Week 1
Jambo from Kenya! After barely escaping a rare Nashville snow storm and back to back 8 hour flights, we arrived safely in Nairobi (well, two of the three of us at least; our final companion missed a connection and made it the next morning.) Despite having been here once before, the drive down the hill into Kijabe was just as breathtaking. This idyllic oasis, this “place of the wind” nestled on the mountainside overlooking the ever-widening Great Rift Valley, remains as aesthetically beautiful as ever. With our comfortable guest house and nightly dinners waiting in the fridge, it is easy to lose sight of the reality of ever-present scarcity that exists all around. Yet as familiar faces welcomed me back to the operating theaters on Monday morning, I was reminded why AIC Kijabe Hospital – built from nothing over the past century – remains such a remarkable place. On our second morning in the ORs, one of the surgeons approached us hurriedly and said, “Dr. Jon, please go to the emergency ward, there has been a mass casualty.”
Two matatus – minibuses that serve as the primary form of transportation for the vast majority of the Kenyans – had collided, leaving dozens injured. Unfortunately, this is by no means a rare occurrence in Kenya. In fact, as many were quick to point out, the road between Nairobi and Naivasha (which runs right past Kijabe) is considered one of the most dangerous roads in all of Africa. Overall, Kenya holds the ominous distinction of having some of the most dangerous roads in the entire world. And Kenya is not alone in this reality.
In 2015 WHO released a report showing that road trauma had cracked the top 10 for causes of mortality in both low- and lower-middle income countries. It had risen to number 8 in upper-middle income countries (of note, it was not in the top 10 for high-income countries). Research suggests that road traffic injuries will jump all the way to number three in causes of mortality globally by 2020. And yet the real tragedy will be the mortality disparity, as it is projected that 90% of global road trauma deaths will occur in low- and middle-income countries.1
By the time we arrived in the emergency ward in Kijabe, the mass casualty protocol had already been implemented. A physician team leader and nursing team leader were wearing yellow vests and had already begun triaging patients into three areas. We split up, serving as extra hands to complete primary trauma surveys, perform FAST exams, and assess patients who may have been in need of emergent surgical intervention. The two ORs that were between cases remained on hold, with staff setting up for any emergent cases. Surgeons came to the ER to assist in triage. In the end, seven patients came to the OR throughout that afternoon and the next day for various fractures or major lacerations; all did well. The system worked. The patients who arrived at Kijabe defied the WHO prognostication because the system worked. It is up to all of us to continue the capacity-building that will allow what we saw this week at Kijabe to expand across East Africa and the rest of the developing world.
Week 2
Since its inception over a century ago, AIC Kijabe Hospital has transformed into a national (and even international) center of clinical excellence. And yet the mission of the hospital does not end with clinical excellence alone. As the institution has matured, its goals have expanded beyond care delivery to care systems development and medical education. Over the course of our time here we have worked alongside medicine residents, obstetric residents, general surgery residents, neurosurgery residents, plastic surgery residents, and anesthesia residents and fellows from not only Kenya, but all of Africa (including Cameroon, Somalia, South Sudan, Ethiopia, Gabon, and Rwanda just to name a few) – training at Kijabe and planning to return to either their county or a country equipped to provide high quality care.
Despite once being known as the “neglected stepchild of global heath” surgery (and anesthesia) Africa has an ever-brightening future. I can say without exaggeration that AIC Kijabe Hospital is playing a major role in improving the future of healthcare delivery – especially surgery and anesthesia care delivery – for an entire continent. Yet so much work remains. One of the KRNA students told me that in her home hospital in El Dorat, only 1 of the 40 anesthesia providers has been trained in ACLS. The pediatric anesthesia fellow currently training in Kijabe will return to her native Rwanda as the only pediatric anesthesiologist. While the United States has over 20 anesthesiologists per 100,000 people, much of sub-Saharan Africa has 1 (or even 0) per 100,000. Kijabe hopes to change that. Twenty years ago Kijabe had two operating theatres – today it has eight. A training program that began over a decade ago with a class of 5 KRNA students has expanded to roughly 16 students per year, training over 18 months. For the first time, Ethiopian anesthesia residents have begun rotating at Kijabe, in addition to pediatric anesthesia fellows from across Africa.
