September 18 is my younger brother Kevin’s birthday. I was in Siaya, and I wanted to travel back to Nairobi to celebrate with him. There was not much to do in Siaya after dark. The town turns ghostly after sunset. The local traders in the market slowly wrap up their wares in a choreographed fashion and walk together, mostly as a band of women to their households in the villages. The men stay a little longer on their motorbikes waiting for customers or catching up with the day’s political gossip. The shopkeepers and butchers quickly follow the women, trying to close before the scheduled power blackout. It’s strange, but electricity supply from Kenya Power consistently disappears between 7pm and 9pm. Both of these times are crucial for the few people with televisions who tune in to listen to the local news broadcasts from Nairobi. When there’s power, Siaya residents religiously watch the news broadcast, tuning into both the Kiswahili and English broadcasts, two hours apart, even when it is a repetition of the same broadcast.
In any case, darkness brings most things to a standstill. Siaya hospital, where I worked, is flung into total darkness. The generator often lacks fuel and it takes partners like the organisation I was working for to chip in monthly with some sort of supplementary funding. It was this darkness that we were running away from. I made a few phone calls to my colleagues Vinnie, Christina and Eric and we all huddled in Vinnie’s brand new Toyota and set off for Nairobi. We were in high spirits. We had had a long week of providing care to hundreds of children, and collecting terabytes of data to support licensing of our malaria vaccine study.
Local communities in Siaya are magnets for public health research. A rural community, with basic infrastructure and poor health indicators is fertile ground for local research organisations like the Kenya Medical Research Institute (KEMRI) and Centers for Disease Control and Prevention (CDC) to set up shop, attract funding and conduct research.
The men and women of Siaya are probably more famous than they will ever know, though mostly as statistics in peer-reviewed papers and publications. The educated world of infectious disease probably knows much more about these households through malaria and HIV data than the local chief does. A PhD student at an American university could probably model an accurate predictor of mortality in these villages from the troves of personal data collected from these people.
I had worked in Siaya hospital for a few years. I had very little business going into any wards except the paediatric one, where children participating in our vaccine study were hospitalised. We worked hard to make “our side” (the research side of the ward) live up to the required standards expected by the donor. Five feet away, on the government side, was a sad reminder of what lack of funding and resources looked like. It was cold and uncertain, and had a perennial shortage of essential supplies. The “research side” and “the government side” were on the same floor, yet they were worlds apart in terms of resources and health outcomes.
I wonder what went on in the minds of the mothers in the “government side” when they walked through the “research side” to use the bathrooms. I wonder what they felt when they noticed no one was sleeping on the floor, or sharing beds with strangers. Or that kids on the research side received a better diet, or that the process for discharging patients recruited in research was efficient, and no family would spend an extra day or two detained for not having enough money to cover their hospital bill. On the research side, there was always an ambulance on standby to get participants to Kisumu for specialised care when needed. Our side had the facilities, equipment and adequate staff; the government side had hope as the only sure intervention within crumbling infrastructure. I knew this reality, though it seemed so distant to me outside my privileged life.
My colleague Vinnie was driving that day. We were probably speeding when we lost control and plunged into a huge ditch off the road. We managed to get out with the help of a few well wishers who rushed us to a nearby paramilitary camp for first aid. I had sustained minor head injuries. My colleague Christina had significant back injuries. Vinnie and Eric had minor scratches. The car was extensively damaged.
The clinic at the camp was managed by a nurse, whose first aid box only contained cotton wool and methylated spirit. We were surprised – this was a paramilitary camp after all and we had expected a little bit more. These supplies were too basic to manage our conditions. We had to move to a better facility so that my head could be examined and attended to. Christina was also in excruciating pain and we were worried she had extensive injuries that needed urgent attention.
The reality of our situation started to dawn on us. The only transport option available to us was a Land Rover with a flat, open bed at the back. The officer in charge of the camp was gracious enough to offer us the Land Rover, though we were worried that a ride at the back of it would aggravate the injuries Christina had. We thought of trying our luck stopping random vehicles on the road but it was late, and very few people would have risked stopping for strangers at that time of the night. The camp officer suggested that we reach out to the medical officer in charge of Molo District Hospital for help. The hospital had an ambulance that was better suited for our needs. Besides Christina’s injuries, my head was swollen and throbbing wildly. I feared that I may have extensive head injuries and I knew I needed to get to a hospital fast and get a CT scan. Whatever privilege we had in Siaya was nowhere in sight in Molo. The more helpless we were getting, the more paranoid I was becoming.
