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or the first time sincewearrived inKenya fourdays ago, I managed to sleep soundly throughthe night. I am hoping that by next week, I willbe able to sleep a full night despite the cacopho-ny of animals, torrential rain, and people pump-ing water before dawn. I am also developing apersonal vendetta against the rooster outside ourwindow that insists on crowing every five min-utes starting at 4:37 AM. I know this numberbecause whenever he starts sounding his call, Iblearily open my eyes to check my watch. Con-sistency is his strong point. Relinquishing con-trol to this feathered annoyance represents oneof the adjustments we have had to make toKenyan life: relaxation. Time is flexible and un-predictable, so it is difficult to stick to strict regi-mens and bullet-pointed schedules. Perhaps thisreflects an agrarian lifestyle, but it is also testi-mony to how people here value family, friends,and traditions--everything else will get therewhen it gets there.

With fifteen othermedical students fromNorth-ern Louisiana, I have traveled to a small towncalled Bungoma in Western Kenya during mythird year of medical school. We are working

with a local non-profit organization to conductmobile health clinics. Every day, we squeeze in-to vans with medications, translators, and asmuchwater aswecancarry;we travel for as longas two hours on makeshift dirt roads to get toremote areas of the region.We see patients of allages with a wide assortment of problems. Thereis no way to predict what we will see on anygiven day.During our very first clinic, one of thefourth year students was seeing a six year-oldgirl who suddenly began to have a seizure. Asher limbs were flailing outward, we could onlylook on as this student held on to her to preventher from hurting herself. We called for the vansto rush her to the hospital, and it was only aftershe was on her way with one of our attendingphysicians by her side that we noticed this stu-dent’s scrubs had been soiled with excrementfrom the little girl. Someone lent her a jacket that

A Slice of Ugali: Thoughts from a MedicalStudent in Kenya

1Louisiana State University Health Shreveport School of Medicine, Shreveport, LA

Monika Kumar, BSPH1

Figure 1. Bungoma, Kenya: Western Kenyan landscape on theway to mobile clinic.

F

Corresponding Author: Monika Kumar, BS, School of Medicine,LouisianaStateUniversityHealthShreveport, 1501KingsHighway,Shreveport, LA 71103.Email: monica.kumar6@gmail.comThis author claims no conflicts of interest or disclosures.AMSRJ 2014; 1(1):88—91http://dx.doi.org/10.15422/amsrj.2014.05.013

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she fashioned into a skirt and promptly went onto see the next patient.

Some of their medical issues are easy to diag-nose, like lower back pain from years toiling inthe fields. Other issues like dementia are diffi-cult to communicate even without the addedchallenge of a language barrier. I had fully ex-pected every patient to be afflicted with malariaor typhoid – the typical “zebras” one hears aboutin medical school. But in a twist, perhaps linkedto globalization and certain practices like smok-ing and drinking, there has been a rise in chronicdiseases in the developing world.We see lots ofhypertension, gastroesophageal reflux, chronicobstructivepulmonarydisease, andother “breadand butter” conditions I commonly see backhome in Louisiana. On the other hand, a majordifference is that being out here removes the se-curity blanket of upper level residents, bloodtests, and imaging we have in the hospital. I amthe first line - and sometimes the only line - be-tween a problem and a resolution. I have to relyon my ability to examine a history and unearthclues with a good physical exam. As a third yearstudent who has just begun my clinical training,

this experience has brought me confidence-–confidence in my skills, in my knowledge base,and above all, in knowing that I have chosen agood and decent profession.

While I firmly believe that we are doing solidwork for the community, it is easy to feel over-whelmed with the number of patients we do seeand the numbers we do not. The far-reachingbureaucracy and challenges of maneuveringwithin the systemmake it difficult to balanceourdesire to be advocates for our patients while be-ing respectful as outsiders. I feel conflictedwhen I see people in their eighties walking greatdistances with lung disease or giant “jungle” ul-cers from cutaneous leishmaniasis to see abunch of foreign doctors with limited suppliesand few diagnostic capabilities. It is, in fact, themost frustrating aspect to a trip like this. I wantto be more than a bandage.

Parts of these struggles we end up discussingevery morning, a time for introspection and re-laxation before the eight hours of work ahead.Breakfast takes place in the gazebo, a structurethat actually resembles a giant hut, replete withthatched roof, concrete floors, and mismatchedplaid furniture. I happen to like its kitschy look.In addition to daily presentations about tropicaldiseases, we huddle together around the long ta-ble, eat mandazi (a traditional fried bread remi-niscent of beignets), and drink chai. A few peo-ple have brought someminiature speakers soweoften play music, which brings a little bit ofhome to our African experience. It is these mo-ments that feel the most surreal to me. In themidst of everything, bits and pieces of our lifeseep through– impendingnuptials, clerkship ro-tations, even favorite restaurants back home. Iknow that our personalities - which, for many ofus, had never crossed before - in thirty minutestime will be replaced with our doctor selves,more mature, aligned and in tune with the mis-sion at handworking in this unfamiliar land. Butwe all have medicine in common – something

Figure 2. Samoya, Kenya: Pairs of students seeing patients incommunity building.

“I want to be more than a bandage.”

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that has its own language and mannerisms. Itpropels us to function and be productive as agroup. I feel like a stronger version of myself,and I am able to let go of what are trivial con-cerns in comparison to the everyday strugglesformany of the people here. I remember treatinga five year-old child at the school who had beenhit by a bicycle on his daily two mile walk toschool. He was scratched up and bleeding fromboth knees, but he still went to classes andshowedup to school thenextday.This is nothingnew.This is every day.Andwemay temporarilyadapt and become part of this scenery, but in theend, I know that I am going back to an entirelydifferent world.

