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Matibabu Foundation – Deepika Parmar, MD

Written by Deepika Parmar, MD, PGY-2 at Kaiser Permanente Oakland Pediatrics Program while on Global Health rotation at Matibabu Foundation in Ukwala, Kenya in October-November 2016.

Matibabu Foundation Hospital is a Level 4 hospital located in Ukwala, Kenya serving the community at large. *Note: Kenya Level 1= pharmacy; Level 2= dispensary; Level 3= Clinic with pharmacy; Level 4= inpatient hospital with outpatient clinic, lab, pharmacy; Level 5= inpatient hospital with intensive care unit and some sub-specialties; Level 6= referral center.* It is primarily privately-funded via Tiba Foundation, Dutch Rehabilitation non-profit organizations for the disabled and other private donors. They have an inpatient unit with laboratory services, maternity services (pre-/post- labor), maternal child health services but does not have ICU level care. They see patients in on-site outpatient medical clinics, HIV clinic, optometry clinic, dental clinic, and pharmacies. They excel in community health-based projects including reproductive health services, cervical cancer screening and cryotherapy, disability support/physiotherapy/orthopedic device fitting, HIV screening, and many other community based projects. Social services and fieldworkers identify families in greatest need qualifying for government subsidies. Many families have been denied but Matibabu has been successful due to their extensive documentation, pictures and testimonials to approve funding for many families in the community. Subsidies entitle families to about $20/day which is the difference between getting transportation to and from medical services, prescriptions, or food supplementation for families suffering from protein malnutrition. Matibabu has also been successful in reducing the stigma of disabilities and creating support groups. The support groups have been particularly productive as they create a larger presence to advocate for better accessibility in the community. They create businesses including poultry farming and small market stands to allow fundraising to support disabled people and their caretakers. The reason this programming is paramount is due to cultural stigma against people with disabilities. It is seen as a bad omen and these kids are often hidden from the community, kept indoors, receive minimal stimulation, socialization and minimal nutrition.

We stayed at Nyaserek Mall Guest House. It includes a “bed and breakfast” type facility but also has a barbershop, internet café and little convenience shop. It’s 3 stories tall. The 2nd and 3rd floor have individual rooms equipped with a bed, clean sheets, mosquito nets, outlets, tiled floors, locks for the rooms and a bathroom with a “Western” toilet (flushable), toilet paper, sink with running water and faucet and bucket for baths. George the caretaker was nice enough to provide flip flops and a kettle for hot water heating so that we can fill the bucket with hot water and cool water from the faucet to take bucket baths. The rooms do come with a towel but I suggest bringing your own towel, pillow and blanket as well. I also brought snacks, power bars, easy to boil foods and we bought a case of bottled water for a trustworthy grocery story in Kisumu. The Mall itself is across from a police complex, next to 2 schools and nearby, the Matibabu Nursing School (recently accredited).

Concerning the communication, Esther (volunteer coordinator) provided us a phone in Kenya. We bought “top up” from Safaricom and Airtel stations (found everywhere) for minutes. For internet we used the phone as a hot spot using a safaricom sim card (airtel had poor service) and bough a data package to be added to the sim card so that we could use the internet to make educational talks, resources, provide NRP cards for the hospital but also to keep in touch with our families back home.

Kevin the driver picks us up and drops us off daily from Matibabu hospital about 5 bumpy minutes away. It’s about a 1.5-mile walk (downhill towards the hospital and uphill back to the guesthouse). Main roads from major cities are paved but the rest are unpaved dirt roads. Be wary of motorcyclists and trucks and buses.

Food: Tea is spiced with maybe cardamom, mandazi sweet breads (donut-like consistency but without all the sugar), eggs and bread for breakfast. For lunch it tends to be heavier with steamed corn cakes (ugali), rice, boiled beans, boiled moong lentils, boiled fish (tilapia) in a broth, boiled chicken in a broth, pulao (rice cooked in stock and tomatoes with beef strips), and chapatti bread.

The community of Ukwala has a large Catholic population but also a Protestant community as well. They have a large farming community for corn, wheat, avocados, cassava, ground nuts, beans, kale, tomatoes and livestock including chickens, goats, sheep, cows. They eat a lot of fish. There aren’t many wild animals just the occasional skittish monkey that prefers to stay away from the community. Kisumu is the largest city nearby with a local airport near Lake Victoria.

Kenya is a land full of warmth. Warmth in the hearts of the people, the love for their community, the gratitude for the resources they do have, and the visitors who make the effort to see them. They have shown us nothing but love since arriving that you soon forget to feel homesick and ignore the lack of luxuries. Kids are extremely lovable and curious, love to greet you, very respectful and well-behaved and thoughtful. People are immediately aware that you are not a local when you are in Ukwala. The patients we encountered taught us so much. The first day we arrived, we met a woman in labor. We were able to teach the nurses and clinical officers how to do a head to toe newborn exam and what things to be aware of and refer for audiology screening and specialists. Every day we rounded on the entire hospital and several times we were able to run rounds with the nurses and clinical officers which was a great experience. We met many adults and children with malaria. We admitted for clinical/laboratory findings consistent with severe malaria: impaired consciousness, seizure, poor feeding, respiratory distress, hypotension, clinically jaundice or other vital organ dysfunction, hemoglobinuria, abnormal spontaneous bleeding, pulmonary edema, hypoglycemia <40mg/dl, acidosis (bicarb <15), severe normocytic anemia (hgb <5), hyperparasitemia >5% or 250,000/uL) or renal impairment. We were able to provide care for twins with extensive eczema and secondary staph infection. We admitted a 23-month old for extensive burns. This opened my eyes to the problem of indoor coal/biomass burning for domestic energy in simple stoves leading to high levels of indoor air pollution and risk of burns and injuries. We counseled many families on moving the stove outside. Other very common admissions include: farming accidents/trauma, CHF, DVT, dehydration, hypertension, malnutrition, UTI/rheumatoid arthritis, pneumonia, viral illnesses and Tuberculosis.

