Pain Management in Kenya: A Team Experience
A team of Canadian health care professionals travelled to Kenya to volunteer at a remote facility. This article describes the challenges in providing pain management services at the medical clinic in an established Kenyan orphanage (Mully Children’s Family Charitable Foundation) during the summer of 2013. Such experiences contrast the differences in health care needs and resources between North America and Africa, and also highlight the opportunities for pain physicians to broaden their understanding and expertise in this field.
Mully Children’s Family (MCF) is a charitable Christian orphanage founded by Dr. Charles Mulli in Eldoret, Kenya. Since 1989, MCF has rescued street kids, orphans (including those with HIV), and single teenage mothers and their children. In that time, more than 6,000 children have been rescued and rehabilitated. Services provided for these children include food, shelter, education, and support—much of this dependent on charitable donations. Free medical services also are provided for adults and children in local neighboring communities.
On June 28, 2013, the authors were part of a team of 34 volunteers (33 Canadian and 1 American) who worked at MCF Ndalani, 2.5 hours east of Nairobi, for 2 weeks. The team included 21 adults—including two physicians, one dentist, one physical therapist/nutritionist, one pharmacist, four information technology experts, three mothers who helped in triage, and 13 children and young adults—several of whom were high school/university or pre-med students. After an 18-hour flight, our first few days involved orientation and touring of the extensive facilities, which includes a farm in Yatta as well as school classrooms and a baby orphanage. During this time, our team adjusted to the local climate and diet.
Over the subsequent 10 clinical days, we saw 2,510 patients. The breakdown of patients seen is summarized in Table 1. It took villagers anywhere from 30 minutes to 4.5 hours to walk to the clinic. Some patients traveled by motorcycle for up to 3 hours to reach the clinic.
Diseases and Conditions Treated
The majority of pain complaints (80%) were caused by chronic infectious diseases including typhoid, malaria, brucellosis, amebiasis, and giardiasis. Typhoid patients typically described gastrointestinal pain, including lower abdominal bloating, early satiety, and chronic constipation. Malaria patients classically described headaches and joint pains accompanied by intermittent fever and chills as well as night sweats. Brucellosis patients described severe back pain with widespread aches and pains and/or numbness. A simple algorithm was used:
- fever + headache, think malaria (treat with artemether-lumefantrine or quinine)
- fever + irritable bowel symptoms, think typhoid (treat with norfloxacin)
- fever + fibromyalgia symptoms, think brucellosis (treat with doxy-cycline or trimethoprim and sulfamethoxazole)
Approximately 20% of patients presented only with localized pain due to repetitive strain. These injuries included plantar fasciitis and knee osteoarthritis (Figures 1 and 2) from prolonged weight-bearing, head-neck pain from patients carrying heavy firewood on their shoulders, and vertebral subluxations that responded to manipulation therapy by Linda Finn, PT, ND (Figure 3).
A few patients (1%) had neuropathic pain resulting from post-traumatic amputations (Figure 4) or burn injuries and classic findings of brush allodynia. It was difficult to administer the Douleur Neuropathique 4 (DN4) questionnaire due to translation problems.
A number of patients (1%) presented with acute traumatic pain (occurring within 2 weeks of presentation) resulting from fractures or sports injuries (Figure 5). One of these cases involved a teenager with knee effusion from a karate injury, in whom 50 mL of serous fluid was aspirated twice.
Spastic diplegia was seen in a 2-year-old patient with probable birth trauma and cerebral palsy (Figure 6). This patient was injected with incobotulinum toxin A to reduce the equinovarus deformity of the feet. This injection also was administered to an adult with cervical dystonia.
Comorbidities included uncontrolled hypertension in 10% to 20% of patients, with the highest recorded blood pressure being 250/110 mmHg. Some patients also had diabetes as confirmed using glucometer testing. Three patients who presented with abdominal pain were unaware that they were at least 7 months pregnant.
Medical procedures performed by our team included pelvic exams for vaginosis and pelvic inflammatory disease, prostate exams for painful urination, catheterization for urinary retention, and silver nitrate application for epistaxis in a child. In addition, 2 children required extraction of painful foreign bodies (eg, corn) in the nose, one of which was difficult even with administration of intravenous diazepam sedation. A simple suggestion to sniff black pepper was the solution and the child sneezed out the corn. Another case involving a deep intra-aural foreign body had to be sent to a Nairobi hospital for intervention.
One emergent older female was brought in unconscious, but with intact vitals. A positive sign of conversion disorder was noted (hand lifted up over her face would not strike her face when released). She later regained consciousness and improved after given dextrose 10% in water orally via syringe, suggesting that she was possibly hypoglycemic and/or prediabetic.
Several cases of advanced cancer were seen, including inflammatory breast carcinoma that rendered the affected breast twice the size of the nonaffected breast, and squamous cell cancer of the scalp with a lump measuring 4 inches. Another patient had marked scrotal swelling the size of a grapefruit that did not transilluminate (probable elephantiasis). Surgery at the hospital was recommended but declined by this patient.
All patients were pleasant, respectful, and grateful to be seen. No patients had any complaints or grievances against the staff for having had to wait in the triage holding area for several hours. As a courtesy, MCF provided free lunch for all patients and their children. Triage also tried to first attend to those patients who had walked 3 to 4 hours so they could get back home safely before dusk.