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Jones* was absolutely heartbroken when he found out that he was not eligible to join medical school in Kenya when he finished high school. Coming from a humble background, he could not afford to pursue his dream. However, Kenya was just starting to train nurses at degree level and Jones was able to get into the pioneer class.

Four years later, with a degree rightfully earned, Jones headed off to practice an art he had come to love. He took the Nightingale Pledge to heart and practiced it with his whole being. He loved his patients and worked with utmost dedication. Within a few years, he was back to school studying hard to become a critical care nurse. He had found his calling.

Away from work, Jones spent his free time playing basketball at a local club. He had played for his high school team but had been away from the game for quite a while. It felt good to be back in practice. He also started dating a young doctor he met during his specialist training. Life was turning out pretty well for a young man who had thought he would never recover from losing his dream.

However, one evening, during a basketball tournament, Jones suffered an injury and fractured his tibia and fibula, the bones of the leg. What followed was a dark period of excruciating pain and frustration at not being able to do either of the things he loved. He underwent surgery but had to remain in hospital for some time.

To manage his pain, he would receive opiod injection medication every eight hours. The shots would be a welcome relief as not only would they suppress the pain but would also knock him out and allow him to sleep away the endless hours he spent lying there. When he went home, despite having adequate pain relief from the oral tablets that he was prescribed for, he struggled to sleep.

With his girlfriend being a doctor, it was possible for Jones to get a prescription for sleeping pills  but he wasn’t quite able to get the kind of knockout he wanted. He pleaded with her to bring him prescription opioid injection medication and he would inject himself to sleep.

Five months after the injury, Jones was back to work. He was happy to get back to doing what he loved. However, despite healing well, the 12-hour shifts in the critical care unit spent on his feet were heavily taxing. His leg would throb after work and he couldn’t wait to get home and put it up and rest. However, he found himself drifting back to sneaking in a shot of the opioids to alleviate the pain and sleep.

Before Jones knew it, he was regularly injecting himself prescription medication to sleep. He began pilfering the medication from the dangerous drugs locker in the critical care unit to meet his needs. What started as a medical need was turning into a monster that Jones was having trouble taming. He did not have the capacity to face up to the magnitude of the problem.

The addiction roller-coaster had long taken off. Suffice it to say, Jones never played basketball again. His relationship with his girlfriend hit the rocks and his supervisor caught up with his pilfering. Instead of a disgraceful dismissal. Jones was offered an opportunity to hand in his resignation.

The cycle of addiction is the same irrespective of the drug of addiction. A bright young nurse who was on the path to a bright future, was instead on a downward spiral to oblivion. Seven years of moving from one job to another, one seedy apartment to the next, losing friends and family eventually culminated in finally losing his license to practice for grossly endangering patients’ lives.

There a many reasons why anyone would find themselves going down the slippery slope of addiction. Many are harshly judged, especially when they are hooked onto illegal substances. For healthcare practitioners, the easy access to prescription drugs of addiction easily fuels the addiction flames in record time.

Unfortunately, no one is usually paying attention until things get out of hand. Unfortunately in Kenya, there is no mechanism in place to deal with health workers who get into prescription drug abuse.  In the Unites States of America, there exists a robust physician health programme that is set up to support practitioners whose ability to practice safely is impaired. The impairment may be medical such as mental illness, cognitive impairment or drug addiction.

The risk these practitioners pose to patient care cannot be underestimated. Nobody wants  to be under anesthesia and the doctor responsible for your life slumps in a corner from the effect of a pethidine shot he gave himself instead of you. Of that moment when you are bleeding out and the doctor’s hands are shaking too hard to put in the lifesaving cannula required to transfuse you. Or when your teenager is writhing in pain from a sickle cell crisis and the nurse has injected him with saline since she cannot account for the pethidine via meant for him but she has already injected herself.

A health practitioner suffering addiction, and specifically prescription medication addiction, is not only a danger to himself but is an even bigger danger to the patients. As we strive to take care of our patients struggling with addiction, we need to set up a system to ensure the same care is extended to our health workers.

The system must work by providing a safe place for them to seek help without judgement. We must also enable fellow health workers to report their colleagues who may be unfit to practice due to addiction. However, the reporting should not be for punitive purposes but for enabling access to support and care. It is definitely time for a physician health programme in Kenya!


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In the month of May, the world turns its attention to one of the key components of woman-ness. The conversations around menstrual hygiene are here with us as we struggle to make it a normal conversation for all people, irrespective of their gender, age or background.

The emphasis on reproductive health education for the young people is so critical if we are to achieve menstrual hygiene for all. The sustained advocacy to ensure every young girl is kept in school during her menses is essential. Access to menstrual hygiene products and clean water for all women is a basic right.

However, as we address the normal challenges of this key aspect of nature, today let us also take a look at those who have unique challenges when it comes to menstruation and menstrual hygiene management.

Natalie* is a 21-year old college student with excruciatingly painful periods. Her gynaecologist says that Natalie likely has endometriosis, a condition where the tissue that forms the inner lining of her uterus has migrated to other parts of her pelvis. Since this tissue is responsive to hormones, it means it bleeds every month in places where it should not, causing painful inflammation and unbearable pain.

Seline* a 27-year old banker has menses for an average of 12 days every month. Her periods are so heavy that she has undergone repeat blood transfusions to stay alive. She was diagnosed with Von Willebrand Disease, a rare condition where her blood clots poorly, making her susceptible to heavy bleeding from any source. She wishes she could just get rid of her uterus but her gynaecologist is hesitant and is encouraging her to have children first before taking such drastic action. Seline dreads the risk of bleeding to death during delivery.

Monique’s challenges are different. She has no menstrual problems but her 19-year old daughter, Ruby*, has Down’s Syndrome with limited cognitive development, posing a significant intellectual disability. She started her menses at 15 and four years down the line, they are still struggling with her menstrual hygiene management especially during the day when she is away at school.