Despite all of these amazing cases on the wards, my favorite experiences were providing LARCs and cervical cancer screening to the many women I met in the clinics. We had twin adult women who presented for Nexplanon placements. One had just had a baby and was trying to convince her twin sister that getting the Nexplanon was the smartest thing she could do for her other 3 kids and their financial status. What I learned from them was that Kenyans, specifically Luo people, believe that a larger family elevated the status of the patriarch of the family because they are seen as being wealthy, responsible and can then serve on counsels and positions of power within the community. Therefore, even if a family was struggling, many men forbid their wives from getting contraceptives. However, the medical community was working on putting the power back in the women’s hands.

One of my most humbling experiences were the afternoons we spent doing home visits to children needing physical therapy. These children had CP, developmental delay, club foot and polio. Many of the kids fail Ponsetti serial casting method due to frequent follow-up required, cost of transportation and need for family support and understanding to adhere to the follow-up. So when they fail, they often are left untreated. Matibabu is able to use allocated funds $500/foot to provide corrective surgery, 6 weeks of long casting, 4 weeks of short casting and minimal weight bearing and then provide regular physical therapy and follow-up. Surgical months are April and December. They also negotiate with the hospital to help subsidize the cost of the surgeries. They then are responsible for post-op follow-up, physical therapy and family education to provide therapy at home daily. There was one home in particular that had 2 brothers who both suffered from bilateral clubfoot. They had difficulty walking, many of the kids would not play with them, the community saw the family as being sickly and unwell, the family had to buy new shoes for them every 2 weeks as they would wear holes through the sides of their shoes, developed weakened calf muscles and suffered from poor self esteem. Matibabu Foundation hospital provided each of them one foot to be corrected in April and were now recovering from surgery and improving their strength. When we arrived for a home evaluation, the kids were playing outside with other kids. They were walking with their dominant healed foot, both feet still in appropriate bracing and in sturdy shoes with thick soles. The corrected foot had healed quite well with good range of motion without pain with stretching. But most importantly, they were more active, happier, improved performance in school and socializing more with the community. The stigma against the family was lifting and they were beyond thankful to the team that identified, supported, funded, and continued to heal them.

In certain cases, Arielle (fellow resident)and I held the responsibility to refuse certain requests such as providing patient care without the presence of a proper interpreter because we felt we would be endangering patient safety but also because the medications available were often different from what we would use. For example, the dispensaries and clinics in certain parts of Saiya County did not have inhalers for asthma control. Therefore, we would give other options for what we felt would be best for patient safety and our own experience and level of training.

We also had a side project building a hand-motorized wagon for adults with polio who had goods to sell in the markets but unable to transport their goods. For example, we met Mary who knitted sweaters. She was able to use the wagon to transport herself and the sweaters to the market!

However, despite a few barriers, we provided teaching on rounds to the nurses and clinical officers on how to perform a newborn exam, how to perform and complete neurological exam, differential assessment and plan for children with ataxia. We also did a formal presentation on NRP and orchestrated a mock code for the hospital staff to practice skills on a newborn SIM doll we borrowed from a nursing school. We provided new updates on the HPV vaccine guidelines from the CDC. We provided a talk to the nursing school on career advice. We discussed antibiotic stewardship due to the overuse in government clinics of antibiotics for obvious viral infections. We provided implanon/nexplanon, IUD placement, cervical cancer screening (vinegar and iodine) exams and cryotherapy. Matibabu Foundation Hospital provided funds/equipment/training for government facilities in the area to provide IUDs, Cervical Cancer screening and implant placements and then follow-up monthly to ensure funding/equipment were being appropriately managed and utilized. We were able to go out the with Tiba group to help provide physical therapy, patient education and nutritional and mobility support directly to patient homes in the community.

We also provided career advice and support for the Matibabu Nursing School. The largest problem is that they have a shortage of health care providers. Many clinics have only 1-2 nurses seeing 100+ patients a day leading to suboptimal care and high rates of burn out. Lines form outside the clinics beginning at 8 a.m.and patients are turned away at 11 a.m. However, morning is the optimal time for people to complete many of their farming tasks to optimize crop growth. But the Matibabu Nursing school was set up in 2014. Was accredited in 2015. They now rotate through 3 government hospitals as well as government clinics and Matibabu Hospital. The nurses complete courses during their first year and then begin rotations their second year including a community outreach rotation.

Further support: Belgium team comes regularly to provide education on physical therapy, occupational therapy and such.  They came our second week. Physicians from Kaiser as well as from Japan come and rotate regularly as well.

Overall we had an amazing experience. We met extraordinary people along the way who made our experience truly unique. They were all warm, welcoming, accommodating but they pushed us to be better physicians; to consider the whole picture, to consider the housing, finances, accommodations needed, transport needs and need for cultural competencies.

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