Student Reflection by Christie Henshaw

Reflections on a Summer Research Studentship through the ASANTE Research Partnership in Eldoret, Kenya

Christe Henshaw internship Kenya

My 10-week international health research experience in Eldoret, Kenya (June to August 2009) made possible through the Medical Alumni Association (MAA) and Dr. Elva May Rowe Fund was a formative and defining experience. I have completed research with refugee populations in Canada, studied tropical infectious diseases, and volunteered previously in Africa; at this time in my medical training, the opportunity to assemble the best of the skills I had gained from these into a cohesive learning experience by conducting research in a developing country was significant.

Previous Experience
In a previous seven-month volunteer term in Africa (Benin, Liberia, and South Africa), I was exposed to medical work in developing nations where meager resources were prioritized for those who might live. It was here I first saw the beauty of the hope offered by medical science juxtaposed with the harsh reality of its inevitable shortcomings, but I had never wanted to be a part of it more. Most significantly, I gained a stronger, more focused determination for empowering individuals to become advocates for their health. Upon returning to Canada, I began to consider that global health research offered a critical opportunity to influence health issues in the developing world through sustainable, culturally sensitive and contextually relevant means. It is a way to share ideas, develop best practices, and learn from the experience of the broader academic community. I highly valued the opportunity to return to Africa this summer in a research capacity; this provided an appropriate opportunity to meaningfully contribute to global health without overstepping the well-placed boundaries applied to the “developing” medical skills of the first year-medical student in Toronto.

On the Value of and Established Research Partnership
The opportunity to be involved in research in Eldoret, Kenya is based out of the ASANTE Research Consortium, a group of North American universities which partner with Moi University Medical School, and more specifically, the Moi Teaching and Referral Hospital in research and practical initiatives. Based on the strength of the Indiana University Kenya Partnership (instrumental to the development of medical school at Moi University), the program provides the necessary foundation and infrastructure for successful international research collaborations. Because of this framework, a strong network of partnerships, expertise, and experience was available in Toronto and waiting in Kenya. Especially in Africa, pre-established relationships were found to be to be essential to the navigation of an unfamiliar academic and healthcare setting; the ten-week project time frame would not have been sufficient to develop these from the ground-up.

Shared Experience
My experience and research project was shared with Julie Wright, another first year medical student at the University of Toronto. The ability to share the experience, and reflect and process with another Toronto student was valuable, and is continuing to be so after returning. We approached the experience with few preconceived expectations of what the research or summer experience would entail. It was our aim to contribute in any way that best met the needs of the research program, our Kenyan counterparts, and hospital community. This attitude helped considerably, and the flexibility it encouraged became critical to our success.

Research Project
Our project involved the assessment of quality of care (as measured by patient and health worker satisfaction, the duration of clinical encounters, and accuracy of recorded information) at the busy antenatal clinic at MTRH before and following the implementation of electronic records (set to occur this summer). Although such records may seem elaborate, electronic management of medical information has been found to improve delivery of patient care, staff efficiency, and reporting of public health data to the Ministry of Health in developing countries.

The antenatal clinic at MTRH provides primary antenatal and postnatal care and education, gynecological and family planning outpatient services, counseling for prevention of mother to child transmission of infectious diseases, immunizations for children under five, and community health initiatives including malaria prevention and a safe water initiative. A delay in the transition to electronic records modified our original objective to conduct pre and post assessments this summer, but collection of baseline data remained feasible. Although very busy, nurses and staff at the clinic provided invaluable support, insight, and guidance. We found it very intimidating for many women visiting the clinic to be approached by a “muzungu” (white person/foreigner) seeking their opinion as to the quality of care received. Of greater concern was confusion related to language barriers, which developed when we were unable to explain our purpose for approaching the women. In such cases, clinical staff were instrumental to resolving confusion, but we had some concerns that this was detracting from their heavy workload. Although our patient satisfaction survey was available in both English and Kiswahili, we quickly learned that while many women were fluent in Swahili and preferred this language to English, many could not read Kiswahili as English instruction predominates in the Kenyan school system. Having a designated translator available for such instances or to mediate when required would be helpful for future clinical projects.