Painful periods (severe dysmenorrhea) are NOT normal by any long shot. The causes of painful periods are quite varied. For the young adolescents who are new to menstruation, as the menstrual cycle stabilizes, not all cycles are accompanied by ovulation. These menses without ovulation can be painful but are generally short-lived and this settles with time.

However most painful menses are associated with underlying disorders such as adenomyosis, endometriosis, polycystic ovarian syndrome, uterine fibroids, polyps, pelvic inflammatory disease or uterine synechiae (scar tissue within the uterine cavity). All these are gynaecological conditions that require a proper diagnosis and appropriate management to relieve the pain.

Menorrhagia (heavy menses) is described as periods that come regularly but the total amount of blood lost per period is more than 80mls. Alternatively, periods lasting more than seven days may be considered to be menorrhagia. Most women will not be able to quantify the amount of blood loss but are more likely to see the doctor when the blood loss causes uncomfortable symptoms.

Menorrhagia could result from a myriad of underlying medical conditions too that require urgent diagnosis and treatment. Conditions of the reproductive tract such as fibroids, polyps, endometritis (inflammation of the inner uterine lining), endometrial cancer and adenomyosis can cause the woman grief. Endocrine disorders (disorders affecting hormone systems in the body) such as thyroid disease, bleeding disorders such as platelet disfunction or Von Willebrand disease, polycystic ovarian syndrome, approaching menopause, chronic liver disease, some contraceptive methods and certain medications will also lead to heavy periods.

Menorrhagia, left unchecked, will lead to anaemia, which in the long run, can result in heart failure and even death. Therefore, the cause must be aggressively sought and treated, to avert unnecessary complications. Women must be aware that changing the pad hourly is a sign that something is not right. Bleeding until one passes out is an emergency.

Treatment options for these complications may be surgical (such as in removal of fibroids or polyps) or may be medical (using non-steroidal anti-inflammatory drugs, hormones or hormone-receptor blockers). Treatments resulting in heavy bleeding may need to be stopped, adjusted or replaced.

What of special category ladies like Ruby? Ruby’s periods may be regular, non-painful and of normal volume. However, her incapacity to change her own pad is a challenge when she is away from her mother, who is her primary caregiver.

Despite Ruby’s intellectual disability, her reproductive health rights must be fully protected and solutions for her challenges must align with the law. Monique was never prepared for this eventuality, especially as Ruby’s development was slower than her agemates. This, coupled with Ruby’s child-like appearance, means that even the doctors taking care of Ruby did not remember to discuss with Ruby’s mother on alternatives to help make womanhood for Ruby easier.

It was such a relief for Monique to know that there were safe options for Ruby. We settled on putting Ruby on a ‘Menstrual Holiday’ through the use of hormones. Now Ruby can have periods once every three months, which coincides with her school breaks. Monique only has to worry about her baby’s menstrual hygiene at her convenience. No more soiled skirts in class, no more stained P.E. shorts, no more burdening Ruby’s caregivers in school with such personal matters as Ruby’s menstrual hygiene!

Menstrual holidays are not a new thing in gynaecological care. While for Ruby, the only concern is the inability to deal with the menses on her own, for some women, this is the only way to deal with heavy menses or with painful ones. Keeping the periods away for a given duration helps the anemic woman build back her blood to normal levels. For the one suffering pain, no periods means no pain.

In the world of sports, periods are kept on hold during major competitions. Women have learnt not to compromise their rise to stardom in swimming, gymnastics or tennis when that tournament is scheduled at the same time as the period. It would be impossible to win a marathon, running 42km while bleeding!

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Picture courtesy of Pixabay

One of my favourite shows growing up was Bill Cosby’s “Kids say the darndest things”. Besides the fact that it left us all in stitches, it was so refreshing to sit back and enjoy such forthright reasoning from the innocent minds. Children do not belabor the point. They say it as it is to the level of their comprehension.

The beauty of this innocence is that it carries through even when they are unwell. Ruth was embarrassed when she walked into the consulting room. Her daughter Mabel had just broken a toy in the reception while awaiting to see the doctor. She was full of energy and curiosity and her hands were wet from attempting to feed the fish in the fish tank in the reception.

Yet the night before, the whole family had not slept. Mabel had been spiking fevers of 400C on and off, which were unresponsive to paracetamol. Twice she had vomited the medication and the heaving left her so weak. By morning, the fever had settled and Mabel had even managed to take a few spoons of oatmeal before coming to the hospital.

Ruth felt like an imposter describing her daughter’s condition. She did not realize that children are exactly like that. When the illness weighs them down, they are listless and in a low mood. They get glassy-eyed with fever or teary with pain. Immediately the discomfort settles, albeit temporarily, they bounce back with amazing speed. One would be forgiven for thinking they had imagined the whole affair.

A great paediatrician who taught me many years ago, ingrained in me when I was a medical student, the importance of listening to the whole story. He emphasized that the history of the illness is critical to arriving at a diagnosis, even before one got down to examining the patient. This golden gem of advice has served me well over the years. It taught me patience and I learnt to pick important clues from distressed moms and dads.

However, examining a child is a whole other skillset! While adults will lie down on the couch and cooperate without question, children require the doctor to be extremely warm, attentive and highly creative. It is said that one cannot make a good paediatrician if they genuinely do not love children. Children turn even the sternest of professors into fuzzy, warm beings.

Paediatrics rotation was my very first clinical rotation in my fourth year of study. Our lecturers were diverse in nature but each had their unique bag of tricks when handling the children. It was fascinating to watch their interaction. During one of the teaching ward rounds, as the lecturer was examining a five-year old child, he asked her to cough so he could assess whether the increased pressure in the chest would make the neck veins bulge abnormally. The child looked at him blankly and calmly stated that she did not have an urge to cough. We all burst out laughing, much to the bewilderment of the girl.

One hot afternoon, we stood around a nine-year old girl’s bed learning about meningitis. As any medical doctor would tell you, examining the central nervous system is one of the most difficult skills to acquire. The little girl was extremely cooperative, even getting out of bed and walking in a straight line. However, when it came to the past-pointing sign, she dug in her heels. The doctor asked her to alternate between touching the tip of her nose and the tip of her left index finger, which was held about foot away from her face.

