Costly Surgery

I was surprised by the judicious use of disposable materials in the OR here in Kenya, so I made a list of the staff and the disposable materials used during the first operation that I saw in the OR, an inguinal hernia repair:

Medical staff:
1 Physician (non-surgeon) – equivalent to a resident in the American system
1 Scrub nurse
1 Anesthesia tech
1 Circulating nurse

Anesthesia:
2 spinal needles
1 IV catheter
3x 500 ml IV saline
Lidocaine
Ketamine
2 syringes

Surgery:
1 2/0 chromic suture
1 0 nylon suture
1 4/0 nylon suture
1 scalpel blade
12 gauze sponges
10 mL iodine
2 feet of cloth tape
3 pairs of sterile gloves

Very rough materials cost: $20

Now, here’s a list of the staff and disposable items used for the same surgery in the states. This is from memory, so I’m likely going to miss quite a number of things, but you’ll get the point.

Staff:
1 Attending surgeon
1 Resident surgeon
1 Medical student
1 Scrub nurse
1 Circulating nurse
1 Anaesthesia attending
1 Anaesthesia nurse

Anesthesia:
1 IV catheter
Benzodiazepine to calm patient
3x 500 mL IV saline
Paralytic agent
Propafol
1 endotrachial tube
6 syringes
4 EKG pads
6 pairs of exam gloves
2 feet cloth tape
6 sterile gauze pads
1 Bair Hugger (inflatable warming blanket)

Surgery:
3-4 disposable gowns
10 pairs sterile gloves
6 head covers
6 face masks
3x prefilled chlorhexidine prep sponges
1 Ioban antibiotic skin cover
2 SCDs (inflatable leg compression wraps)
2 foam heel pad booties
~5 impermeable paper drapes
2 light handle covers
1 Bovie skin pad
1 Bovie
1 Bovie tip
1 scalpel blade
6 feet of plastic suction tubing
1 Yankaur sucker
1 suction canister
1 sheet Ethicon Prolene hernia mesh
1 0 nylon suture
2 2/0 Vicryl
1 3/0 Monocryl
1 tube Dermabond
1 island dressing

Very rough cost: $2,000

This is just material costs and does not include surgical fees or any supplies used in the recovery room. Nor does it include the cost for the surgeons, anesthesiologists, nurses, and assistants, which are similar orders of magnitude more expensive in the US.

Now, I’m not going to claim that the outcomes of these procedures are the same. I would much rather have my hernia repaired at a hospital in the States than at the one where I’m currently working, but it was still amazing to see that 100x difference in material costs.

One thing that is the same when you compare Kenya and the US is that people have trouble paying their medical bills. The difference is that in Kenya, you know the price upfront since it's posted on the front wall of the hospital. [Click on the picture below to see a bigger version]



Don’t you wish things were this clear in the US? For reference, 80 KSH
= 1 USD and these prices are still a hardship for many families.

Coolest matatu ride ever

So last week, M forgot the adapter for his computer plug when he went to the hospital for the day. Thinking he would need it, I decided that I would go on an adventure to take it to him. Each morning he drives the 20-25 minutes to the hospital with Mungai but I knew there had to be a way to take a matatu there so I set off.

Three matatus and 100 minutes later, I was deposited at the hospital where I found out that M was borrowing an adapter and didn't actually need it. Perfect. Well, I guess I'll have some lunch before heading back. I can't be too upset about the wasted round-trip because it set me up for the coolest matatu ride ever.

On my trip back, I'd been riding for about 5 minutes when we stopped to pick up a young women and her small child that I'd guess was about 13 months old. The woman was veiled and dressed in several bright kangas (the colorful wraps) and had her little boy in a sling made of another kanga. Her hands were full of fruits and vegetables since we'd picked her up at a roadside market. As she boarded the matatu, she hunched forward to climb in and the child started to slip out. I was seated at the window but the man closest to her appeared to be unfazed by her fratic clutching as the little boy started to fall. I threw my arms open and met her eye and she swung the little boy to me. I untangled him from the now untied kanga and she moved past my row to sit down.

