I'll never forget her smile as she waddled into the makeshift treatment room. Esther was considerably shorter than the rest of her classmates in Two Lion, so much so that most of the other students at the Abedare Ranges Primary School treated her like an invalid toddler. With a student on each hand helping her to walk, Esther's slender, bowed legs betrayed a spot diagnosis.
“Rickets”, my supervisor whispered as he knelt to shake our new patient's hand and commence the paediatric charm offensive. Esther coyly withdrew, blushed, and scrunched her donated uniform between her fingers, two sizes too big and certainly not African in origin. Dr James Robertson, a six-foot-one white man with a shaved head from an Aboriginal medical service in Sydney, was the epitome of an oddity in Kenya, and the children were understandably awed by his impressive presence.
Our mission was to screen all 300 children in the school, living in either the adjacent orphanage or the internally displaced people's camp a few kilometres down the road. Known as “Pipeline”, the camp is home to 6000 Kenyans living in ramshackle tents donated by aid organisations after the 2007 national election riots. Families of ten or more live in dirt-floored spaces most accurately compared with a chicken coop. Even more heart-rending was the hard truth that the charity-run school could only support one child from each family.
Joanna, the school librarian now improvising as interpreter, formally introduced us. “Esther is from the orphanage”, she announced. This comment brought with it the silent acknowledgement from all present that some horror had afflicted this poor child's family, most likely poverty and the desperate behaviour it unearthed: primordial hunger, anger, abuse and neglect.
Esther had been rescued from the rubbish dump in Nakuru, a smaller city north of Nairobi that became a safe haven during the riots. As an enterprise, the dump was serious business. Every day, the self-appointed matriarch put children as young as three to work finding food scraps among the mounds of waste and refuse. What the children couldn't get their hands on, pigs rooted out with their snouts and hooves. When fat enough on garbage, the pigs were sold illegally in town to buy fresh water for the 200-odd inhabitants dwelling on the dump's margins. Children and pigs, fighting over spoilt food on a continent with more starving mouths than there are people in Europe. It was here that Esther probably developed a serious nutritional deficiency.
Esther was clearly appreciative of the attention, giggling as I applied the blood pressure cuff to her arm. In my best Kiswahili, I fumbled some muddled instructions asking her to sit still. As the needle slowly came down past 120 on the mercury, it began to bounce irregularly, some beats strong, some weak and others completely absent.
I repeated the measurement and felt for her pulse. Again, the same. Confirmed: irregularly irregular.
“This is how I pick up most of the asymptomatic atrial fibrillation in my clinic at the Aboriginal medical service”, Dr Robertson said as he pondered Esther for any sign of distress.
There are no statistics on stroke risk for atrial fibrillation in a 5-year-old; and even if there were, we didn't have a means of paying for treatment. Still smiling, still giggling, Esther watched on as if we were conducting a children's performance while we discussed what to do for her bendy bones and hiccoughing heart. We were as powerless as many of the other medical pilgrims who had made their way to Africa, driven to make a difference and yet helpless without funds or the accoutrements of modern medicine.
The afternoons were spent seeing people from the camp on a walk-in basis, mainly parents of children at the school. Wilson, a security guard and father of one of the students came to us complaining of breathlessness and hearing whistling from his lungs during patrols. Forced from Nairobi with his three children and wife during the violence, he recounted making the walk to Nakuru over 2 weeks. Every night, they slept in fields or next to the road; no roof, no bed. He thought he might have contracted tuberculosis from exposure to the night-time fog on the journey. Now, some 5 years later, he was lucky enough to have secured a steady income through the charity, and even luckier to have the use of a car.
When you're constantly dealing with weird and wonderful infections, throwing bilateral pitting oedema and severe hypertension into the casemix provides an unexpected clinical respite. We knew the story well from back home; work had allowed Wilson to adopt a decidedly Western lifestyle, paving the way for his newly diagnosed heart failure. At 55, he'd never had his blood pressure taken, and had little idea about diet and exercise. After loading him up on what was left of the available antihypertensives, it was my job as the apprentice to give the preventive health spiel: walk 30 minutes per day, lose weight, drink less, reduce salt consumption and don't smoke. I thought little of the talk as I tore out a page from my notebook and neatly transcribed the instructions in block letters.
On the first evening, Wilson could be seen doing laps of the camp, waving and smiling to the other inhabitants as if on a royal tour. Curiosity built, and on the second evening five men could be seen walking in a V formation with Wilson at the front. A long line of adults all wanting their blood pressure checked formed on the third day, and we were swamped. Rarely has a public health message spread so fiercely, like a message stick passed from house to house, summoning all and sundry to devotion. The whole camp seemed to be exercising that night, men in three-piece suits and women in flowing dresses dragging babes behind. An army of the displaced, marching on the fuel of new-found knowledge. For us, it was the medical equivalent of a drought-stricken farmer witnessing a downpour for the first time in years. With this procession of community solidarity and affirmation, the burden of counselling patient after patient in the suburbs to change their habits disappeared.
“God says it is a good day”, our neighbour Leah called out to us from her potato patch. She saw the scene occurring on the road in front of us as evidence of the divine, thanking the Lord and giving us her blessings. “God says it is a good day because we are here in His presence. Witness the marvel of His creation, we are happy people doing our best with what He has provided.”
The hardest part of the experience was collating the contradicting stimuli into a coherent picture. If I shut my eyes, the deep earth of Kenyan soil still tussles with the acrid stench of rubbish fires in my nostrils. I hear children playing in the daylight hours, and howls of abuse from husbands drunk on bootleg liquor in the evening. But the overriding vision is of hope and joy and oneness in a community with nothing. I'd come prepared to experience a godforsaken land, and conceded that I was at the blissful mercy of its people.
In the middle of it all was Esther, the child most in need with the widest smile.
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