 The good doctor even went ahead to demonstrate but our little angel absolutely refused. When asked why she didn’t want to do it, she bluntly stated that she did not want to look as stupid as he looked. It was absolutely hilarious! None of us had thought just how silly the action appeared because our perspective was purely medical.

Despite the moments of mirth that little children bring to the wards, the bigger lesson remains that the art of medicine is heavily dependent on social skills. A doctor can easily extract a diagnosis just by listening and doing a thorough examination on the patient. Some of the examining procedures may be unpleasant but they must be done and the findings documented.

The wonder of being able to not only appreciate a heart murmur but also characterize it, should not be allowed to lose its magic. The first time I listened to the chest of an infant with bronchiolitis, I was awed. The little boy sat calmly in his mother’s lap while his chest sounded like a marching band. I totally understood why he would have trouble breastfeeding. The cacophony in his chest was his airways struggling to get enough oxygen to him despite being overrun by inflammation. It is not the same as just seeing the abnormality on an X-ray film.

Unfortunately, this fine art is slowly being disregarded as we become more and more reliant on technology. Patients are less satisfied when the doctor fails to order a battery of lab tests or imaging diagnostics. The results may be objective but their interpretation is subject to the patient’s history and examination findings.

We must not allow the robotic culture of technology to replace a good patient experience that can only be brought about by a good conversation and a skilled examination. The ideal process dictates that diagnostic tests are meant to confirm a diagnosis, not to go on a fishing expedition.

Technology is here to assist us to decipher what is wrong with our patients, not to turn us into lazy technology-obsessed antisocial caregivers!


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Science is interesting. You can bend it, you can stretch it sideways, but facts are stubborn. They do not change.

When a patient is sick, a lot of diagnostic tests are carried out as part of care. Some tests are done to pinpoint a diagnosis; others evaluate the severity of the disease; others help to guide us in the best treatment options; while others help us to evaluate the response to the treatment given.

One Tuesday morning during our postgraduate training, during a major ward round in the teaching hospital, a colleague went about the business of the day. He presented a patient to the team who had been in the ward for about five days. She was about 26 weeks pregnant and was with us because she had a urinary tract infection.

 By itself, that was no news. Urinary tract infections are quite common in pregnancy. The pregnancy hormones make the mother susceptible to the infections. In addition, the growing uterus distorts the urinary system, leading to incomplete emptying of the bladder when passing urine, further increasing this risk. It is one of the more common reasons for admitting pregnant women in hospitals before delivery.

The dramatic news though, was when the doctor stated at the end of his presentation, that the results of the urine test done revealed that the bacteria responsible for the mayhem, was not responding to any of the antibiotics we had in our arsenal! This test, which takes at least 72 hours to give us results, is a painstaking process of isolating the offending bacteria from the patient’s urine, growing it on a special plate with various antibiotics and establishing which ones are capable of killing the bacteria and which ones cannot cause it any harm.

The whole team in the ward round was perplexed. How do you tell the patient that despite being in the wards in search of a cure, we knew what was ailing her but did not have cure? We are not talking about cancer here, we are talking about something as simple as a urinary tract infection. We were stumped! All the antibiotics we were pumping into her were a waste of time.

How do we end up here? Experts have warned us repeatedly that we are consuming too much of antibiotics in our foods. The problem with this is that the antibiotics reaching our system, having gone through animals, are of variable doses. When bacteria are exposed to small amounts of antibiotics, whose dose is inadequate to wipe them out, they have an opportunity to develop resistance to these low doses. Eventually, when one needs to use the same antibiotic to treat these same bacteria, they have developed thick skin and will not be affected by the drug even in correct doses.

And then there is the cohort of patients who use antibiotics indiscriminately even when they are not warranted. These are the patients who get the influenza virus and refuse to leave the doctor’s consulting room without an antibiotic prescription. Parents are the greatest proponents of these bad practices when it comes to their children. So much so that a social media joke was coined, targeting parents, stating that a fever is not a sign of ceftriaxone (a potent injectable antibiotic) deficiency.

The other end of the spectrum has those patients who do not follow their antibiotic prescriptions to the letter. Once the symptoms subside, they never bother to complete the dose. They pose a danger, not only to themselves but also to the entire public. They frustrate care providers to the point of taking drastic measures to ensure compliance. This is how the Ministry of Health ended up having two patients with tuberculosis incarcerated for refusing to complete their treatment!

We must abide by prudent prescription practices if we do not want to wake up in the next 20 years and find ourselves having converted bacterial infections into terminal illnesses. We are all guilty. Doctors who do not abide by good prescription practices, pharmacists who sell antibiotics without a prescription from the doctor, patients who treat themselves by demanding unnecessary antibiotic prescriptions or buying these drugs across the counter from unscrupulous pharmacies, and farmers who pump their far, animals with unnecessary antibiotics to increase their yield at the expense of all of us.

What we fail to comprehend as a society is that antibiotic resistance does not affect only those abusing these important drugs. It affects all of us directly. The same bacteria causing pneumonia in one patient is the same one causing meningitis in another, while it is still the same one causing a urinary tract infection in the yet another. Once the patient with pneumonia is improperly treated and an antibiotic resistance develops, the resistant bacteria moves into the next victim and causes chaos in a different body system with equal vengeance.

It is also worth noting that once an antibiotic enters the body, it is not only going to treat the affected system. It travels all over the body and kills off all other bacteria present and responsive to it. It behaves like a terrorist attacking a mall. Despite having a specific target in mind, he will leave hundreds of casualties behind as collateral damage.

The antibiotic journey started Alexander Fleming in 1928, with his discovery of penicillin. If he were to wake up today, he will be extremely proud of the advances that have stemmed out of his discovery. However, he will probably have apoplexy at the thought that such a major discovery that has had such a dramatic impact on humankind, is about to be declared obsolete in less than a century.