She settled her things but then made no move to come back for the child so I settled him onto my lap with his little head coming up to my shoulder. He was such a warm, soft little presence on my lap but I figured this wouldn't last long. After a few seconds, his little head slowly looked upward to me and blinked and I braced myself for his inevitable terrified cries when he realized that I obviously wasn't his mother. He gave me a good long stare but then simply started looking around. He was amazingly calm and just sat contently in my lap. As we whipped around curves, I held his head to my shoulder and he nuzzled in grabbing my shirt monkey-style.

I had heard that in Kenya, children are raised much more communally with extended family, church/mosque members, and close friends constantly passing the babies around. The babies are incredibly secure in their maternal bonds because the mother is always present to nurse but other people spend a lot of time holding them and loving them. Even knowing this, it was amazing to see it in action because he's never, ever seen me before. And frankly, given his age and the remoteness of where we dropped them, I may be one of the few mzungu he's ever seen.

I watched his mother out of the corner on my eye and she didn't appear to think this was strange at all. She could clearly see me but also wasn't watching me intently like I might hurt him. She just relaxed in the back of the matatu and let him be with me. I'm not sure if he could see her or not but if he could, her posture was signaling that this situation was completely natural.

After about 10 minutes she moved past me to disembark and after she climbed down, I scooted over and handed him to her. She smiled and waved at me as we drove away. It was all so simple. Not a single word was exchanged but the whole experience was so lovely. It strikes me that children, babies especially, are probably as close to a universal equalizer amoung women as you can find. This child's mother and I have almost nothing in common but she shared him with me and I helped her keep him safe for a split second. It was such a great moment and I'm so thankful that I took that unnecessary matatu ride because it turned out to be the best one yet.

Mombasa: Day Two

After two weeks of drinking chai tea, M demanded coffee first thing on Saturday morning. There’s no Kenyan equivalent of Starbucks that we’ve found so far and the concept of “to go cups” is also foreign so we took a seat at a little café for some coffee and pastries.

After the coffee pit stop, we continued to walk until we came to Kongowea, a giant, open-air, second-hand clothing market. There were hundreds of small shops crammed into the area, each selling clothes imported from Canada, the US, and sometimes though rarely, Europe. Second-hand clothes are big business in Kenya and you see evidence of this daily as shirts and hats of American sports teams float by on the street. Apparently post-Superbowl, we’ll see the losing team’s merchandise everywhere according to a local friend. Our favorite so far has been the “Cleveland recycles” shirt we saw last week. Do you think the previous owner knows how recycled that shirt would become?

The owners of the stalls in Kongowea buy clothes by the kilo and typically specialize in one item such as shirts or pants. The upside for us is that all the clothes are in American sizes and I’ve picked up a few skirts and shirts along the way. Other than tourist places, I haven’t seen a single store selling new clothing though I’m sure they exist in certain areas.

We didn’t linger at Kongowea since it’s notorious for pick-pocketing and so we hopped a matatu to Fort Jesus in Old Town Mombasa [that's the flag on top of the fort in the first photo]. Fort Jesus was built by the Portuguese in the late 1500s and then proceeded to change hands a bunch of times.



It is on a gorgeous point of land at the mouth of the harbor. It’s built on coral bedrock so in addition to the fort built above there are rooms and staircases carved into the coral below.





After exploring the fort for a while, we strolled through Old Town which is full of small twisting streets with glimpses of the water if you look down the correct alleys. As previously mentioned, Mombasa is a port city with a very diverse history. At points on our walk, it seemed that we could have been walking through Mumbai, Riyadh, or Nairobi as the neighborhoods shifted ethnically, religiously, and culturally.

We are starting to get the hang of which greetings to use for which people. “Salaama” is said between Muslim Kenyans (who may be ethnically African, Indian, Middle-Eastern or “Arab” as they say here) and is a borrowed word from Arabic (as many Swahili words are). It is currently pretty easy to identify the Muslim Kenyans because the women are veiled and the men wear circular caps; this may change at least for the men after Ramadan. To a non-Muslim Kenyan, you use “Habari” which means “news” in Swahili; “Jambo” is really reserved for tourists. Everyone seems delighted when mzungus make the effort to speak Swahili so we try to use the correct words whenever possible.

