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Part I: Chronicles, culture shocks of ‘village surgeon’

 Stethoscope in the hands of a doctor [Courtesy]

My first book, The Chronicles of a Village Surgeon, captures my experiences in rural parts of Kenya, which I will share in a two-part series.

After my training and landing a job in rural Kenya, I would often get frustrated at how a simple disease like acute appendicitis would sometimes frustrate me. The classical textbook appendix patient seemed to elude more often than emerge.

In rural areas, possibly from a delay in health-seeking behaviour, the appendix will land in hospital shouting-from the patient’s face, then the abdomen. Even without lab works, the disease shouts. And that cuts across to perforated peptic ulcers and established bowel obstruction.

The danger is in the prolonged convalescence that accompanies delayed disease presentation.  

Then there are the recurring comments that colour my conversation with the admission clerks and ward managers: “Is this covered by NHIF?” “The NHIF request has been approved!” “The patient has to pay premiums for 12 months.” And so it goes...

Most hospitals boast over 80 per cent of their clients are controlled by the national insurer. As such the funding challenges that abound will be shushed if they are in conflict with NHIF contracts. I have worked in institutions where a Caesarean section cost Sh40, 000 against a contract approval amount of Sh30, 000. The hospital had to operate in the negative hoping to re-scoop the loss in subsequent procedures.

Working in rural Kenya also means dealing with health as a devolved function.

And though some counties have invested heavily in equipment, machines and specialists in the hope of stymying the exodus of patients to the capital. Some have neurosurgeons, oncologists, paediatric surgeons, urologists, yet, the long-held mentality that specialist doctors are only in select cities still reigns supreme.

I receive calls from colleagues in Nairobi wondering why they were handling referrals we could manage in our remote part of Kenya. Some patients have been referred back to my clinic after trips to Nairobi. Reason? They thought that is where they would get the best treatment.

Last week a friend complained how a patient had trouble looking for contacts in a specialised hospital in the city for a procedure that can be performed by a general practitioner or a general surgeon in rural Kenya. The list goes on. Perhaps time will heal this wound. Or perhaps targeted sensitisation is the magical suture.

Culture shocks

Indeed, landing a job out of Nairobi as a pampered cry baby had its fair share of culture shocks. You cry for lack of this special test, that specialized colleague and that critical assistant. But the patient is not interested in all those ‘best way forwards’ and you start looking at what can be done comfortably and ethically.

Sometimes you are emboldened by preceding colleagues, other times you’re inspired by the miraculous recovery of patients previously in extreme condition.

The fiscal space does not allow for that special equipment. And you get caught up wondering whether to set up and operate in an ideal set up irrespective of the burden on the system and the patient.

I had a breast cancer patient who could benefit from removal of the tumour and the lymph nodes in the axilla without sacrificing the entire breast. This arrangement needed a specialist pathologist and a radiologist all armed with their special tools and equipment. Without this it would be too risky to attempt breast salvaging surgery and extirpation.

I offered a referral, but the following week she walked back and demanded mastectomy. She did not care.

A research paper published a while back showed that the overall outcomes after surgery were poorer in low- and middle-income countries-all factors considered. This means chances of dying from the same procedure, carried out on patients of similar characteristics and by surgeons of similar experience and expertise was higher in low-income countries-like Kenya. At the turn of this year, I was part of a global research on outcomes after cancer surgery. After assessing over 15,000 cancer patients across over 82 countries, the findings were similar. Post-operative outcomes in the low-income countries irrespective of cancer stage and procedure type were worse-bringing to the fore the scarcity of dedicated specialized support to the surgeon like intensive care physicians, specialised trained nurses, theatre assistants and the like.  

As a surgeon you see the patients, dictate the procedure, advice on instruments and often direct the assisting nurse. You know your part very well. Then you end up being expected to know the other ancillary support staff’s roles equally as well: what special instrument you need, who can supply it, how the supplier will get to the hospital in case you need their assistance with the procedure and how they are to link up with patient and the procurement department.


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