This acceleration towards gross antibiotic resistance needs to be brought to a screeching halt. We must all understand that antibiotics are not sweets to be dished out like a cheap dessert with every meal. We must reverse the trend or perish!

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It is a beautiful new year and we are all grateful for various things.

Armanda* is grateful for good health. 2018 was an extremely difficult year for her. Armanda had always been an active person, playing basketball for the school team throughout high school. When she joined university, she carried on the trend and soon she was appointed the team captain.

Armanda has always been a disciplined person. It takes a lot of self-drive and initiative to attend practice daily even when everyone else was off having a good time. While her friends hit the clubs on weekends and slept all day nursing hangovers, Armanda was shooting hoops and swimming.

Despite such an active lifestyle, Armanda noted that she was putting on weight. She was distressed when she had to change her wardrobe. Her mother took her shopping without fuss but she was worried. Her mother had been diabetic for the past 12 years and it was not an easy journey. She changed her lifestyle and by extension, that of her family. She ensured she served healthy meals at home and encouraged everyone to keep fit to protect them from diabetes.

So far, Armanda had been her mother’s success story. She ate right and was physically fit. Her mother worried that maybe, being away from home was making Armanda’s diet inappropriate, hence the weight gain. However, she did not want to make her daughter feel judged.

Things got worse when Armanda suffered injury to her ankle and could no longer play basketball. She had minor surgery and the recovery took several weeks. During her convalescence, Armanda added yet another twelve kilograms. She felt terrible and the stress began to affect her. She slept a lot, spent all her free time in bed and wore big clothes to conceal the weight.

Though she lost her appetite, the pounds kept piling. She lost interest in many of the fun things she did and she even avoided swimming altogether despite the doctor recommending it. At least she could work out without straining her ankle in the pool. Armanda could not fathom buying a bigger swimming costume and expose expanding waistline.

As she battled with weight and self-esteem issues, a new problem was creeping up which took her a while to get her attention. She started missing her monthly periods and when they did come, they were excruciatingly painful. She had always suffered discomfort during menses but suddenly they got out of order.

As if that was not enough, she developed bad acne that was unresponsive to any home remedies she could think of. She noticed that the three strands of hair on her chin that she had meticulously managed to conceal all these years with the help of her trusty tweezers had suddenly multiplied while the one on her head was falling off in clumps!

In the wake of all these unwelcome changes, Armanda was struggling to keep her grades up. Her social life suffered as she gave up basketball for good and preferred spending her weekends at home curled up on the couch with a blanket, watching movies on Netflix. She would struggle to get through assignments and concentrate in class.

Her mother intervened and brought her for a consultation one afternoon. It was the start of a long-term relationship. Imaging tests and several blood tests later and Armanda was diagnosed to have multiple hormonal problems.

She suffered from polycystic ovarian syndrome, a condition that caused her the menstrual problems she was experiencing, coupled with the acne and facial hair. The imbalance of her reproductive hormones and an excess of testosterone in the system were wrecking havoc in her body.

As a result of the polycystic ovarian syndrome, her risk of getting diabetes was increased sevenfold. This, in addition to the fact that she already had a family history of diabetes, and the huge weight increase she had experienced, made her the perfect candidate for the condition. She was diagnosed with diabetes much to her mother’s distress.

As if that was not enough, Armanda was also diagnosed with hypothyroidism, a condition where the thyroid gland was unable to make enough thyroid hormones. Thyroid hormones are responsible for driving metabolism in the body. In Armanda’s case her metabolism was slowing down, making her put on even more weight.

Armanda is currently under the care of a multidisciplinary team. As we manage her gynaecological problems, she also sees an endocrinologist for her thyroid and her diabetes, a health and fitness doctor for her weight management and a dermatologist for her hair and skin problems.

As she bids farewell to 2018, she is ecstatic. She has lost 10% of her body weight, her skin is much better, her menses are back on track and she is back to the swimming pool! She no longer needs to take diabetes medication as she can now manage her blood sugar on diet alone. And her grades are back on track.

Armanda is a perfect example of the complexities that can result in weight issues. Not all weight gain is a result of a careless lifestyle. Sometimes it is just a symptom of an underlying medical problem. Therefore, as you make your new year’s resolutions to lose weight, it is wise to ensure you are not masking a bigger problem.

Do not blindly join the dietary fads without talking to your doctor. You could easily find yourself in a coma in the intensive care unit as you attempt to starve yourself out of obesity!



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Joe* is always the life of the party. He is a big guy with a big heart with a great sense of humour to match. Everybody loves Joe. He loves to make fun of himself, something that probably resulted from being teased as a kid growing up. He was always the biggest kid in his class and he had his fair share of barbs in adolescence.

Joe and Aggy* have been married for seventeen years now and were blessed with one son. Complications during delivery rendered Aggy incapable of having any more children. This shattered their dream of having a large family. However, coming from a tightly-knit extended family helped. Their son grew up around his cousins and hence did not lack for company.

The many family get-togethers over the weekends were a time for the children to play together, the ladies to catch up on their gossip and the men to indulge in binge drinking and watching sports. Joe has always been the family guzzler, easily drinking a bottle of his whiskey in a day. Everyone jokingly attributed his drinking capacity to his big size and his nephews and nieces call him Uncle Grizzly Bear.

However, Joe and Aggy recently had a fright. Aggy woke up one Sunday morning and went for an early jog. She came home to find her husband on the bathroom floor doubled over in intense pain. He had woken up to go to the bathroom and keeled over in such intense pain in his abdomen, he could not move from the floor.

Aggy called for an ambulance in panic and Joe was whisked off to the emergency room. Hours later, after the dust had settled and Joe had been admitted into the critical care unit, the doctor was able to put a name to what was ailing Joe. He had suffered an attack of acute pancreatitis.

This was a completely foreign term to Joe’s family. It was difficult for them to fathom how the pancreas could turn on itself and start digesting its own cells. It was even more surprising to them how Joe, a person who easily handled his alcohol so well, could be teetering on the brink from something they all took so casually.