***
One of the thoughts that engulfed my swollen head was about a close encounter with a patient from my past. I didn’t know him, but I remember him because he shouted my name from the male ward where I had gone to see a friend. I am not sure how he had come to know my name. I went and sat next to him in the bed, feigned acquaintance and lent him an ear, preparing myself for the usual request for some sort of financial or social help within the hospital. He was quiet for a long time. I noticed there was a thick discharge from his ear; there were stains of discharge on his bed sheet too. I called out to the nurse to alert her about the discharge. She told me that a doctor had already done ward rounds and made plans with him and his family for treatment. He had been a victim of a motorcycle accident and had been brought in a few days ago.
The man was obviously not doing well. I asked the nurse what I could do to help and she told me he needed to get to Kisumu for a CT scan and specialised care. I asked the man what the plan was, but he was lost in thought and I did not want to interrogate him before understanding his situation. I left with plans to return to see him the following day.
The next day, I did not find him. I was told he had sneaked out of the hospital and no one knew where he had gone. Apparently his family had left to go look for money for a CT scan and two days later they had not returned. He had also not received any message from them, so he apparently left to go and find them. In such circumstances, the family needed money for ambulance costs, on top of treatment costs and any other extra costs. A simple accident can have major financial ramifications for poor families. They were probably trying to sell an animal or some property to get him the help he needed. Or they had lost hope and abandoned him. I don’t know. I learned from one of the doctors we worked with that the discharge was from cerebral-spinal fluid forced out by intra-cranial pressure from his head injury. The man was facing imminent death. He left and never came back. So I knew I had to get a CT scan urgently.
While at Siaya, we were privileged to hold senior positions and so we could always put in a request and two SUVs, sometimes three, would be at our disposal for project work. We also had a fully equipped ambulance that responded to emergency needs and facilitated emergency transfers of staff and study participants from Siaya to Kisumu. A few months before this accident, I had received an emergency phone call from one of my staff members in the field requesting for an ambulance to pick up a father of one of children enrolled in our studies and rush him to Siaya Hospital. My colleague had been at the home when the man was hurriedly brought in by his friends. From the commotion in the background, I could discern distress. My staff member’s voice was also strained and heavy with emotion. The father had been bitten by a snake, and his condition was deteriorating rapidly.
There is a lot of pressure that comes with having the responsibility of deciding if a person has access to a service, such as transport to a hospital, which has the potential to save his or her life. We had reached a compromise with the main management of the research study that I could make a call for community use of the ambulance if one of our study participants was in danger and needed urgent rescuing. But technically speaking, this man wasn’t a participant in our study – his child was. We had the ambulance, but the challenge was how to manage urgent requests from the broader community and respond to them while not jeopardising our good relationship with the community.
We had decided that such requests would be escalated to the transport management at the headquarters. This though was a unique call because my colleague was stuck in this situation. He was at the home, at the heart of this emergency. I quickly called the ambulance driver and told him to be on standby. I also reached out to the headquarters and it took me some time to get through with the request. While we were still sifting through the bureaucracies, peeling off one layer after another, there was commotion at the emergency entrance of the hospital. A woman I could faintly recognise was crying her lungs out while others tried to hold her back. It was the man’s wife; she had brought him to hospital but he did not make it. He died on the way to the hospital on the back of a motorcycle where he was precariously balanced, hanging onto dear life.
This particular case woke me up to the reality and complexities of health care and research in rural settings. There was death and chaos hidden behind the quiet grass-thatched houses and one never knew when it would spring out and grasp the next victim. I would later call the field staff to enquire if the wife had said anything about us. A sense of guilt hung over me every time I thought about him. I deliberately started to avoid this particular woman whenever she brought her child for routine check-up at our study clinic.
It came as a relief when I later learned that not much could have been done in this particular case. It was not easy to get anti-venom in this hospital and considering how quickly the man had succumbed to the snake bite, I was told there was little the hospital could have done to save his life. I took comfort in this; any guilt for personal failure was quickly erased by the glaring failures in the health system.
***
The officer in charge of the camp placed a call to the medical doctor at Molo hospital. It was midnight, so there was no guarantee we would find the doctor awake. Luck was on our side though. He picked up the call. The officer in charge explained the situation to him. From this end of the call it seemed that the two were agreeing on a lot of issues. This was a good sign. The call ended and we waited for the good news.
