barbaric," James said. "People end up feeling pain. They can end up dying for what should be a safe and simple procedure."
The modern medical missions performed by Kenya Relief and other countless organizations around the world are continuing to fill this health care gap in Africa, but there are limitations, James said, especially when doctors and nurses who are capable of intervening surgically cannot be as effective as possible because of a lack of resources. "It's extremely difficult to go on a medical mission to a Kenyan hospital," James said. "Even if the doctors are prepared, they might encounter significant problems where they can't do the surgeries because of machine problems."
With the Brase Clinic, James hopes to keep attracting general doctors and specialists who can intervene and treat a spectrum of illnesses. Kenya Relief is also raising money to build a much larger hospital in Migori that can accommodate more people and is equipped with the high-tech tools that doctors need to diagnose and treat patients.
Normal childhood accidents like climbing a tree, falling, and breaking an arm - as what happened to Isaac - are fixable with comprehensive care. In Kenya, however, a year can go by with no fix at all, turning an accident into a preventable tragedy.
"I'm not sure that Isaac will ever get his arm fixed in Kenya," said James, who did not accompany the Detroit team but travels to Kenya several times a year to work with other volunteer medical teams from across the U.S. "It's a highly specialized procedure that would require a bone graft, and that's rare even in America."
This same concern, of course, weighed heavily on Roth and her colleagues from metro Detroit who staffed the Brase Clinic for those three days in September. Isaac's case, and the countless other adults and children who came to them for help, exposed the major challenges of even highly experienced medical teams. It was a fascinating look into how doctors, stripped bare of their normal support systems, must find ways to deal with the reality that all health care providers at times are vulnerable and limited.
"People have to be very open-minded, very flexible about the unknown," said Dr. Gregory J. Basura, a surgeon and associate professor at the University of Michigan who traveled with the team to Kenya and had experienced similar challenges during a medical mission in Asia. "People have to be able to cope."
Some of the team members, like Dr. Lydia Donoghue and Dr. Kellie McFarlin, are general surgeons in their day jobs with Children's Hospital of Michigan and Henry Ford Health System. Some, like Basura and Dr. Lamont Jones, specialize in surgery of the ear, nose, and throat. All of them delivered highly technical care during their time in Kenya, performing 66 surgeries over 72 hours along with the assistance of anesthesiologists, nurse anesthetists, surgical techs, post-operative care nurses, and a lone pharmacist.
None of them specialized in orthopedic care, however, even though they all knew that Isaac's catastrophic injury might eventually kill him. This hit Roth, the only pediatrician on the team who saw every child who walked through the clinic doors, perhaps the hardest. She also marveled at Isaac's ability to survive. "Honest to God, if this had been an 11-year-old in America, he would have been dead," Roth said. "I don't know what it is with these kids. They're so resilient."
A couple of hours later, Isaac sat in a different treatment room, expressionless, as Roth, McFarlin, and Jones examined his arm and discussed possibilities. Roth had already learned - though the interpreter kept giving different accounts - of what had happened to Isaac in the year since his fall. Apparently he had initially gone to the local government hospital. A doctor had tried to put the arm back together. But the bone popped out again at some point. He had never received antibiotics. Now, it looked as if gangrene had set in. There was a strong odor coming from the wound.
"You look at it and you think, it's only a matter of time before he goes septic," Roth said.
It was a heartbreaking dilemma for the doctors who could only speculate about a temporary solution that might make Isaac feel better, but come nowhere close to fixing the problem.
"So what are you saying, cut the bone below the skin here and see what happens?" McFarlin asked Jones.
"I mean, I don't know," Jones said. "If it can't be reconstructed, what would be the point of saving the arm?"
A small amount of hope was in Isaac's right hand. He could still move it even though the elbow appeared to have "turned to stone," Roth said. As her colleagues continued to discuss options, she called a friend at the Detroit Medical Center - Dr. Henry Goitz, an orthopedic surgeon and specialist in sports medicine - to tell him the story and get some direction. He could only say what he would do in Detroit in an ideal environment.
"I would salvage the arm and get rid of the infection as best you can," Goitz said through the iPhone speaker. "If the arm is still functional, I would try to save it."
How Isaac would go about getting his arm saved after the Detroit doctors left was another matter, and this exposed another serious challenge of working in environments where long-term care is unavailable. That's why the concept of "medical tourism" at times can be dangerous, said Basura, especially if doctors are expecting to perform in an environment based on what is available in their home country. Instead, medical care providers must drastically shift their thinking - and must be extremely careful in administering help based on what the patients will have at their disposal after the doctors leave. Doctors may want to be as integrative as possible - their natural instinct is to fully cure the patient, after all - but Basura said professionals must take into account all the deficits around them and work with what they have.
"How much are we really helping?" Basura said. "Are we setting them up for a better quality of life, or are we setting them up for a harder road?"
Ultimately the Detroit team had to work within this framework with regard to Isaac, knowing they would be unable to fully fix his arm because of the extent of his injury and their limited knowledge of orthopedic medicine. They administered intravenous antibiotics to Isaac to guard against possible sepsis. The next day Donoghue clipped off the portion of the humerus that was dead and cleaned out the wound, getting rid of Isaac's local infection as much as possible. They gave him pain medication and a Michigan T-shirt. For the first time Isaac smiled. He seemed to feel better, but his future was so uncertain.