Acute pancreatitis is a condition where the pancreas is literally under siege. This small and flat organ in the shape of a leaf, nested out of sight under the stomach, can be a source of such intense agony. The pancreas responsible for two major functions. It is a manufacturing point for insulin, which regulates the metabolism of sugar in the body. It is also responsible for manufacturing about 15 different digestive enzymes that are conveyed to the small intestines via the pancreatic duct.

The pancreatic duct meets with another duct, the common bile duct, from the liver on the opposite side, to then empty into the first part of the small intestines, called the duodenum. The pancreatic enzymes then go about the business of digesting our food for absorption further along the intestinal tract. In normal function, these enzymes are in inactive form until they enter the duodenum.

In acute pancreatitis, there is activation of these enzymes while still within the pancreas. This results in the enzymes digesting their own factory, causing massive inflammation in the same organ they are made in. The result is pain that can be excrutiating.

The commonest causes of this condition include gallstones and excessive alcohol consumption. Most drinkers will experience an attack following an episode of heavy indulgence. It may also result from use of certain drugs and medications, severe trauma causing injury to the pancreas such as in road traffic accidents or stab wounds to the abdomen. Rare causes include genetic abnormalities, tumors, toxins such as snake bite poison, and as a complication of certain surgical procedures.

Acute pancreatitis may be mild, with the symptoms fading off in a few days. However, the more commonly seen picture in heavy drinkers is a dramatic one, with disabling pain, nausea, vomiting, diarrhea, fever, rapid heart rate, difficulty in breathing, muscle spasms and shock. Just like Joe, there may be need for intensive care to keep the patient alive.

As the doctors fought to keep Joe alive, his family prayed that their big-hearted kin would pull through. Day and night, Aggy stayed put on his bedside willing him to pull through. By the fourth day, Joe was off the ventilator. Typically, in Joe style, he could not resist good humour, wondering why it was so cold in heaven.

It was a long walk back to health for Joe. He managed to avoid surgery and did not suffer additional complications. He recovered steadily, with the multitude of tubes and probes he was attached to, coming off one by one.  He was re-introduced to oral food to replace the parenteral nutrition he was being supplemented with and he started physiotherapy to restore his body to function.

Today, Joe is back to his old self, humour and all. The big grizzly is thankful to be alive and is fully divorced form alcohol. He intends to be around long enough to ride a bike with his grandchildren and hopefully hold his great grandchildren in his arms. Aggy is grateful to have a jogging partner on the weekends too.

As we indulge this festive season, let us be mindful of this little organ. A little alcohol moderation goes a long way! Happy holidays!!

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At the beginning of this month, the world marked World AIDS day with an interesting twist. Focus on the youth. Watching Phenny Awiti on television talking about her journey living with HIV from birth was not only amazing but also gratifying to know that we are making progress in HIV care.

She’s got 26 years’ experience of living with a chronic disease and she is definitely in charge. She is not defined by her illness; instead, she is living her life and her illness is kept in line because she is the boss.

We are still struggling with reducing new infections in Kenya. The most vulnerable age group right now are the youth, 15 to 25 years who are recording the highest number of new infections. Nevertheless, as we take stock, we can say we are winning in the management front. Patients in need are accessing treatment and they are doing a fine job of adhering to it. This is evidenced by the drastic reduction in death from AIDS-related illnesses.

In the 2000s, 70% of our medical ward beds were taken up by patients suffering from AIDS-related complications. The tide is turning but the replacement is not pretty. Now we are struggling with non-communicable diseases. Diabetes, hypertension, heart disease, stroke and kidney failure are becoming the order of the day. The outcomes are not appealing.

What did we do differently? All these are chronic diseases just like HIV, yet death from heart attacks is becoming commonplace. We have new dialysis centres sprouting all over the country and yet we have not met the needs of our populations.

The secret may lie in the care model. HIV care firmly puts the patient in the driver’s seat. A patient goes through an empowerment process before commencing on treatment. From testing and diagnosis; establishment of the disease baseline; counselling about medication, adherence and side effects; and understanding the role of monitoring and follow-up, the patient is prepared to be the key driver of the process.

HIV patients know their drugs by name and dosage. They can recite their CD4 counts and viral load figures for the past five years without missing a beat. They go everywhere with their medication and will walk into any health institution and request a dosage in the rare event they misplace or lose their bottle. Mothers will cross mountains to ensure their little ones have the full benefit of prevention of mother to child transmission.

These patients lead from the front when it comes to their care. They do not sit back and wait to take instructions from the doctor. They actively participate in their medical decisions. They will show up at their clinic whenever things do not “feel right” rather than wait to come in to hospital in an ambulance. They mind their diet without prompting, manage their lifestyles and plan their future.

The success of their care has been pegged on adequate education about their condition, the course of the illness and the consequences of their choices. They have seen how quickly things head south for those who make bad choices. They understand what their lab test results mean and their role in good outcomes.

It is therefore disheartening to see that what has been tested and proven to work is not being applied across board to other chronic illnesses. Mama Paula* is a typical example. She presented in the clinic with abnormal uterine bleeding 10 years after menopause. She underwent appropriate tests and was scheduled for surgery.

However, from the outset, we noted her moderately elevated high blood pressure. On enquiry, she admitted that she did have episodes of high blood pressure that necessitated on and off treatment. She had last taken medication 6 months prior. Further probing got her daughter all worked up. She went on and on about how her mother did not adhere to treatment and would keep hopping from one doctor to another, trying out faith healing and traditional herbs, just to get out of consistent treatment.

Mama Paula may have been obstinate about treatment but taking time to explain what high blood pressure was all about, how the illness progressed, the role of treatment, the expected complications from non-treatment and what she could do to help her body handle it better, changed her mindset completely. She realized she been making choices about her care based on lack of information.

She willingly saw a physician and was glad to take up medication. Her blood pressure stabilized well, allowing her to undergo surgery with minimal risk and tolerate it well. She recovered well and though discharged from our clinic, she continues to see her physician religiously. She has lost weight and is very strict about her diet. She is the one who reminds her daughter about prescription refills and scheduled appointments and tests. At 63, she knows how to operate her home blood pressure monitor and can tell when the readings are not good. In addition, she is the local self-designated hypertension peer educator in her home village, pushing her contemporaries to get screened and to adhere to treatment.