Timeline and International Health Research Setbacks
We began work on our shared research project in March 2009 in attempt to submit applications for ethical approval in Toronto and Kenya prior to our arrival. Despite this, all of the details were finally resolved and the appropriate approval secured in late July, 6 weeks into our time in Kenya. This resulted in the modification of our original project in scope and objectives, but also enabled us to take advantage of learning opportunities (attending lectures, learning from visiting faculty, participating in broader community outreach initiatives) and to be involved in initial stages of another research project also in partnership with the University of Toronto. Through this, we began work on writing a protocol for a neoadjuvant cisplatin regime for HIV+ women with cervical cancer (80% of cervical cancer deaths occur in the developing world, where a lack of resources for women’s health and/or screening programs means most cases are diagnosed at later stages where few treatment options are possible/affordable). This was a new and challenging area for us, but helped to further our understanding of emerging and pertinent global health concerns. As we worked toward starting our original project (which remained our first priority), our Kenyan supervisor Dr. Omenge was a valuable resource and encourager: having spent time in Toronto, he had an appreciation for the academic environment from which we came, and provided helpful research guidance and cultural insight.

IU House and Academic Community
We lived at “IU House” throughout or time in Kenya, a well- established residence for visiting academics, physicians, residents, and medical students staying for varying lengths of time. The accommodation was more than adequate, and seemed luxurious at times in comparison to Kenyan standards. This community became a central part of our experience, providing us with a place to work, to meet with others pursuing a similar opportunity and to learn from them, to discuss, and to become more involved in relevant learning. Having a constant supply of medical experts (some from the University of Toronto!), residents, and medical students further along in their training helped to provide context and clinical insight for our experiences. We attended lectures for Kenyan and North American medical students, observed ward rounds on a morning when it was lead predominantly for North American Students by a resident from Indiana (so as not to take learning opportunities from Kenyan medical students), participated in “Fire Side Chats” where relevant medical and social issues were explored from an academic perspective, and spent time volunteering at initiatives associated with the IU Kenya Partnership, including working at a farm which provides food for HIV patients and their families, and volunteering at the Sally Test Centre which provides activities for children at MTRH and care for abandoned babies. In addition, the IU-Kenya partnership has become highly developed to provide antiretroviral therapy for HIV/AIDS patients across Western Kenya through AMPATH (the Academic Model for Access to Heathcare), a subset of the partnership. Through this, we were able to learn about a highly effective model for providing access to antiretroviral therapy (through which common treatment procedures are disseminated to a flowchart which can be applied by clinical officers (non-physican medical professionals) at rural sites; more complicated treatment decisions are made at major centres, i.e MTRH), and to visit a rural clinic with Dr. Joe Mamlin, the founder of AMPATH and an inspirational clinical role model.

Through a tutor working out of IU House, we were able to take basic Swahili lessons which were instrumental to forming some of our clinical relationships. For our purposes, living in an academic community with access to internet and the guidance of others was critical to accomplishing our research objects. Had we come for a clinical encounter or to work more closely with Kenyan medical students, living at the medical student residence would have provided greater opportunities for learning and developing shared experiences. We were grateful for opportunities to meet up with 2 Kenyan medical students who had completed an elective rotation in Toronto in spring 2009. Having first connected with the students in Toronto, it was great to reconnect with them in Kenya, listen to their insights as to differences in medical training between Kenya and Canada, and to meet other Kenyan medical students.

Reflections on Healthcare in Kenya
Overall, less than a paucity of medical services, it is disjointed development and a systemic discontinuity of care which I found most challenging to understand this summer. For example, the hospital has an MRI, but may not have amoxicillin available. Lumbar punctures and bone marrow aspirations are possible (~1/day for the patient who needs it most/can afford to pay), but basic blood gas readings cannot be obtained to open up a world of diagnostic potential. A patient could realistically to pay for a CT scan at 70 shillings (less 1 dollar CAD), but the cost of being on supplementary oxygen is often prohibitive. Having spent time in Africa before, I found not the poverty in Kenya to be shocking, but was most surprised by such disparities and evident gaps. In my time in Benin and Liberia, patients died as a consequence of abject poverty and resource disparities. As unfair as this may sound, it is understandable – it is easy to pinpoint why the patient did not receive treatment; because it was not available. While that situation is frustrating, it is also empowering; although you are working against ill-defined complicated, multifaceted problems, there is satisfaction and gratification in working against something tangible. I found the issues to be different in Kenya – there’s still poverty and disparity, but there is also more corruption, and poor health outcomes are less easily understood when access to treatment is theoretically available.

At the end of the day, although it may seem like the only feasible approach, no one goes into medicine or development work to be a utilitarian or because they were inspired by one…we choose these things because they are heroic, idealistic, and because we believe at some level that change is possible. As such, although we observed vast disparities this summer, the opportunities to appreciate how global health research and partnership can combat these were more significant. We were presented with so many outstanding examples of clinicians (both Kenyan and North American) and researchers who were both inspiring and providing good examples of how global health partnerships can significantly improve heath outcomes this summer. To this end, the experience was relevant, well-timed, and provided substantial insight into a global health career – I cannot express enough thanks for the opportunity to learn so broadly this summer!