“Daktari amesema mulete pesa ya mafuta.” (The doctor says bring money for fuel.) The officer in charge said this in a matter-of-fact way. We knew we had to do what he had requested; he had all the power over the ambulance – the same power we wielded in Siaya. We also knew we could bargain over the amount, but we could not escape paying for it. But we also had no doubt he actually needed fuel. This was a government hospital; everything is hard to come by and everything costs money. We had some money in our Mpesa accounts in our phones.
However, unbeknownst to us, there had been another development with our belongings at the accident scene. While were worrying about Christina and my swollen head, our friend Eric had made his way back to the car to salvage our belongings. He had encountered two men rummaging through the wreckage of our car. These men had taken our phones and Eric’s efforts at negotiation failed to get back the phones. One of them – he said his name was Biwot – actually sympathetically assured Eric that at a fee, he could come back for the phones the following day after we had received care. There we were, unable to send money to the medical officer in Molo because a stranger called Biwot had stolen our phones. We thought quickly and borrowed the officer’s phone, called a colleague who sent 6,000 shillings to the doctor’s phone number. An ambulance was promptly dispatched. We immobilised Christine and set off for Nakuru.
The next day, all of us, except Christina, were discharged. But I was angry at how callous and soulless this Biwot guy was. How he had robbed Eric when all we needed was help. The thought of him getting away with this act bothered me greatly. My brother Kevin had come to Nakuru to pick us up, and I requested him to drive us to Molo police station to file a report.
As we were waiting for the officer commanding station (OCS), we started to tell one of the policemen about Biwot and our unpleasant encounter with him. The police officer’s face lit up. It turns out he knew this Biwot. He called his colleague and we quickly set off to find the man. The police officer quickly located Biwot’s house that was not very far from the accident scene. He kicked the door and demanded to see him. A woman who I suspected was some form of acquaintance in the single room that served as a kitchen, a bedroom and a living room, all in one, told us Biwot had left just moments before we arrived. It did not take much persuasion from the policemen for the woman to admit that Biwot was hiding in a neighbour’s house. The two policemen quickly fetched him and used whatever methods they learned in training to coax out our phones. Violence of any form is hard to watch. But it is also hard to understand why anyone would steal the belongings of accident victims in need of desperate help. Biwot produced our phones, which appeared to be damaged. We exchanged glances as the policeman slid them in his pocket. They were now evidence under his care. I was eager to have to have my phone back so this was a bit disheartening.
Back at the police station, my friend Vinnie had already met with the OCS. Vinnie told us that the OCS has generated a small list of items that he wanted Vinnie to “authorise” him to salvage from the wreckage for his personal use. He wanted the tyres, the car battery and the radio. He promised not to charge any of us with careless driving and assured us that the insurance people would receive a great report in exchange. We did not care. Neither Vinnie nor anyone else wanted anything to do with the badly damaged car, but the veiled power play was distasteful – he kept telling us he wasn’t going to charge anyone and reminded us of the powers and options he had at his disposal.
While listening to Vinnie, the policeman who had our phones showed up and requested to talk to me privately. He wanted me to show him some appreciation for getting our phones back. I reached into my pocket and fished out crumbled notes amounting to Ksh300 and gave them to him. He looked a little surprised and quickly demanded for more. He wanted Ksh3,000. My head was aching, and here I was negotiating with a police officer for my phone. Our accident had turned into a huge enterprise for a number of people. I was also surprised by how little charity we had been accorded by these strangers so far. It looked like every corner we turned, someone saw an opportunity to make a quick profit from our circumstances. We were getting introduced to a Kenyan reality that our status had insulated us from for very long.
We eventually made it to Nairobi. The CT scan was performed by a doctor who we exchanged jokes with throughout the process, another privilege afforded to us by our medical insurance cards. A radiologist quickly read through my files. My card was on file so there really was nothing to worry as far as my ability to pay was concerned. I was a little nervous when she looked into my ears, but she smiled and told me she saw no fluids except some need for ear cleaning. She gave me a clean bill of health.
I was ready to go back Siaya. I was also hoping to meet two people. I was hoping to run into the guy who had the fluid flowing from his ear. I knew this was impossible but I was hoping for a miracle of sorts. I learned that no one ever heard from him since he left the hospital. And no one had his contacts either. I wanted to tell him I understood.
I also wanted to meet the mother of our study participant whose husband died from the snake bite. I wanted to let her know I was sorry, and to explain how the system works and that I had followed a protocol I did not believe in.
But first I needed a phone. We all needed new phones. We had paid the policeman three hundred shillings for our phones. The only problem was that the phones had also died.
