I am in my third year of residency and by most standards I feel fairly well prepared to pursue a career as an internist or a subspecialist in the US. As I've realized over these past two weeks, this does not mean that I am well-equipped to practice in Kenya. The medicine here is very different, in all senses of the word. Because of the lack of resources, diagnoses are based on history, physical exam and clinical gestalt. In many ways, this is the way medicine was supposed to be; taking a precise history and performing a thorough and exacting physical exam have always been considered the art of practicing medicine. There is no question about this. The physicians I revere most in the States are those who can generate a short differential diagnosis just based on those skills. But not having the ability to confirm your suspicions with specific tests is quite challenging, sometimes frightening, and very frustrating!

For example, last week, a 27 year old gentleman was admitted to the ward with seizures. He was too altered to give us any history, but his brother told us that he had seized three times that morning and was supposed to be taking anti-TB and anti-HIV meds (but wasn't that compliant). His CD4 count was 22. On physical exam, he was unarousable but breathing on his own with a decent pulse. Temperature was 39, neck was as stiff as a board, pupils were reactive and he extremities were completely flaccid. The possiblities here were several: bacterial meningitis, toxoplasmosis, TB meningitis or cryptococcal meningitis. History and physical could not truly differentiate these and there were no reagents in the lab to perform any blood or CSF analyses. There was no way to image the head or spinal column. What to do? I was at a loss. The physician here, however, had been through this so many times before... the answer: treat them all to the best of our ability and hope that something works. So, we put him on anti-TB meds with steroids, high dose medication for the possibility of toxo and some IV antibiotics for the possible bacterial meningitis. The pharmacy had run out of medicine to treat cryptococcal meningitis, so we couldn't bother with that. As of Friday, the patient had stopped seizing and no longer ran a fever, but wasn't waking up very much. We'll see how he is tomorrow....

The conditions under which physicians practice are extremely challenging. The wards here (pictured above) consist of concrete rectangular rooms with about 25 beds. There are often two patients per bed, each with his or her own communicable disease. The dirty walls, overpowering smells and abundance of flies and mosquitos is also disconcerting. Lab reagents and imaging studies aren't available currently (except for HIV test, CD4 count, hemoglobin, malaria smear and a chest x-ray) and sometimes the pharmacy doesn't have the appropriate medicine. These conditions make me worry that we are encouraging disease propagation rather then healing. Thankfully, many patients do improve, thanks to the very limited resources that clinicians here are able to use and provide. What is amazing to me, is that the conditions now are much better than what they used to be! Despite the lack of resources, patients with HIV/AIDS today are getting medical care, which is a HUGE step in the right direction. This has helped curb the prevalence rate in the Suba district from 45% in the late 1990s to about 20% now (stats are per one of the clinical officers here; I still have to look up the official rates myself).