Munib Mafazy grew up on Lamu. He went to Chicago to become a nurse and is now a PhD candidate there. When he came home to visit he received a lot of visitors, not just wishing him well but wishing for their own wellness. He took blood pressures and checked blood sugars. He wrote prescriptions for all the medications needed to treat these patients, and then when he left, his brother, Majid, continued to take blood pressures and blood sugars of family members, sent the results to Munib who then sent back prescriptions. With this experience the family realized there was a need for better access to preventive health care in Lamu. Majid moved his workshop out of the first floor of the family’s house near the center of Lamu Town. With new walls, new flooring and new paint the workshop became a clinic. It opened its doors just a month or two before I came.
At about the same time as I came to Lamu, Aziza started working at the clinic. As a clinical officer her roles are much like a nurse practitioner in the US. She has worked in other clinics performing all services of general practice; she has treated chronic illnesses, delivered babies, and diagnosed surgical problems. She grew up in Lamu and knows everyone and their circumstances. My goal was to teach her anything I knew about taking care of kids with a focus on asthma.
The first day at the clinic was busy. The Town Crier had gone around town with his megaphone a few days before I came. He announced that an “asthma specialist” was coming to the clinic. I tried to dispel that myth but quickly realized it just didn’t matter. My limited knowledge was still going to be helpful to Aziza. Aziza helped with my limited Swahili.
I started out seeing all the patients myself with Aziza interpreting. Soon I realized I needed to learn from her. I taught her about asthma; she taught me about malaria, intestinal infections, and jiggers. After a few days, I knew the patients would be better served by Aziza making the diagnoses and treatment plans. I acted as merely a consultant.
Much of the asthma we saw was bad. There are a lot of triggers in Lamu for asthma. Dust is everywhere. The kids kick it up playing football; the donkeys kick it up hauling bricks. It’s impossible to avoid. Even worse than the dust is the smoke. Most people cook over charcoal or firewood, often with poor ventilation. Many of the men smoke cigarettes only adding more smoke to the environment of the island. And then there’s the trash burning. It seemed I could smell burning plastic everywhere. Even my healthy chest started to feel tight.
With all these triggers many of the patients needed albuterol every day. Some of the adults were still using oral albuterol. It can’t be good having that medicine course through one’s body, only a fraction getting to its target, the lungs. It has so many side effects including speeding up the heart rate. Having it work on an adult’s crummy heart in such doses can only lead to bad things. These people needed a better delivery system.
When I was in Istanbul I had purchased a nebulizer from a pharmacist. The guy was great. He was excited to help me take something good to Africa. He even gave me a discount. I only wish I had taken his card so that I could send him a picture of one of the many patients to whom it brought relief.
Still the nebulizer could only relieve the symptoms while the patient was in the clinic. So Aziza and I taught patients how to use an inhaler. We also began inhaled steroids on numerous patients. This required a visit to the local chemist (pharmacist). What was available? Turns out all sorts of things at various and seemingly random prices. Prices were set by where the medicine was made. Indian medicines were half the price of European and American.
Prices became the determining factor in what we prescribed. There are inhalers of steroids only, but they cost twice as much as the combination of short acting beta agonist (albuterol) and steroid. Aziza and I started prescribing the latter for most of the patients. Here was the “preventative” part of Lamu Center of Preventative Health. With this medication we could help reduce the inflammation in their lungs and thereby reduce the frequency of their attacks. The cost of the daily medicine should be offset by a significant reduction in hospital visits. As the lungs improve the patients will hopefully be able to reduce the amount of medication they use, and therefore, reduce their expense.
I saw more than asthma, of course. Patients arrived with a multitude of problems that had nothing to do with their lungs. The various and sundry complaints many of the adults brought with them reminded me why I’m a pediatrician. In addition to my limited knowledge, my limited resources at the clinic kept me from treating all of the problems I encountered. Still I felt I reached my goals in Lamu. Aziza was creating treatment plans and teaching her patients how to control their asthma in their own language. I’m keeping in contact with her, as a consultant and a friend.