"There's the difficulty of knowing what you want to do, but not knowing how to do it," Roth lamented, "And not knowing if you'd ever be able to do it even if you could, and not feeling comfortable just putting a Band-Aid on him and sending him out into the world."
A CRISIS OF CARE
Beth Click is a full-time volunteer with Kenya Relief at the Brase Clinic. Like James, she is a native of Alabama. A surgical tech at home, she felt a calling two years ago to stay long term in Migori after her first medical mission. Click has sympathized with all the health care workers she's seen come and go, knowing the feeling of urgency they bring with them when they see a patient who so desperately needs help. But as she's observed, the dearth of adequate medical care in Kenya and the reality that most are living in survival mode every day makes it easier for people to accept whatever circumstances their lives present.
"There's no sense of emergency here," Click said.
Click saw this play out with a young boy a couple of years ago who was waiting in line at another clinic in Migori. She noticed that he began to have extreme trouble breathing, so she pulled him out of the line. As his condition deteriorated rapidly, doctors gave him drugs to help with his breathing, but it was clear he needed oxygen. So they drove him to a local mission hospital, and Click remembers the little boy gripping her hand in the van.
"His eyes were bulging out. I could tell he was in horrible pain. He just wasn't able to get any oxygen," Click said.
They took the boy into the emergency room, which had two beds and one oxygen tank, Click said. But the workers at the hospital didn't seem to think it was an actual emergency, she recalled. It took them five minutes to hook him up to the oxygen machine, but it didn't work and he eventually stopped breathing. For two minutes a Kenyan doctor and nurse did chest compressions, but the boy died. Click said he could have been saved, and that normally extraordinary efforts would have been taken with medication, oxygen, and at least half an hour of CPR.
"That situation just killed me," Click said. "It's just a constant struggle. No one seems to try hard ... It's not just because they don't want to help. It's because they don't have the right equipment, so people just seem to give up."
LEARNING TO HEAL WITH LIMITATIONS
Basura, who performed several surgeries over his three days at Brase Clinic, had one patient whose ear infection was severe. A woman in her 30s, she had gone deaf as a result, and Basura speculated that she suffered from a disease that would eventually erode the base of her skull and cause a progressive brain infection like meningitis. It was something that needed to be fixed surgically, Basura said, but he did not know the extent of the infection because he did not have the imaging tools like a CT scan that would have shown him what he was dealing with.
Basura also did not have a facial nerve monitor, a tool that surgeons like him rely on at home to guide them through procedures where they are working close to critical nerve endings. Without the help of the facial nerve monitor, Basura was concerned about getting too close to the woman's facial nerves and potentially causing paralysis of the face.
So Basura had to make a decision about what he could do to help the woman without creating a bigger health problem. "I went in with the idea of doing a basic surgery to remove the disease, but knowing there was the possibility she would need more extensive surgery down the road," Basura said. "I know in my heart it was the right call. You have to do the right thing under the circumstances. The surgery I gave her would give her enough time until she's able to get that second surgery. But that's the thing - there's always going to be a continuity of care with [health problems] like this."
Countless other patients presented themselves during those three days - some shocking, like Isaac, and others, like babies with asthma or other chronic conditions, who could have been treated successfully and relatively easily at better-equipped hospitals. One boy had inhaled a whistle into his lungs, but needed a specialist who could remove it. Another young boy about 2 years old had traveled 10 hours by van with his parents, who are members of the semi-nomadic Maasai ethnic group of Kenya. He had a cleft palate, and it needed to be fixed surgically. His parents had been worried about him since the day he was born but had not had a chance to get him treatment until they heard that the Detroit doctors would be arriving.
Luckily Jones could perform the little boy's surgery. With similar training as Basura, Jones is the vice chair of the department of otolaryngology at Henry Ford Health System. And like Basura, he's traveled on other medical mission trips and has experienced the dilemmas associated with working out of an environment with significant constraints on resources.
At the same time, Jones has been able to work without red tape or the political problems associated with the health care system in the U.S. that, more often than not, can be just as problematic for health care providers who want to efficiently treat patients. It's a situation that can make these types of medical missions just as rewarding as they are frustrating with their inherent limitations. For example, when Roth saw a young patient with enlarged adenoids, she was able to walk him right down the hall to see Jones. That wouldn't have happened in the U.S., Jones said, where providers don't always have control over who gets treatment or who is allowed to see specialists.
"The art of medicine and the need to make money often contradict each other," Jones said. "But when we work here [at the Brase Clinic] it's not about insurance. It's just about practicing medicine in its purest form. It's about doing the right thing."
"We all go through a metamorphosis with these trips," Jones continued. "It helps us re-energize our practice here and at home, and it helps us remember why we wanted to be doctors in the first place."
The services the doctors performed were not free - James said they charge nominal fees for the clinic's services to attach value to what the visiting health care providers are doing. But the surgeries end up costing about $25 each, a fee that most people can afford as opposed to the hundreds of dollars patients would be spending at a Kenyan hospital. The care is also of a higher quality, James said, and patients are often treated more safely as a result.
As the quest to raise money to build a hospital in Migori moves forward, James was adamant during lunch last September that Kenya Relief will continue to make a difference. He worried about the terrorist attack, which he saw as a setback to people coming to work in Africa where so much humanitarian help is still needed even as the continent becomes an emerging economic market.
“That terrorist attack was devastating, it’s going to hurt the economy, and people will be afraid,” James said. “But it’s not going to distract us from our goal, which is to work with Kenya to provide raw, pure health care. We will continue to grow in every way.”