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Community medicine in Kenya's Rift Valley.

Dr. Seth Sullivan traces his interest in global health to his senior year in high school, when he served as a French interpreter to a surgical team working in Haiti. The experience inspired Dr. Sullivan to pursue medicine, and to provide care for people in underserved areas.

"I knew I wanted to use the skills I would acquire to help those in need," he said, Dr. Sullivan earned his medical degree from the University of Missouri, Kansas City, in 2002. He is currently a third-year internal medicine resident at the Mayo Clinic in Rochester, Minn. He recently spent a month working at St. Mary's Mission Hospital in the Rift Valley of Kenya. St. Mary's is a Catholic center of health care ministry that is owned and directed by the Assumption Sisters of Nairobi, under the auspices of the Archdiocese of Nairobi, Kenya.

What was the nature of your work in Kenya? Were you seeing patients in clinics, in their homes, or both?

A significant amount of my time was spent caring for patients in the men's ward, which is a medical and surgical ward with approximately 50 beds. Many of the patients were recovering from orthopedic, general, or urological procedures. Others were admitted for general medical conditions.

But I also spent considerable time documenting cases of cutaneous leishmaniasis in children attending primary schools in the surrounding community. I worked with a team that included a local dermatologist, an American dermatologist, a local laboratory technician, and an expatriated medical administrator.

How was the hospital staffed?

The full-time hospital staff is all Kenyan--part of the vision of the St. Mary's hospital system is to train and foster Kenyan physicians and other medical professionals.

How is medical education different in Kenya compared with the United States?

It is quite different. After their medical school and internship, physicians work for a few years as generalists before applying for specialty training. They have to pay tuition for all of their training, so many of them moonlight to make ends meet, in addition to following a rigorous residency schedule. They then must work for an unspecified period of several years before being recognized as the U.S. equivalent of a board-certified specialist. Our system seems more objective and standardized.

What types of conditions did you see in the men's ward?

There was a lot of general "bread and butter" medicine, in addition to some of the infections that are more common there, although fortunately the Rift Valley doesn't have as many cases of malaria as other parts of Kenya. My mentor is a physician trained at the Mayo Clinic, Father Bill Fryda, who has been living and practicing medicine in Kenya full-time for more than 20 years. I was shadowing him at the hospital, and we treated teens and older men with conditions including diabetes, pneumonia, malaria, and other types of infections. There were many patients who were recovering from orthopedic procedures, as well as those with burns and chronic wounds that needed dressing changes.

Some of the men were victims of violence likely related to political upheaval that is common in Kenya after an election and transfer of power. At these times, groups of people essentially become refugees in their own country.

What was the protocol for your treatment of children with leishmaniasis?

The objective is to get treatment for the children and to raise awareness of the condition. Our team went to four nearby schools and examined more than 1,000 children. One first-line treatment for many of the leishmaniasis cases is ketoconazole, which is relatively cheap and easy to administer. Part of the protocol involved getting permission to do skin biopsies on children who had active lesions, so we brought equipment with us for that, as well as toys for the kids who had to have the biopsies. We saw some children with mucosal and cutaneous leishmaniasis who needed intravenous treatment with stibogluconate. The logistics of getting those children to an area where they can be treated are among the obstacles that we are still addressing.

We have been trying to send slides to the United States for review so we can confirm the diagnoses of the serious cases (although we were strongly clinically suspicious), and that has been a slow and challenging process as well.

We saw other conditions among children in the schools. For examples, there was a girl with a chronic cough who was very small for her age. We suspected that she had tuberculosis, and we were able to send her elsewhere for treatment.

What were the greatest challenges of practicing medicine in Kenya?

St. Mary's Rift: Valley is a branch hospital that has been open for about 2 years, and they have full medical and surgical capabilities and several operating rooms. But while I was out in the community, the limited resources challenged me to practice in a pragmatic fashion. Lack of access to patient history, physical examination, and the available diagnostic tools shortened my list of differential diagnoses, so I relied more on assessing the response of empiric therapies.

Also, I undoubtedly missed many of the subtle clues to patients' histories because of the language and cultural barriers.

And there are political problems--sometimes the local government wants to know what you are doing, and how they can "help." The reality of taking care of patients there is that you have to play by the local government's rules, which could mean paying a per diem to "helpers" you don't need in order to continue doing your work.

Did you do any patient education?

With the help of an interpreter, we conducted a crude epidemiologic survey that involved questioning families from an area particularly affected by cutaneous leishmaniasis. We talked to them about their understanding of leishmaniasis and how it is transmitted. In general, people knew about it.

Many of them had tried herbal and topical remedies, but because the condition is usually self-limiting, you never know what really had an effect. And some of them would go to local medical facilities, but they didn't always know what medication they had been given.

What were some of the greatest rewards?

I am already anticipating revisiting the many friends I made during the month I spent in Kenya. These friends are my most valued rewards. I learned from their perspectives as they attempted to teach me their language and culture. I was also rewarded by the sincere gratitude of the patients.

What are your next steps for medical training and medical practice? How did your overseas experience impact your vision for your medical career?

This July, I will begin a fellowship in infectious disease here at the Mayo Clinic. I intend to incorporate a significant international and global health experience into the fellowship. This overseas experience served to reinforce my vision of a career in global health. Although it would be fun to experience many new cultures, I suspect that digging in and getting familiar with one area, such as the Rift Valley, is the way to be really effective.

What advice would you give to other doctors who are thinking of volunteering overseas but are unsure of how it may affect their personal and professional lives?

I would advise them that it will affect their personal and professional lives, and it is for this exact reason they should do it. Most of us go into medicine with the vision of helping others. Traveling to an impoverished area of the world reminds us of this vision and renews our passion for medicine in its purist form.

For more information about St. Mary's Mission Hospital, visit www.stmarysmissionhospital.org.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, visit www.wordwidemed.org or send an e-mail to imnews@elsevier.com.

--Interview by Heidi Splete
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Title Annotation:WORLD WIDE MED
Author:Splete, Heidi
Publication:Internal Medicine News
Article Type:Interview
Geographic Code:6KENY
Date:Mar 1, 2009
Words:1308
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