More recently the leadership of the anesthesia training program at Kijabe (led by some of the very first graduates of the program under the mentorship of Dr. Mark Newton) has expanded the reach of the training program even further. Every Wednesday and Thursday morning at 0700 sharp, a teleconference is set up between Kijabe, Kisumu (in western Kenya), Somalia, and South Sudan. This week the Wednesday lecture covered anesthesia care of burn patients and the Thursday case conference reviewed the anesthetic management of a 12 year old boy with a skull base fracture (see attached photo). On the remaining mornings, we have been giving lectures to the KRNA students. Throughout the day we continue to teach both the KRNA students and Ethiopian residents, in addition to serving as examiners for the senior KRNA students’ final assessments. We work junior KRNA students on the basics – properly setting up the room, checking the anesthesia machine, and learning how to understand the monitors. We cover more advanced topics with the senior KRNA students and KRNAs, and have been able to teach regional techniques and review more complex topics with the visiting residents (see attached photo of Dr. Meyer teaching ultrasound-guided TAP blocks to two of the Ethiopian residents).
With physician burnout in the United States at an all time high and the realities of the US healthcare system often leading to job dissatisfaction, it is easy to become cynical, even while in training. Here in Kijabe, it is hard to be cynical. Every provider we help train will have a tangible impact on reducing maternal mortality, decreasing morbidity from road trauma, and setting a new standard for anesthetic and surgical care for all of Africa. The residents and KRNAs who graduate from AIC Kijabe will not only be well-trained clinicians, but also leaders in their hospitals and clinics. They will show their communities what is possible. They will be the ones to make health care equity a reality.
Week 3
This was my second visit to Kijabe. After three weeks of early morning lectures, emergency cesarean sections, assessments for the senior students, ICU rounds, and occasionally enjoying the beautiful weather, I came to a realization. Despite being halfway around the world and what many would consider a wholly different cultural environment, I could not help but feel that the things that connect us as human beings immeasurably outpace the things that divide us. To quote Maya Angelou (and yes, via that one Apple commercial) “we are more alike, my friends, than unalike.”
For many years now the most famous of all buzzwords in global health (and development work as a whole) has been sustainability. Though I am by no means an expert, I would offer the hypothesis that true and lasting sustainability – whether in global health or simply in life in general – has less to do with funding or strategy or even mission and much more to do with relationship. Even though I only spent a short three weeks here in Kijabe last April, walking into the ORs this time felt like a homecoming. Our very first day in Kijabe we were walking along the road and a car stopped. Two former junior/now senior KRNA students jumped out and gave me a hug, excited that I had returned and would be around for their assessments. The KRNAs welcomed me back with literal open arms. Programs like Kijabe are built on relationships that starts with Dr. Newton and Mary Mungai and now continues with each new resident that comes through, even for a short while, and becomes a part of this ever-expanding story.
In just three short weeks we learned the stories of so many of the students and KRNAs. They have so many of the same dreams, the same stresses, the same fears as we do. They are getting engaged, planning their job searches for after graduation, paying off loans, stressing for exams, and dreaming of their futures. Of course, I don’t meant to pretend that they also are doing all these things in a starkly different environment than in Nashville. Some of their families are struggling to find food amidst drought, some worry about whether they will get home safe at night, and some will return to positions where they will be the only trained anesthesia provider for their entire hospital or even region. And yet, despite the stark differences and even injustices, we are indeed more alike than unalike.
Today as we said our goodbyes, I had students who just yesterday had failed their assessment come up and thank me for assessing them and teaching them. I had a KRNA call me his brother and ask me to send him photos if and when I ever have children in the future. It is such an amazing honor to be allowed into these lives for a short while. The students’ appetite for knowledge is palpable and insatiable. As I interviewed several of them, their motivations for becoming anesthesia providers nearly moved me to tears. Without exception, they spoke of their desire to lift up their communities, to heal whenever possible with the highest quality care, and to comfort always. While of course I am grateful for the excellent clinical and teaching experience at Kijabe, the relationships are what I will carry in my heart. They will sustain me in this profession, and I can only hope my brief time at Kijabe will help sustain some of them.