Building a healthcare relationship in Kenya

I consider myself very fortunate to have participated in a one-month global health exchange program between the Indiana University Division of Plastic Surgery and Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya, as part of the Academic Model Providing Access to Healthcare (AMPATH) program. Established in 2022, the global exchange program was designed to work in conjunction with the general, plastic and orthopedic surgeons at MTRH in Eldoret, to trade experiences and mutually impart knowledge to improve patient outcomes.

Beryl Munda, MD, in July 2022 was the first resident to visit Indiana University as part of this exchange – and I was privileged to visit Eldoret later that fall.

Introduction to Eldoret

The fifth-largest city in Kenya, Eldoret is at the center of the Uasin Gishu District of the Rift Valley Province. "Eldoret" is derived from the Massai word "eldore," meaning "stony river," which was used to describe the riverbed of the Sosiani River that runs through the city. Swahili and English are the official languages of Kenya, with a preference of Swahili for most people.

The economy in Eldoret is supported by various industries that include large-scale farming and textiles, telecommunications and manufacturing. In addition, runners flock to the 7,218-foot elevation of Eldoret for middle-and long-distance training at the International Association of Athletics Federation High Altitude Training Center.

Eldoret also is home to MTRH, which was founded in 1917 and serves Kenya, Eastern Uganda, Northern Tanzania, South Sudan and the Democratic Republic of Congo. It serves as the teaching hospital for Moi University College of Health Sciences – as well as for several medical training institutions. MTRH also hosts the College of Surgeons of East, Central and Southern Africa (COSECSA) residency training in general surgery, orthopedics and trauma surgery and pediatric surgery.

AMPATH

The Indiana University School of Medicine and Moi University in 1992 established a partnership to care for Kenyan patients, conduct research and educate Kenyan and American medical students. With the success of this partnership, several North American universities joined the coalition and in 2001 formed the AMPATH program. The program's mission is to create a sustainable model in which education and research improve healthcare services, decrease healthcare disparities and mitigate social determinants of health. In addition, this program has been instrumental in working with the Kenyan government in establishing a universal healthcare program to improve access to care. Given the success of this model in Eldoret, the program has been able to expand to more than 300 care sites in Kenya, as well as Ghana and Mexico.

Time in Kenya

I arrived in Eldoret on Sept. 26 for my month-long rotation under the guidance of Brian Christie, MD, and Gregory Borschel, MD. Although I had no previous global health experience, I prepared for a month of working alongside our colleagues to expand surgical access to patients and improve patient outcomes.

On our first day of clinical work, we were invited to round on patients and discuss clinical needs. The rounds were led by the orthopedic surgery chief resident, who commanded the team with the expectation that every team member was well-versed on the patient's history, pertinent anatomy, disease process and expected clinical course. Unlike the consultant-heavy nature common in the United States, the orthopedic and plastic surgery physicians managed all aspects of patient care – including wound care, general medicine conditions and laboratory abnormalities, as well as post-discharge social needs.

The wards were very different from the United States, with up to 20 patients maintained in a single room – often with multiple patients to one bed. Family members were often responsible for dressing changes, as well as providing food and clothing to the patients. Acknowledging these limitations, wound care was designed so that it could easily be completed by patients or their families. Following rounds, surgical patients were discussed, and the residents arranged for O.R. time in the upcoming week.

MTRH surgeons identified two main areas in which they desired improvement: microsurgery and nerve surgery/brachial plexus. Although an operating microscope had been donated to MTRH, and microsurgical instruments had been obtained through the help of a grant, the surgeons had no formal training in microsurgery, and micro-suture quantity was very limited. In addition, availability for postoperative flap care was limited by a lack of ICU beds for hourly flap monitoring, no nursing education on flap monitoring, limited availability for O.R. access overnight and inconsistent access to a pencil doppler.

Although supply concerns could be mitigated with grants and donations, surgeon and nursing education – along with the logistics of flap monitoring and care – necessitated a longer-term approach. The plan was made to start with microsurgery training, providing the surgeons with microsurgical training kits and meeting regularly to discuss improvements in technique. In the future when microsurgical reconstructions are planned, education can be provided to residents and nursing on flap monitoring – and an O.R. team can be identified to assist with takebacks overnight.

Brachial plexus and nerve injuries are common in Kenya due to obstetrical injury, high-morbidity motorbike accidents, work-related accidents and trauma. The injuries are devastating to patients, given that the affected adults are often the primary breadwinners of their families, and there's no access to disability payments or worker's compensation. Adult patients also often present late after injury due to delayed referral. MTRH surgeons made clear that they wanted experience with surgical management of brachial plexus injuries, given that they'd had no previous formal training.

Fortunately, essential occupational therapy (OT) access was available at MTRH, with a very knowledgeable staff, led by occupational therapist Roy Kirwa. In fact, all obstetric brachial plexus injuries at MTRH are immediately referred to OT, and the pediatric brachial plexus patients who were assessed at the time of our visit had notably supple joints with good adaptive functioning.

We met with many brachial plexus adult and pediatric patients, and we found several patients appropriate for surgery. We performed a latissimus dorsi/teres major transfer for shoulder external rotation and abduction in a pediatric patient – and the OTs and casting technicians were involved in the immediate post-op period by assisting in the construction of a shoulder spica cast for the patient. We also performed a spinal accessory to suprascapular nerve transfer, a Leechavengvong procedure and an Oberlin transfer for a patient with a C5/6 injury from eight months prior.

There was no formal nerve stimulator available for intraoperative assessment, so a train-of-four stimulation box was adapted with sterile wiring and 18G needles to create a low-cost nerve stimulator. Given the successful completion of these procedures, the ready access to OT and the significant patient need, MTRH has a very promising brachial plexus program ahead once community education on early referral is adopted.

Our time in Kenya was a collaborative experience that placed emphasis on building sustainable systems to improve patient care. We attempted to integrate ourselves into the wards, clinic and O.R., but also to make sure to listen to the needs of the local surgeons and staff, and provide education as requested. I hope that through these efforts, we've built a strong bond that will improve healthcare access and patient outcomes in the future. I feel privileged to be a part of the first visit to MTRH, and I look forward to seeing how this relationship grows and develops in the future.

I'm humbled and honored to have worked alongside the talented surgeons, residents and staff at MTRH. I also want to emphasize that global health should be an extension of what we do at our core: We help patients. Global health shouldn't be seen as a chance to "save" a population or establish a non-sustainable healthcare program. Global health provides us with a unique opportunity to critically assess patient needs and collaborate with our international colleagues to optimize patient outcomes given the resources provided. As such, we should all strive to make participation in global health equitable and accessible.

Dr. Cook Beresford last year completed a one-month surgical rotation at Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya.

Acknowledgements

Thank you to Dr. Munda, Dr. Mutwiri, Dr. Momanyi, Dr. Vadgama, Dr. Mwangi, Dr. Lelei, Dr. Lwegado and Dr. Malungo for their hospitality, mentorship and guidance throughout my time in Kenya.