I have learned so much about perspective andstruggle from the people with whom we havebeen fortunate to work. They are unsung localheroeswho spend every day of every yearwork-ing to make their homes safer and healthier: aformer bishop turned away from the church fordaring to speak out about HIV, women taking astand for maternal health, teachers who workevenwhen their paychecks do not come in. I seethis daunting task of administering medical aidto people in villages far away and while somewould argue that what we do is merely hand outa temporary reprieve, the reality is that we buildtrust and goodwill. It has been a privilege to bea part of this vision. It is not just about health orpolitics or finance alone, rather a careful balanceof all. Sustainable development relies on theidea that communities cannot sustain these slowand grueling changes without involvement ofthose very same members they seek to affect -forwhich trust is a key component. These amaz-ing people are fighting upstream for a differentfuturewhen somanywould have faltered or quitby now. For me, some of these seemingly com-plex social and economic issues have beenharshly simplified. One of the Kenyan doctorsworking with us carried a little sketchbook usedto take notes or sketch diagrams. He showedmeone of his charts from a time when he had been

contemplating malnutrition. The chart was sim-ple: “Rich children vs. poor children; have foodvs do not have food.” And for me, that starkdifference is difficult to reconcile.

I will not forget our encounter in a village calledMasango. It was “near” in the words of ourguides, which meant over an hour away. On thedrive over, Masango seemed to be in a more de-velopedandpopulatedarea than someof theoth-er places we had been. There were lots of shopsand gas stations along the way. The roads weregenerallywell paved, andwe saw lots of schoolswith actual playgrounds.Whenwe arrived at theclinic site, the town hall building was too small,so we set up our tables and chairs outside in thesun under the trees. Shortly after arriving, thiswizened old woman named Judith came to visit.She was a tiny little lady with a huge smile andsomemissing teeth, but had somuch energy andsweetness. She said hello to all of us as sheclasped our hands individually and kissed them,thanking God and us for being there. Shebrought out a drum and rounded up some chil-dren to sing awelcome song for us. Both she andAnn, oneof our favorite translatorswhomadeusrice and beans, led the song, echoed with thevoices of both kids and adults. They tried teach-ing us some of the words, but we were all toohappy to settle with dancing.

It started pouring later that afternoon so we hadto grab our equipment and rush inside the smallhut. This still turned out to be kind of fun, eventhough it was cramped and we smelled like wethay. Some children who ran in after us to hidefrom the rain huddled in a corner, looking a littleafraid and wary - that is, until we gave themlollipops.They lit upand just stood therepatient-ly and happily. The only sounds anyone couldhearwere the lowmumblesof conversation, rainon the roof, and discordant rhythms from suck-ing on that candy.

Being here makes me happy. I feel competentand feel like I am doing something worthwhile.

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ACKNOWLEDGMENTS

No matter how little the gesture, it is appreciat-ed. I especially love working with the very oldwho exude this rugged patience and remarkablequality of “I can wait” that is seemingly the an-tithesis of theWestern “I want it now.”Wherev-er we seem to go, people – 99% of the time,hordes of children – come running out towave atus and yell, “Mzungu!” (translation: foreigner)or “How are you!” (not as a question; usuallysaid in lieu of hello). I feel as though my armswill fall off, but I cannot in good consciencewillingly not wave back to a child. Kenyans aresome of the most welcoming people I have en-countered in the world. From a hotel waiter inNairobi to a cart vendor inBungoma, all overwehave met people who have tried their hardest tomake Kenya a second home to us. They havegone out of their way to make our weeks here ascomfortable as possible,whether it is cookingusmeat when meat is quite a luxury or putting alight bulb in our room so that we can see in thedark.

Part of me feels like these memories belong tosomeone completely different who has lived an-other life: barefoot children laughing and run-ning after our van in the dust, learning how tomake chapati in the kitchens inundated withsmoke, wonderful conversations with some ofthe Kenyan doctors and translators challengingour principles and figuring out that we all aresearching for something fulfilling in life. I re-member the group going out one night to a clear-ing in an open field to see the stars, because onthis side of the hemisphere the constellations aredifferent. It really did not matter since it ap-peared wewere only adept at identifying the ev-er-popular Orion’s belt anyways, but our lack ofastronomical knowledge could not underminethe beauty and grandeur of a clean, unpolluted

sky. Looking out at this great expanse, I couldnot help but think: we are small and yet we arelarge.

As I go through medical school and realize be-coming a doctor is a more tangible goal than itwas four years ago, the dream I once had as achild of being able to travel the world and helppeople becomes more feasible. My experiencehere has been a trial in independence and hasshown me that I can do this. I love this workdespite the challenges that come with it. I amtruly privileged to havemet somanypeoplewhohave altered, for the better, my insights intomedicineand themoral andprofessional respon-sibilitiesofbeingaphysician.Weare inacriticalposition to defend the rights of individuals toattain a better quality of life through improve-ment in personal health and dignity. As manysayand I still perceive tobe true,wegetmoreoutof experiences like this than thepeoplewe serve.My eyes have been opened - shades removed.

Maybe it is something in thewater,maybe this isa part of growing up, but I simply feel different.I have been given a wonderful gift, a realizationthat perhaps some people can discover withoutgoing abroad but something that for me hasmade all the difference because I did go acrosstheworld: themental clarity to know and seemytrue self. And the certainty that this is just thebeginning.

This author would like to thank Support forHumanitarianism through Inter-continentalProjects (S.H.I.P.) and theotherwonderfulmed-ical students and attending physicians who trav-eled together to try to do some good.

“We are in a critical position to defend the rights of individuals to attain abetter quality of life through improvement in personal health and dignity”

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