Kenya, January 2008

These edited emails were sent by Dr. Garzon while in Kenya with Médecins Sans Frontières, or Doctors Without Borders. Parentheses (like this) are the author's; brackets [like this] were inserted by the editors. See the inside back cover for color photos.

Wednesday Jan 8. The MSF "Emergency Response Team" has been staffed by three Kaiser E.D. docs and "operational" since October. Their first true "activation" of this team is for the current impending crisis in Kenya. It happens that I am "first up" this month for them, so I have been asked to go (alert yesterday, green light today, travel tomorrow).

I have been asked to fill a position as Medical Coordinator…to establish what MSF has to do to prepare for the potential deterioration [and] civil unrest which has occurred as a result of the elections in December. I will initially be in Nairobi and focus on the needs of the slums [there]…. There is potential to travel to western Kenya which is the other area impacted by the civil unrest. I depart tomorrow morning (Jan 9th) at 9 a.m.; Mission duration is up to 4 weeks.

Wednesday morning, Jan 16, Nairobe, Kenya. We have gotten through the first day of Parliament without much incident. Today is the first of three days of planned protests by the opposition party.

I have spent a couple of 16 hour+ days touring through the Mathere slum, visiting potential sites to set up clinics with consideration for both accessibility for patients and security for the team, visiting area hospitals, putting together trauma first aid kits to include sufficient medical supplies to treat 70-100 victims, and I have spent many hours in Nairobi traffic.

The slum in which we are working in more mixed than most, with neighboring areas of differing ethnic origin…people will have difficulty getting through one neighborhood to another to seek help or shelter. Different ethnic tribes are at risk from each other, and pro ODM (the opposition party) supporters who protest are at risk from the police who are known to use excessive force to quell crowds.

6:30 p.m.: Political Situation: Everything is pretty tense. The police shut down the city center and quelled almost all rallies. Three people where shot (dead) in the slums by police. Some peaceful demonstrations and some minor violent ones throughout the country. Just a few hours ago the president suspended parliament (which he supposedly has the power to do), so who knows what this will cause overnight.

MSF work: The day was quiet, for the most part…. We saw about 50 regular patients in the HIV clinic and 7 victims of violence, some treated and discharged, but three sent to the hospital for major fractures and head trauma.… One of the national staff here is an amazing young man who is a vital link between the MSF program and the local community in the Mathere slum.… [I asked him:] "How are things in Mathere?" His single word answer says it all: "Unbearable."

Thursday Jan 17…was not like the relatively peaceful day before. The morning started slowly, and I had a chance to help the MSF clinic with their usual business of seeing HIV and TB patients. I joined the Field Coordinator for the Mathere slum MSF clinic and two other staff in driving the clinic ambulance into the slum to retrieve patients who had missed their appointments and were reportedly too ill to get out of their beds. While I have heard about and seen pictures of the Nairobi slums, nothing can really prepare you for the lives that people endure [there]. The squalor, poverty and suffering are unimaginable. The ambulance can only drive up to a certain area, and from there we have to enter the slum on foot because there are only narrow, muddy, stench-filled alleys between the corrugated metal boxes called homes. We were able to repatriate an HIV and a TB patient who were quite literally dying in bed, too weak to get out of their dark metal boxes. 20 percent of the slum population is HIV positive.

We couldn't continue that repatriation because we soon started hearing stories of shootings in the slums. I have already seen a number of articles in the news detailing the numbers of casualties, and can tell you that they are at best inaccurate. The police were in force quelling demonstrators even before they got to assembly points (better to suppress crowds that way instead of after they form). We saw violence of two types - civilian vs. civilian beatings and stabbings, and police vs. civilian shootings. In total for the afternoon we saw:

• Two gunshot wounds to the head
• One gunshot wound to the abdomen
• One gunshot wound in the arm of a 5 year-old who was hit when a bullet went through the wall of his shanty
• And at least a dozen beatings with lacerations and orthopedic injuries.

After stabilizing the patients, we sent the majority to the hospital.

From the early part of the day, Robert Frost's words kept on recurring for me in my thoughts:


          A voice said, Look me in the stars
          And tell me truly, men of earth
          If all the soul-and-body scars
          Were not too much to pay for birth

Monday, January 28 12:08 a.m. We had three relatively quiet days in Nairobi, but…over the weekend there has been much violence in an area about 50 miles from Nairobi [Nakuru], with at least 90 dead and hundreds injured, houses [and] people burned alive, and a monastery with people seeking safety under siege by rival tribes and protected by police. A small team from MSF-Spain has been trying to help in one of those area hospitals, where they have received over 160 injured, with 90 of these requiring surgery. MSF-Spain's team is mainly a primary health care team…so they have asked MSF-France to take over that hospital. We have already requested a separate 6-person emergency team to staff that project separately (from what we are already doing in Nairobi and in the western part of the country). We have also ordered another metric ton of medical supplies to arrive in 48 hrs. Later this morning we [our coordination team] is making a trip to the area to assess the situation in person.

