Give thanks and pray

Further reflections from Honora, a young American doctor in service in Kenya. And please be sure to read Cameron's story in the next post.

Dear Friends and Family,

My first weeks in Kenya have been wonderful. The days are full, eye-opening, and often very rewarding. Yesterday was a truly wonderful day. The two prior were the most intense that I have ever had in medicine, and were quite hard. But I am doing very well, and feel balanced, supported, and so privileged to be here.

The wards are filled with young women; most of them aged 25-35, and most of them dying of complications of HIV or other diseases of poverty. There have been certain moments over the last few days that capture the gravity and intensity of it all; the combination of hopefulness, humanity, helplessness and desperation. The twisted and stirring mix of emotions and smells; one patient sitting at another's bedside, holding her hand or feeding her dinner, the rush of family members that fill the wards during visiting hours, the song of a preacher that hovers over the evening air that feels heavy with death.

I have been lecturing to the 4th year medical students several times a week, and also have had the chance to get to know the group of 4th and 6th year students on my team. I am compelled and intrigued by the students' response to my questions about how they see HIV/AIDS affecting their country and its future. My inner sense of shock and desperation is tempered by their practical impression that things are improving slowly. They hear the census numbers showing a decline in prevalence of disease and are reassured. I can't help but wonder if more people are simply dying, and thus driving prevalence down. I am surprised when their comments revealing an astute understanding of politics in the US are followed by their comment that HIV/AIDS is not a political issue. They explain that making HIV a political issue is a sure detriment to any candidate who broaches the subject, as who can win when they try to campaign on an issue like HIV? No one candidate can show that they have made a difference and it certainly won't make them popular, they explain.

This conversation over lunch followed by one students comment to me on rounds the next day, when we pass by many beds where a pillow is shared by one woman's head and another's feet. "AIDS is destroying our people," he tells me. Rounding on the women's ward, I am struck by how much AIDS has become a disease of impoverished women. I learned recently that when a woman has sex with an HIV+ man, she has a 1/200 chance of acquiring the infection. When a man has sex with a woman with is HIV+, he has a 1/700 chance. What a terrible biologic injustice that compounds the underlying and sobering disadvantages faced by a woman in the developing world.

Last night I ate dinner at a friend named Francis's house. I was invited there with my friend, John, who has lived here before and has many old friends in Kenya. Francis lives about 30 minutes outside of town heading west on Uganda Road . His home consists of a small wooden home with electricity where we dine. Next door is a separate shed with a mud floor and a wooden fireplace for cooking. While we sit in the living room, Francis's niece and wife prepare our feast. Francis works as a driver and transportation director for AMPATH, the HIV outreach program that has expanded to 18 clinics throughout the Western Kenya.

Over dinner, Francis tells me that he is the youngest of 13 children. He has the biggest and warmest grin of anyone I have ever met, his sparkling white teeth shining below his ebony skin, and his eyes and whole body radiating warmth. He explains that in his tribe, value is placed on the number of children that you have, and his parents had many children, even though they couldn't afford to feed or school them. His father was an alcoholic and would hit his mother. And at the age of 11 he left home for the streets. He has endured much in his life. But now he is married to a woman who is not Luya (an unusual thing to marry outside of one's tribe) and he has two children of his own. He has decided that two beautiful children is the right number for him.

At one point Francis asks if doctors in America show compassion for their patients, of if they treat the interaction like a business exchange as he has seen Kenyan doctors do. We speak about the time and resource challenges faced by Kenyan doctors, and one of the other Mzungus (white person) with me at dinner rushes to say that in the states there are many doctors who are also brisk and uncaring. It is different here, I argue. I have the utmost respect for most of the Kenyan doctors and students I have met here, and many are deeply caring. But most do not show the same kind of personalized care and compassion for patients that is expected in the U.S.. I don't know how they could. Daily, they see people dying from things that would be easily treatable at home; they know that their hands are tied, that there is often little that they can do. Before transferring a patient for an emergency operation one needs to check not only if there is an ICU bed available, but if there is a surgeon who will come from hours away to see the patient, if the ventilator is cleaned, and if there is oxygen available today.

I see the kind of care that Francis asks about as a kind of emotional contract between two people, a personal connection between patient and doctor by which both are affected, and where there is trust and hope. I think it is a rare Kenyan and a rare human being who can work in a system with such desperation and continue to show that kind of compassion. For me, this experience and these feelings are all time limited. My reality is one where patients have access to the most technologically advanced treatments; where they can afford hope and compassion. We then go on to talk about the stigma associated with HIV and I answer his questions about HIV virology and the hope for a vaccine.

His children dance. And at the end of the meal we sing Swahili hymnals, give thanks, and they pray. It is a beautiful night.