Kenya: the AFTERMATH

2017, what a year.  3+ months of doctor strike, 5+ months of nursing strike, plus two elections which each shut down the country for a week.  That's about 9/11 months of complete dysfunction (disaster number arrangement unintended).  Plus university lecturer strikes, early school closings, economic stagnation, erratic rains.  This month the nursing strike ended, and the court upheld the second election.  So are we back to normal?

NO.

A year like this has a long tail of misery.  The dictionary defines "aftermath" as

aftermath |ˈaftərˌmaTH| 

noun

1 the consequences or aftereffects of a significant unpleasant event: food prices soared in the aftermath of the drought.

Which sounds about like Kenya right now.  It's been unpleasant, and there are come consequences.

When we returned Friday evening (a week ago) with Jack, we learned that the responsible doctor for OB had gone out of town, and hired a recently graduated intern to cover.  Not OK, as the nurses correctly surmised, so Scott ended up spending all night doing 3 emergency C-sections and then pulling a stuck breech twin out.  The rest of the weekend went from bad to worse, so that by Monday there had been 7 deaths in NBU and 5 stillbirths.  That's terrible.  Not to mention the still-alive babies with bad apgars.  To Naivasha's credit, our Med Sup called OB and Paeds into his office for a meeting.  What's going on?

Quite a few things, as it turns out, a perfect storm. 

• Massive surge of demand for services after the long period of "drought".  When we sat down for our meeting, the nursing officer reported 19 normal and 8 C-section deliveries in the last 24 hours.  That's a pace of over 800/mo, which is a 30% increase from our pre-2017 average of 600/mo.  The place is a zoo.  40-50 babies in NBU, another 40 some on the floor, and that's not counting anyone who isn't significantly sick.  We're back to doubling up in the spaces.  We're running out of gloves, out of IV cannulas, routinely.  Today we were even out of charts to write on.  Infections spread in this atmosphere--we have 7 cases of suspected necrotizing enterocolitis.  
• Rearranging coverage so that there are few with experience.  All year, there's been a sense of "we'll rotate people when this is over."  Incredibly, the hospital decided to switch the Medical Officers (like residents) at the same time that the interns were changing (every 3 months) at the same time that the Nursing director felt it would shake up the newly returned nurses to move them all around in the hospital.  So 50% of the nurses on maternity have never worked on maternity before.  It's a strictly learn-as-you-go system.  The learning curve is steep.
• And just to make things more chaotic, a nursing and clinical officer training school that had no lecturers this month (see strikes above) decided to bring all its students on a bus and dump them on our wards for November.  So suddenly we had oodles of zero-experience young people with no supervision massing on rounds.  And if a nurse decided to teach or supervise them, that cut the patient-care ratios even further.
• The general drag of a year of lethargy on attitudes and expectations.  After working at a lower pace level most of the year, people aren't used to being efficient or quick.  The strikes got people a few perks, though not as much as one would think for all that time.  They didn't return rested and raring to go, shall we say.  They mostly returned bitter and disillusioned.  Oh, and in spite of all those months of slow-down or absence, the strike time did not count as holiday time.  So most of the senior people have accumulated their 6 weeks of leave, and what better time to take it than mid-Nov to the end of the year for the holidays???  Truly.
• The reality that all those months of decelerated services meant that sick people were accumulating, and now we're paying the price.  For instance in the nursing strike time, we had triplets in our NBU that we cared for for a month and sent home stable. But then there were no immunization or weight check clinics open, so they languished at home for 4 months without follow up.  One died, the two remaining ones came in and another died.  Mom had felt she had inadequate milk for the three so was buying formula but mixing it half-strength to last longer. Women coming in for delivery have had zero antenatal care.  
• A culture of discouraging asking for help. This is something that we push back against, but it takes time to change.  

All in all, it was positive to meet for hours and hash these things out.  Some individuals were held accountable, training on specific gaps was planned, a couple of key nurses were switched back to their old jobs, ways to make the student onslaught live-able were discussed, ideas to improve efficiency for getting women to the theatre for c-sections were analyzed.

Those are all workable steps, but Kenya is not yet well.  On Tuesday, the returning President will be sworn in for his second term. But the opposition candidate has already announced he will have his own ceremony to be sworn in as "the people's president".  Meaning that he's not accepting the court ruling, meaning that the half of the country who follows him will be encouraged to disrupt and not cooperate.  Meaning more violence ahead.  And also meaning that all the above issues will only become worse, because people are genuinely tired of the uncertainty and hostility and stagnation of progress.

The word aftermath, it turns out, has a second definition:  

2 Farming new grass growing after mowing or harvest.ORIGIN late 15th century ( sense 2): from after (as an adjective) + dialect math ‘mowing,’ of Germanic origin; related to German Mahd .

This year, Kenya has been mowed down.  But after the mowing comes new growth. This reminds me of Psalm 126, one of my favorites.  The tears of this year can be the beginning of new life.  We've lost, but there is now space and I hope will for rebuilding.  Join us in praying that 2018 will be a year for flowering in East Africa; that Kenya will be back out in front showing the way.  Zimbabwe's example of peaceful change gives us hope.  The babies in the photo will grow up in a different world than their parents.  Let's keep on, to make it a better one.