We passed several mosques, a Jain temple, and the dhow registration office before making it to our final destination, the spice market. As you can imagine, the spice market is an olfactory delight with bin after bin of freshly ground spices, chilis, peppers, and vegetables used in the Indian-Arab-Swahili fusion that is Mombasa’s cuisine. After a few minutes of haggling, M bought some tea masala (which is currently sipping in his chai as I write this) with the fresh blend of cinnamon, ginger, nutmeg, cardamom, cloves, and black pepper.

Since the sky was now threatening rain, we hoofed it back to the ferry and started the journey home. It was a successful first foray into Mombasa especially braving the Ferry by ourselves so we celebrated by going to bed early and going for a long run this morning. Yes, we know we’re in our 20s and not our 60s but believe us, it’s exhausting being foreign all the time! You should come visit if you’d like to find out.

Mombasa: Day 1

Because of the Promulgation Day that E eloquently described in the previous post, we found ourselves with a long weekend. We took advantage and headed into Mombasa to explore some of the sites in the nearest large city. This journey began on Friday afternoon with a 40-minute matatu ride to the ferry, which shuttles cars and pedestrians from the “mainland”, to Mombasa, which is actually an island (more ferry info later). Once we arrived in Mombasa, we sampled some fresh cassava chips from one of the many vendors immediately off the ferry (delicious), jumped in a tuktuk (a three-wheeled cab-type vehicle, see below), and wove through traffic to a Penny’s (a colleague) house in Nyali (north of Mombasa), who had offered us a bed for the night.



We put down my backpack at the house, relaxed a bit, and then headed out for dinner. In hindsite, because of Ramadan, this weekend may not have been the best week to go to Mombasa to explore the cuisine. The vast majority of the Muslim-owned restaurants are closed for lunch, and many of them are closed for dinner as well. As Mombasa is primarily a Muslim city, this equals little selection. Of course, the restaurant we had previously identified was closed, so we ended up at Tamarind, a famous Swahili seafood restaurant in Nyali, by our host’s recommendation. It was rumored to be the top restaurant in East Africa so we hadn’t planned on visiting yet, but we are so glad we did. We walked through the entrance and onto the patio, which is perched on a cliff overlooking the river that flows past the north side of Mombasa. At this time (around 6:15), the sun was setting, and the view was amazing. See below.



While still admiring the sunset, an otherworldly sound arose from the city; a building cacophony wafted across the river, amplified by the water. We realized that it was the muezzin, or the Muslim call to prayer. The muezzin is heard at dawn, midday, afternoon, sundown, and bedtime. The muezzin (the person) at each mosque climbs the minaret and chants what roughly translates to “hasten to prayer”. Because it was sunset, on Friday, during Ramadan, the call to prayer is apparently more coordinated, so it was actually quite loud. I’m sure you could find a sound clip of the muezzin, but I don’t think it would do what we heard justice. After being here for two weeks, it is starting to feel a bit like home but this sound really brought us back to the fact that we’re sitting in Mombasa, on the Indian Ocean, during Ramadan. This isn’t any old dinner on a Friday night in Cleveland and we talked about how we are so, so blessed to be experiencing this adventure and we are reminded of that during moments like these.

But, as we marveled at the sound and took it all in, this is real life for the waiters of Mombasa and they’d like to seat us now. After eating homemade “upcountry” food for the past two weeks (hearty, little seasoning), we were very excited to try some authentic Swahili (coastal) cuisine. The coast of Kenya has been a hub for Indian, Yemani, Omani, and Portuguese traders for many, many centuries. As a result, the Swahili people are a mélange of these different ethnicities, and their food reflects this diversity as well, in very delicious ways as we soon found out. The flavors of our meal were incredibly robust; we tasted turmeric, saffron, paprika, cumin, and coconut flavors in various elements of our fresh seafood dishes, and I’m sure we missed some. We both agreed that it was the best meal we’ve had in a very long time, especially with the addition of the Tusker beers and the Pimms cup (Pimms is a British alcohol and something we associate with E’s dad; it’s delicious especially when served Tamarind style with banana and cucumber garnishes). All in all, it was a great meal and a very nice start to the Mombasa adventure.