While it has been relatively quiet [in Mathere]…we have still had a small number of critical cases, [with] significant injuries from the routine violence of the slums and other serious medical cases (see below). The U.S. RN who arrived three days ago has started work. Vivian Reyes, who is an E.D. physician from S.F. Kaiser arrives here on the 30th, and as it appears that this program in the Mathere slum will continue, we are also looking to hire a local doctor, nurse, and additional other staff.

Over the weekend we saw:

1. A man with a tension pneumothorax from a stab wound to the chest, which had actually been sutured the day before at a local clinic. When he presented, the sutured wound was raising and falling with his respirations. He had clinical signs of a tension pneumothorax, and a needle to his chest nicely decompressed the tension.
2. A woman 35 weeks pregnant with seizure and elevated blood pressure (eclampsia) who we referred to the hospital after stabilization.
3. A man with extensive third degree burns sustained when he had a seizure at home and knocked down his cook-pot, setting fire to his house.
4. A woman who was refused entrance to a maternity clinic because she had no money to pay, [and delivered] her child in the street. We came upon her while riding our ambulance, but the infant was already dead.
5. A number of infected wounds, already several days old, many of which had been seen and sutured at outside local clinics; many of these are staffed by pharmacists or people with even lesser training.… We treated for infection,…and sutured them secondarily - something we rarely do in the U.S.…

I have been given the nickname "the tailor" (in Kiswahili, of course) because of all the suturing I'm doing or teaching the other doctors and nurses to do.

My own medical misfortune: I woke up on Saturday to the sudden onset of fairly severe right flank pain. What a lovely time to get my first kidney stone. Anyway, a trip to a local [western] hospital, a CAT scan, about 25 mg of morphine and about 5 hours later, and I was pain free (being fortunate to have passed the stone that quickly). Because of all the pain medication I had to sleep away much of the afternoon, but was back to my usual self by dinner and back to work by Sunday. Yes, I am more vigilant about hydrating now.

…It is difficult to get a sense of where, when or how bad the violence may flare. Several people who know Kenya well are concerned that the violence will return to Nairobi, and as we make preparations to send a new team to Nakuru, the area affected [last] weekend, we are also continuing to staff the Mathare slum in Nairobi. It is really a 16 hour a day job to process all the information, and make adjustments to our game plan almost on an hourly basis. Such is the work in situations like this. My replacement has been requested, but with all the turmoil of the weekend it now appears that I will not get to leave early.… As hard as it is to stay and work in this current environment, it will also be difficult to leave.

Saturday, February 05 7:24 a.m. [Later on the morning of the 28th,] I was dispatched (with 3 others) to a town 60 miles north of Nairobi where violence had been reported the night before and one doctor in a rural Ministry of Health Hospital was caring for 30 trauma victims by himself.… We arrived around 5 p.m., and were up until around 4 a.m. working a ward with 27 trauma victims - four major head injuries, one patient with severe third-degree burns, two patients with collapsed lungs, and multiple fractures from beatings and gunshot wounds.

One pt, already deceased on our arrival, remained covered on the floor between two beds all night. We had only two local nurses, and no housekeeping. The blood stains on the floor remained well into the next day. Because of the safety risk, we could not evacuate the sickest patients until the following day. It was, to say the least, a surreal experience. With national health care staff arrivals the following morning we were able to come back to Nairobi. This day alone could be a rather good novella.

The violence in Nairobi has remained minimal, and we have had a number of slow days in the clinic here (thank goodness). While the number of cases in this clinic has not been great, we have continued to see some rather severe trauma from the routine violence that persists in the slums....

What began as an 8 person emergency team (4 here in Nairobi and 4 in the western part of the country), has now grown to 21 foreign staff and 12-15 national staff. We have not only increased coverage for the Nairobi team, but have also increased coverage for the team in the west and staffed a mobile team that is ready to go to any location necessary.

Vivian Reyes (an S.F. Kaiser Emergency physician) arrived a few days ago and is working as part of the Nairobi emergency team. My replacement arrives tomorrow, on the same day I leave. This has been my last formal day of work. I depart from here tomorrow evening, with a one day stop to "debrief" with MSF and then home by the evening of the 8th.

In a deployment where I have largely been witness to unimaginable violence committed by humans on other humans, it has perhaps been a saving grace for me that today our Nairobi trauma clinic delivered a baby. While I was not there at the time, I will gladly take all of the hope that this new life symbolizes, and make it my own.

hxgarzon@gmail.com