Our diabetic and hypertensive patients need not die. They do not need to live a life sentenced to kidney dialysis, praying for the miracle of a kidney donor. They need not be confined to wheelchairs because of massive strokes. They can minimized the risk of heart attack and sudden death if only we can give these conditions the seriousness they deserve.

To win the war against non-communicable diseases that are threatening to engulf us, we must ensure that the patients are in charge. They must be sufficiently empowered to take over the reins and guide their care. This way, they will demand excellence from us, the care providers. We must be ready to share the role of decision-making with our patients wholly for desired outcomes. After all, they are the ones carrying the burden.

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The past several days have subjected the Kenyan public to the unimaginable horror of coming face to face with the ugly side of death. These are the things which, as a community, we do not stop to think about because our minds would rather not wander into that dark spot.

The public exposure of the bodies of the tiny little babies at the Pumwani Maternity Hospital during the Governor’s visit to the hospital left a bitter taste in our mouths. The pictures circulating in social media were heartbreaking.

As if dealing with the loss of life at such a tender innocent age wasn’t bad enough, the real devastation was in coming to terms with how these little ones were handled after death. Putting these little souls in carton boxes and disposal bags is certainly no way to see them off!

As we ponder the inefficiencies of a health system that left us all feeling so very vulnerable, the reality is that we shall exit this world. For this reason, though we never want to think about this, a small part of us is constantly nagged by our exit.

Death takes away everything from a person with such finality. It equalizes all of us. We immediately stop being referred to as person X and become a ‘body’. We cease to occupy a space in the midst of others and immediately becomes past tense.

The one thing we may fail to recognize is that, our outrage at the situation in Pumwani is driven by the innate need as human beings, to maintain some level of dignity even in death. Death strips us of everything. For that reason, the only thing we want to at least exit with, is dignity.

It is on this premise that the very important process of care given to a body after death, otherwise known as the “Last Offices”, is based on. The process is performed with the aim of demonstrating respect for the deceased and is focused on respecting their religious and cultural beliefs, as well as health and safety and legal requirements (Dougherty and Lister, 2004). This important process is intended to be carried out by the nurse before the deceased is released from the clinical setting to the mortuary.

Once the patient is gone, the first step is to preserve privacy by drawing the curtains around the bed. Thereafter, the doctor then goes ahead to confirm death by checking for cardiac activity (presence of a heartbeat), respiratory function (breathing movements) and state of the pupils (yes, the pupils of the eyes get really wide and do not react to light after death). These are then documented in the patient’s file, along with the cause of death. The time that death was verified is usually documented against the signature and name of the ascertaining doctor.

Once death has been ascertained, the patient’s next of kin are informed of the news. Where the family is within the hospital, they are informed by the health provider immediately. In the event that they are away, they will be summoned to the hospital and informed upon arrival.

This is one of the most challenging duties for any health care provider. To be able to pass on the difficult news with empathy irrespective of one’s own feelings. Many times, the nurse is deeply heartbroken to lose a life so young, or a doctor so distraught to lose the head of a home to a tragic accident, leaving behind a young family. Yet as care providers, it is not our place to out-mourn the family.

After breaking the news, the body should be identified correctly with identity bands that are properly labelled, to ensure their identity is well documented even upon transfer to the mortuary.

Thereafter, the body is prepared before moving. The body is aligned by straightening the limbs and keeping the head to face straight ahead. The eyes and mouth are closed and the bladder is emptied. In case of any open wounds that are oozing, they are dressed up to prevent soaking the whole body. All medical intervention accessories that were in place are removed. The body orifices (mouth, nose and anus) are sealed with cotton to absorb secretions. Afterwards, the body is then dressed.

All the above procedures are performed to enable the patient look presentable to the family to ease their discomfort and pain. It provides for a dignified manner in which to remember the departed hence bringing some peace of mind.

In the event the manner of death requires a post-mortem, then there is minimal intervention. All medical intervention accessories are left in place for further evaluation by the pathologist. These should never be tampered with.

After the family has viewed the body, it is then wrapped in a bed sheet ready for transportation. Across the world, all patients who die in the hospitals are wrapped in hospital linen for transportation to the mortuary. However, in the event the patient is suspected of having had a contagious disease, them the body will be put in a body bag.

Meanwhile, the notification of death form is filled by the doctor, stating the identity of the patient, the immediate cause of death and all other factors that may have contributed to the death. The notification slip is given to the family while the copy accompanies the body to the mortuary.

The importance of the last offices is a special task that is designed to help families and friends handle the difficult moment of letting go of their loved one. There is need for a lot of compassion and capacity to accommodate everyone. The mother who lost her baby during labour should be accorded a secluded area to hold her baby and bid him farewell. Special arrangements should be made to allow the Muslim and Jewish families to perform their religious cleansing rites on the body in preparation for immediate burial as they do this within 24 hours.

What has been happening in Pumwani Maternity hospital is by no means unique in this country. It happens across the country in resource-starved public and private institutions. We must purpose to change this narrative going forward. We cannot drop the ball on dignity immediately after death, only to pick it up after the departed is in a coffin!







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Suki* was at her wit’s end. Her adolescent daughter had finally become a young woman. She had started her menstrual period at fifteen and the proud mother was patting herself on the back for having prepared well for this day.

When most young girls are terrorized by this important physiologic step, Suki’s daughter was bubbling with confidence and ready to take on the next phase of her life with pride. Her period started on a Saturday morning at home and after informing her mother, she took a shower and put on her sanitary towel as her mother looked on. Suki was happy to have demystified the whole process for her daughter well in advance.

The duo went out to a celebratory lunch to induct the young lady into her new status. Suki even took her shopping at her favourite clothing store and she was allowed to indulge in her favourite ice cream and a movie.