August 27th: A New Day for Kenya

Today is a big day in Kenya. It’s been declared a national holiday and people are even comparing this to a second independence day. Dignitaries from all over East Africa are expected and Kofi Annan as well as other prominent international leaders will also join in the celebration. There are rumors floating about that President Obama might show up but that seems a little far-fetched given the current state of the US economy. No matter who shows up, Kenyans are very excited to celebrate the “promulgation” of the new constitution. Promulgation is not a word we really use all that often but here they mean that it’s the acceptance and start of the new constitution.

I’m going to try my best to explain what happened though of course I’m probably leaving a lot out and misinterpreting some things since it’s pretty hard to explain 60 years of history when you’ve been in a place for 2 weeks. Sorry this blog post is a little dry but we have been living with the news about the promulgation since we arrived so we wanted to share it. Most of this description is from conversations with mzee Mungai over the last few weeks.

The original constitution was designed by a very small group of political leaders in the 1960s. It wasn’t even drafted on Kenyan soil but was written in Lancaster, UK. It was the first attempt to govern Kenya after the British left and as the British flag lowered at midnight on December 12th, 1963, celebrations went off around the country and the Kenyan flag was raised. Jomo Kenyatta was elected president and held this title until his death in 1978. After Kenyatta passed, his VP Daniel arap Moi was elected (using the term elected loosely) and held the presidency until he was constitutionally barred from running again in 2002.

It soon became clear during Moi’s presidency that this particular constitution gave a lot of power to the executive branch and lacked checks and balances. Freedom of speech, for example, was not a constitutional right until 1992. When Moi was “re-elected” in 1988, he didn’t allow the casting of ballots but instead made people stand in lines to demonstrate their vote. Clearly this doesn’t lead to a lot of impartial vote casting and people started to consider the idea of constitutional reform.

As previously mentioned, Kenya is made up of many tribes and with power so concentrated in the executive branch, lack of free speech, and a tribal history, it was quite easy for disparity to spread throughout the country. The President and his ministers were free to squash criticism and could easily allocate money to their own regions or tribes. So while one region might have excellent schools and services, another region may receive no funding for years.

After the 1988 elections and especially after 1992, people began fighting for a more equitable system with checks and balances and a more even distribution of funds and representation from regions and tribes. Still though there was significant opposition to a new constitution from various factions who benefitted from the system.

After Moi’s presidency, the current President Mwai Kibaki was elected and with the help of a ruling coalition promised reforms. These reforms have been slowed by the staggering population growth in Kenya (more than 7%) and the stagnant growth of the economy (0-2% depending on the year). Obviously the massive difference between population growth and economic growth creates a math problem that does not even allow for maintenance of services and makes expansion of services nearly impossible. The frustrations over the inability to achieve reform culminated in post-election violence in 2007 as protestors divided along tribal lines to agitate for changes that benefitted their groups and claim victory for their presidential candidate. Over 1,000 people were killed and 600,000 people were displaced.

This bloodshed marked a turning point though for Kenyans, the majority of whom were horrified that their neighbors were being targeted by tribe or political views. Kenyans are very proud of their peaceful history of self-rule and Kenya is seen as one of the most stable countries in East Africa so the violence was shocking to the average Kenyan. This paved the way for the new constitution.

Among other things, the constitution promises proportional representation from each county (like our electoral districts), guaranteed funds allocated to each district for services, gives significant power to local governments, and includes a bill of rights for Kenyans. It was widely praised internationally and despite fears, peaceably passed via referendum on August 4th, 2010. Mzee Mungai has the dyed fingernail to prove that he voted.

Since the constitution was a compromise, there are still some parts that are “less than ideal” (at least by Western standards) but overall most Kenyans are very happy that it passed. One such element is that the constitution still allows the Kadhi courts (courts for Muslim believers to deal with Marriage, Divorce, and Inheritance) and exempts a portion of the bill of rights for people professing the Muslim faith. Protestors argue that this basically allows one religion to live outside the constitution but supporters argued that the constitution benefitted most Kenyans and should be passed. Since that part only applies “to people professing the Muslim faith”, one could argue that it’s easy to work around but in practice it will clearly be very difficult in some communities. Despite this issue, all the Kenyans that we’ve spoken to are excited about the reforms and the new constitution and acknowledge that compromise with the Muslim community was required to pass the new constitution.

