Kenya Doctor's Strike Week Ten: A possible end in sight, and reflections on what we've learned

The strike that seems to never end has some glimmers of hope over the last 24 hours.  The doctors have signaled their willingness to accept a less than 300% salary increase if the government also addresses promotions, education, working conditions, and staffing.  It seems a Human Rights commission in Kenya is mediating talks now.  Which is good, because many humans have had no right to a safe delivery, a bound up wound, a course of antibiotics, or anything else for the last 2 1/2 months.  Pray that the government and the union respect each other and follow through on their compromises.

For the rest of us, the end, if it comes this next week, will be none too soon.  We are tired.  For six of those ten weeks (subtracting our trip to the USA for Christmas/Serge meetings) we've been acting as intern, resident, and attending on Paeds/Newborn Unit/OB for our local sub-county government hospital.  Rounding on every patient on our services, writing dozens of notes a day, routinely doing about five admissions per day, every blood draw, every conversation with relatives, many IV's.  Trying to teach the nurses and the limited clinical officer coverage. Working 6-7 days a week and some evenings and nights.  Our colleagues have been pushing themselves hard at mission hospitals with increased admissions.  The entire public health system cannot shut down without consequences, and even with extra efforts those who are standing in the gap can't do so indefinitely at this pace.

Today was a 3-deaths in 24 hours day, topping off a 6-deaths in 5 days week.

So while I and others feel totally spent, I've also been reflecting on how these six weeks give me insight into the life of our Medical Officers in rural hospitals, the bulk of Kenya's health care system.  Young doctors finish their internships, and then get posted all over the country.  And perhaps some of them feel like I do right now.  Here are what I see as the biggest challenges:

• Being the only one.  Always. No sharing the burden, no input on hard calls.  When you take a break, you do so knowing that people will die, no one will stand in your place.
• Being pounded by death after death, and acuity beyond your expertise.  The people who come to public hospitals have complicated and advanced problems.  They are the school kids hit by a car as they walk home, left with a skull fracture in a coma.  The nearly-40 mom who finds herself pregnant after raising a family, and struggles to have enough milk to breast feed, bringing in a severely (30% drop) dehydrated baby.  The 3-year old whose mother waits until hours from his death to finally come to the hospital, and get the diagnosis that they both have AIDS.  The 14-year old who gets pregnant at school, and whose illegal abortion attempt results in a live crying preemie that gets brought in.  The mom with a 6-month old coming from the western regions to look for work, bringing a severe case of malaria with her.  The women with no prenatal care, who carry in preemies they deliver on the way.  And on and on, all of the above just from the last few days.
• Being innovative with what you can manage.  Like today, holding tubing under water looking for leaks and taping over them, to improvise more CPAP set ups because I had 4 preems at 28-30 weeks all on this breathing support.  No functional thermometer one day, no xrays the next, and on and on.  And I have oxygen (most of the time) and lights (better with a new generator) and more supplies than most.  For the real upcountry medical officers, it's draining to always lack the means to do what you know you could.  
• Daily doubting your own competence and feeling like giving up, when another baby dies.  The evil in this world seems to have no end (technically we know it does, but that's by faith not sight) and an extension of it is the self-condemnation of failing another family, or the lethargy of steeling your heart against caring.  Even after 2 1/2 decades, I have found this very hard.  It reveals some ugliness about wanting to feel like it is ME who makes a difference.  It's a real struggle.
• Being far from family, for most of them, and us.  Which makes the loneliness of the posting more acute....

Yes, there are also some great things about this work.  There is a satisfaction of giving care that no one else will give.  And if you can look at the 82 babies who went home alive in January instead of the 11 who died, that's hopeful as well.  There is the intellectual stimulation of a wide variety of cases.  There is the direct contact with allied health colleagues, and with families.  There is the personal challenge to learn and improve.  

But some days all of that doesn't feel like much.  Even though it's been a challenging time here during the strike, I have hope that it will end next week.  If I was a Medical Officer in Turkana, I'd be going on like this all year.  Or two.  Or three.

So I'd like to think about some of the things that keep us going, to share now while we're in the thick of it, as a way to think about perhaps reaching out to this group of young doctors in the future.

1. Community.  The last couple weeks as I've felt overwhelmed, I made a What's App group with the Kijabe Paeds docs.  Some offered advice.  Some offered sympathy.  Some both.  A particular shout-out to Mardi who has been a great sounding board.  I know the MO's who graduate from Kijabe often text Ari.  That's a great ministry.
2. Lament.  It's good to take a few minutes with a grieving mom.  To acknowledge it is hard for us too.  And wrong.  Here's a beautiful post by Mardi with a poem commemorating the lives that pass through our hands.  The Bible is full of honest lament.  Don't cover up or accept the injustice and sorrow, name it.
3. Big-Picture Thinking.  Today as I was bemoaning the rash of deaths, I decided to go through the death registry and the admission registry.  The denominator is so often forgotten.  It is much easier to see the failures, the bad outcomes, the miseries than to remember that 8-10 go home well with a life ahead for every 1 who doesn't.  Scott has had super complex patients (severe near-eclampsia had a blood pressure of 200/130 as he started one case, a placental abruption that could have been a disaster, ectopics, a ruptured uterus, preterms, postterms,etc.) but in spite of 10 weeks of strike we haven't had a maternal death.  That's something.  Numbers can feel heavy, but in fact numbers can be a great encouragement. (And individuals can too . . the photo is a severely malnourished child, who after weeks finally had the gumption to play peekaboo and smile.)
4. Goals.  Something to look towards.  I think an internal Kenyan medical conference by Kabarek Family Medicine for the upcountry MO's would be amazing.  A way to share experience, not feel alone, and see potential for further training.  
5. Sabbath.  Like our life in Bundibugyo, this phase of work intensity makes Sabbath sweet.  It requires some tolerance of not being able to help everyone.  But that's part of the point of Sabbath, to remind us that we are not the ones saving the world, God is.

Hoping this is the last "Kenyan Doctor Strike" post.  If not, I guess we'll have to come back and take our own advice.