What started out as a wonderful venture for mother and daughter was soon nipped in the bud. Suki’s daughter could not tolerate sanitary towels. By the end of the day, she had broken out in a fine skin itchy rash in the pubic area and upper thighs that landed her in the hospital emergency room.

What a blow that was to Suki! All the while she had prepared her daughter to face her periods with ease, it had never crossed her mind that the disposable sanitary towels that many women used could be out of bounds for her daughter. She was back at the drawing board to figure out what her daughter could safely and conveniently use.

In most parts of the world, menstruation is something that is never talked about in public. Most young girls are left to fumble with such an important step in life, leaving them bewildered and confused. It gets worse if the menses come with medical complications such as severe pain or excessively heavy flow.

As a country, we are making slow but sure steps in ensuring that every woman can go through her menstrual period hygienically and in a dignified manner. However, we are still far from achieving that target. 65% of women in Kenya still lack access to menstrual hygiene products.

Kenya is the first African country to work on coming up with a menstrual hygiene policy and strategy. In addition, the country has been providing sanitary pads to school-going children in disadvantaged communities in a bid to ensure that they are not disadvantaged in any way by their physiology.

To this end, millions of sanitary towels have been distributed across the country and hundreds of thousands of young women can afford to smile. They do not have to miss school because of a period. They do not have to make do with rags, old sponge torn from mattresses or pieces of old blanket.

While Suki’s daughter sat at home in dismay, wearing a wad of cotton wool for a sanitary towel, Suki was up all night on her laptop seeking solutions. It took a loft of sifting though the mountain of information online to realize that there were several local solutions for her daughter’s problem. Unfortunately, none of the products listed were available in the local stores!

Kenya has a host of menstrual hygiene products, most of which are locally made. There are silicon-based menstrual cups available. The Ruby cup, availed in Kenya, is not only a commercial venture, but is also a charitable venture. For every one cup bought, a needy girl in this country will be given a cup for free. The Grace cup, a locally marketed brand, is also available locally, brought into the market by a passionate Kenyan woman whose main desire is to manufacture it fully locally.

Away from the cups, there are reusable sanitary pads, made of unique natural fabric that are available locally too. The pads are washable and waterproof, to prevent leakages. They are good for people like Suki’s daughter who are unable to tolerate synthetic materials. AFRIpads have gone all out to manufacture reusable pads for sale in Africa.

Even further, are Nola period panties. Designed and manufactured by a Kenyan lady, these unique panties come with an in-built reusable sanitary towel. All a girl needs to do is wear it and go!

So, with all these wonderful products available, why are they not on our supermarket shelves? Why are they not stocked in the local kiosk? These are products that are not only sustainable but also environmentally friendly. You would think that as a country, we would be jumping at putting them on the retail outlet shelves.

A big part of the hindrance has been attaining certification from our Kenya Bureau of Standards, so as to allow the retailing. Three years down the line, most of the local manufacturers are still struggling to get the precious stamp. While we are still struggling with the bureaucratic red tape, our neighbours, Tanzania and Uganda, are miles ahead of us. They have certified the very same products and availed them to the public.

Our focus as a country, is spot on. We must ensure that all girls and women in Kenya can have safe, affordable and dignified menstruation period. 16 million Kenyan women cannot continue to be shamed because of a normal physiologic function. It is abominable.

We must all remember, the female menstrual cycle is a key pillar that ensures continuity of the human race. Women are tasked with the noble role of nurturing our future. Let us join hands in giving it the respect it deserves.



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Last week the media was awash with the incredulous story of the suspension of a senior medical doctor in Embu for allegedly assaulting his colleague in the workplace. The story raised quite a debate among colleagues in the profession with many calling for his resignation as the alleged act was viewed to be of the highest level of professional misconduct.

What would lead a highly regarded professional, in the line of duty, resort to an act that goes against the very ethics of his profession? While many will focus on personality and character, a less considered possibility lurks in the background.

Many of us diligently report to our places of work day in day out without questioning the impact of the workplace on our mental status. The world Health Organization (WHO) information sheet on Mental Health in the Workplace states that globally, more than 300 million people suffer from depression and anxiety; estimating that this costs the global economy US$ 1 trillion each year in lost productivity.

The information sheet further notes that a negative working environment may lead to physical and mental health problems, harmful use of substances or alcohol, absenteeism and lost productivity. Workplaces that promote mental health and support people with mental disorders are more likely to reduce absenteeism, increase productivity and benefit from associated economic gains.

While these concerns may seem abstract, the reality is that many people are in jobs they hate or derive no satisfaction from, driven by the needs to earn an income to meet their obligations. Many are in industries they were not trained for or holding positions they are inadequately prepared for, resulting in constant anxiety, that reduces productivity and dangerously threatens their mental health.

The negative impact of poor workplace mental health state is felt even more acutely in the delicate industry of healthcare. In a space where the health workers are entrusted with the most vulnerable in society, the importance of securing the mental health of the workforce cannot be overly emphasized.

Unhappy, demoralized, overworked and demotivated health workers will pose a danger to the very patients they are sworn to protect from harm and endeavour to treat. The health profession is not only noble but also deeply satisfying as it touches on the very core of humanity.

A grateful smile from a patient relieved of pain is deeply satisfying to the physiotherapist who diligently works to rehabilitate him. A beaming smile from a brand-new father deeply reassures the midwife that her work is not in vain.

On the flip side, many mentally ill people continue to struggle in their workplaces as their challenges go unacknowledged and unsupported. The unfortunate outcome of this in the health care setting is that many times, the struggling health worker may end up putting themselves and their patients in the way of harm inadvertently.

That nurse accused of reporting late to work every day may be struggling with depression and her medications make her so drowsy, she is unable to get up in time. That young doctor accused of being drunk all the time may be battling alcoholism resulting from bipolar disorder that has remained undiagnosed for years. That laboratory technician who takes forever to deliver patients’ results may be struggling with obsessive-compulsive disorder and has to repeat his tests severally to be sure of the outcome.