A huge celebration is planned in Nairobi and the army has been practicing for days to be reviewed by the President at the ceremony (sort of like our Inauguration). People here are proud that the constitution passed peacefully and are hopeful for new reforms.

Witnessing this part of Kenyan history has made us very grateful for all we enjoy and take for granted as Americans. It makes you feel ashamed that so many people in our country don’t even bother to vote, let alone pay attention to policy debates beyond snippets on the nightly news. After being here for 2 weeks, you can’t help but feel hopeful for our Kenyan friends and to hope that the promised reforms come through for them.

We have the place to ourselves this weekend since Lucy and Mungai are celebrating with their families. Lucy seemed concerned about leaving us but I assured her that I have a house back in the US and I somehow manage to keep M fed without help back in the US so I'd be fine for the weekend (I said it politely but her concern was fairly amusing). We are going to watch the promulgation ceremony on TV and then head into Mombasa for Saturday to see some of the historic sites.

Quick Observation #1: Socks

Socks are a rare bird in Kenya. Some people walk around barefoot, many use sandals of various forms. Even in the operating theatre, which might be considered the pinnacle of cleanliness, there are no socks. Footwear choices in the theatre include slip-on sandals (like soccer sandals), Croc-like clogs, and high boots, like galoshes. It’s still a little weird seeing so much toe in the OR. I like to think that I’m as adventurous as the next person, but something about wearing communal high rubber boots without socks tickles me the wrong way. Because of this, I’m the cool guy wearing sandals with socks in the OR. So be it. However, yesterday while driving to the hospital, I realized that in embracing the Kenyan love of wearing sandals to work, I neglected to pack socks. Damn. After quick deliberation, I decided that I couldn’t catch anything incurable from these promiscuous shoes, so I went for it. In a way, it was liberating. So far, I report no ill effects…

Dress for Success: Kenya Style

Each day, I get to pick from my collection of skirts and shirts to make an outfit; no one ever wears shorts here. A few of the “skirts” are actually just giant, printed pieces of fabric called “kanga” worn by the Swahili women along the coast. You basically wrap it like a sarong and I like it because it’s just a simple piece of cotton so even if you’re sweaty [which is always], it’s pretty light. I’ve also found a local tailor who has been fashioning a bunch of the kangas into shirts for me and that’s what I’m wearing in the photo above.

The women from the coastal areas typically dress in a similar way but women from “up country” as they call the area near Nairobi will typically dress in more “modern” (their word, not mine) styles like pants or jeans and t-shirts. They believe this modernity is superior but I’m not sure wearing jeans in 90 degrees is progress.

No matter what they’re wearing, Kenyan women dress more modestly than American women of similar ages. Even in “modern” clothes that are fairly form fitting, you don’t see cleavage, upper thigh, or midriff on anyone. Actually, I don't even think I've ever seen a Kenyan woman's knee or shoulder either. To be honest, given the obesity problem in America, we might want to consider Kenyan fashions…but I digress.

To my ensemble, I usually add a hat and sunglasses, copious amounts of sunscreen, and my flip-flops to complete the look. The hat really does scream tourist but since the choice is skin cancer or being passé, I just go with the hat. Plus, it’s not as if I’m a fashion maven in Cleveland so this is all really par for the course.

I’m doing my best to blend in and be respectful, wearing mostly one piece bathing suits except in very touristy parts of the beach. M doesn’t have such problems (other than the need for a hat) since American and Kenyan men wear the same clothes except when some Kenyans are wearing ceremonial dress. I do draw the line, however, when working out. The mwanamke mzungu (white woman) running with M every morning isn’t blending in anyway and there are few people out that early anyway so I wear my regular running clothes then. A few of my roadside “friends” have said they saw me looking “powerful” running with M in the morning and I’m just going to assume that’s a compliment.

Below are two kangas which are always printed with a Swahili proverb or expression. The blue one roughly says "don't tempt fate" and the pink one roughly says “always take care of each other”. The blue kanga used to make my shirt above. We spot new patterns and colors every day and I'm brainstorming other shirt designs that are modest and comfortable.

Tukumbukane siku zote!