When they come under pressure, they crumble and the outcome may get very messy. Health professionals have committed unplanned suicide from accidental drug overdoses in the process of abusing prescription medication. Some have turned violent towards colleagues or abusive to patients during episodes of mania. Others have inadvertently caused delays that have resulted in bad outcomes for their patients as they could not be reached when on call, only to be found dead in their houses having hit rock bottom and succeed in their suicide attempts.

In such a delicate profession, where life hangs in the balance, it is critical that the workplace is a safe haven for all workers. The working environment must be supportive to all so that they are able to thrive and in return, be able to give their very best to those in their care. Healthcare workers must be motivated, supported continuously in their work, provided with the right environment and resources to be able to deliver on their mandate, and appropriately motivated to give their very best.

In the same vein, those suffering from various mental health issues require timely intervention to facilitate diagnosis and treatment. Their right to job protection must be assured as stipulated in Article 27 of The UN Convention on the Rights of Persons with Disabilities (CRPD), which provides a legally-binding global framework for promoting the rights of people with disabilities (including psychosocial disabilities). It recognizes that every person with a disability has the right to work, should be treated equally and not be discriminated against, and should be provided with support in the workplace.

The same applies to all other industries. As organisations continue to recognize the importance of physical health and enroll their employees in wellness programmes, the mental health aspect should not be left behind.

At all times, organizations must endeavor to identify risk factors in their workplace that threaten the mental health of their people and strive to eliminate them. They must continually strive to improve on the strengths of their employees while modify their weaknesses so as to promote their mental wellness.

For those with mental health illnesses or problems, there must be clear policies on how to facilitate them to access care and re-integrate them back into the work environment within their limitations. After all, every industry needs to do their share in saving the billions of shillings lost in this country as a result of poor mental health!



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It has been an interesting week as we advocate for breastfeeding support across the world. The message has remained consistent that breastfeeding is best for baby and every mother requires to be supported in every possible way to make the experience as easy as possible. Special focus has been on supporting breastfeeding in the workplace. There has also been a lot of controversy around breastfeeding in public spaces.

While we continue debating on what is appropriate regarding breastfeeding in the office, park, public transport and restaurants, moms on social media have found a safe space where they can share their breastfeeding experiences with each other without fear.

One mom, Diana Awuor, in her classic humorous fashion talked about waking up in the middle of the night to find herself soaked with milk, but what was totally bewildering to her was that the milk was spilling out of her armpits! The comments that followed were even more rib-cracking.

She reminded me of my fascination during the anatomy classes when we learnt about the mammary line (milk line). This is a developmental step during the growth of the human embryo where an elevated ridge develops, arching from the armpit, down to the groin on both sides. This is the line along which the breasts develop. The rest of the ridge disintegrates, leaving the normal paired breasts behind.

This line is present in all mammals and its persistence can be demonstrated well in mammals that will have more than one pair of teats such as cats and dogs. In humans, where the disintegration is incomplete, extra breasts or extra nipples may be the end result. These will be dormant but may become active during lactation for some moms.

During routine examination, the doctor will be able to pick them out as incidental findings. It is quite helpful to reassure the mom before she is even more traumatized by social media “doctors” who will come up with a perplexing array of diagnoses, including being bewitched. These are not much of a concern but it is important to note that the ectopic breast tissue may be the primary site of development of breast cancer.

Alongside the supranumerary nipples are other acquired breastfeeding complications that may occur during the breastfeeding period. The commonest is cracked nipples. This happens pretty much almost immediately breastfeeding commences, in the event the new mom does not know how to position the baby to latch properly onto the breast. By the second or third day, mommy is in tears every time she has to feed the baby. If there was ever an important task for the lactation specialists, it is to prevent cracked nipples.

Cracked nipples may be the nightmare of many a new mom but it can get even worse. Mastitis, an inflammation of the breast tissue secondary to infection, may result from the cracking of the nipples. Bacteria enters the breast tissue causing the breast to become sore, tender and hot to touch. Coupled with full breasts, it is easy for the mom to miss the early signs of infection, mistaking them for breast engorgement.

Left untreated, the mastitis may result in formation of a breast abscess. The tissue being destroyed by bacteria dies off and results in accumulated pus. This becomes a surgical emergency. What starts out as a nurturing experience may take a downward turn that must be quickly halted.

Additionally, breast cancer can strike at any moment, including during breastfeeding. A diagnosis of breast cancer at any time in a woman’s lifetime is traumatizing. To have your doctor tell you that your breast biopsy has tested positive for cancer when you have a breastfeeding five-month old infant is beyond comprehension. There is no possible way to prepare a mother for what will lay ahead in the course of treatment.

New moms must be sufficiently empowered to recognize the early signs of mastitis to prevent breast abscesses. If it doesn’t feel right, it probably isn’t. Healthcare providers should take breast complaints seriously and not just write it off as breastfeeding inexperience.

As if waking up to the a milk-soaked bed is not enough, Diana brought even more good humour to the group by reminding us just how motherhood has a way of changing all of us in the blink of an eye. From a stylish young lady in touch with the trending fashion, to just a mom more concerned with ensuring her baby is fed.

That is what happened when she forgot and wore the wrong dress on the day was taking her baby to the paediatrician. The moment her little one started wailing for his meal, she suddenly realized that in her new capacity as an official mobile milk dispenser, her tap was completely inaccessible! In the end, she found herself walking around in a workman’s overalls, several sizes bigger, procured from a nearby hardware by her husband. At that moment, it did not matter. She was just relieved to be able to breastfeed her baby, oblivious to the stares she was drawing.

Women have worked hard to scale the professional ladder. They have moved on from wearing dreary maternity wear in the name of motherhood. They have a right to carry their pregnancies in comfort but still look great. In the same vein, when their bundles of joy make their arrival, they should still be able to wear breast pads with ease underneath their power suits at the corporate meeting and glide seamlessly into mummy mode when baby demands so.

The expectation is that breastfeeding should be natural and spontaneous. In many instances, this is the case. However, when this does not happen, we must be empathetic and supportive. Most mothers are juggling so many balls in their life, we must make sure they do not drop the baby!

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