Not All Doctors Are Created Equal!

From "The Fourth Plane"

I remember that it was a day much like any other at my first job as a Medical Officer. Internal Medicine ward round, longer and more nerve-racking than it ought to have been. My Consultant was a Nephrologist of some renown, but she had a peculiar bedside manner for a practising physician: she could be dismissive, condescending, insensitive or downright incendiary as we went about the business of assessing the patients. As we got towards the last room in the female ward that day, we had a new unclerked patient (let's call her "*Eunice") before us who appeared otherwise normal. Lately, she had been experiencing a recurrent localized right lower abdominal pain; her past medical history was hitherto unremarkable. My Consultant had me assess Eunice briefly,  and the only symptom she had was marked tenderness in the lower right abdominal area of her abdomen. I remember suggesting that it seemed likely that this patient might have been suffering from appendicitis, and that she might actually be more of a surgical patient. The Consultant wasn't having any of it and proceeded to berate me in front of the team, which included medical and clinical officer interns, nurses, physiotherapists, nutritionists and a counselor (and let's not forget the patients that were within earshot):

1. Why would I think it was an appendicitis yet the patient did not have the typical "septic" look of an appendicitis patient?
2. Wasn't her abdominal pain localized, and without the typical progression seen in appendicitis? Where are the other signs suggestive of appendicitis? 

I halfheartedly remember suggesting that perhaps it was an atypical case, but she was having none of it; I was summarily told to stop jumping to conclusions (known more technically as "confabulating") and a plan was made to work up the patient in terms of lab work and some imaging studies.

Getting insulted was usually par for the course, so I just took it in stride. Apart from that slight, nothing else really stirs in my memory from that day. Anyway, the ward round - which spanned 2 wards, and sometimes involved consults in other areas of the hospital - took so long such that the rest of the day typically involved drawing samples and tending to other ward procedures. I was also charged with attending to the Outpatient dialysis patients. A lot of the time, you would end up getting the results the next day, so it wasn't something that you could respond to too quickly. Provided the patient wasn't knocking on death's door, a little waiting wasn't really going to hurt.

The next morning was joyously a Thursday. Thursday was the one day in the week that I got to lead the ward round because it was the day when my Consultant was otherwise occupied running the Medical Outpatient Clinic (MOPC). This meant that we usually finished the ward round a lot faster. As I was conducting a preliminary assessment of patients prior to the ward round, I remember asking one of the clinical officer interns for the list of our patients. When I received the list, I noted that Eunice was unceremoniously missing. When I inquired why, I was told that she had been handed over to the Surgical Team. My interest was piqued and I decided to glance in her file to find out what had happened. The sonographer who performed her abdominal ultrasound had detected a mass in the tender part of her abdomen - an appendiceal abscess. What appeared to be more likely is that Eunice had probably suffered from chronic appendicitis; this inflammation was eventually "walled off" by the body, protecting her from the more adverse effects associated with a leaking/burst appendix.

The irony of it all is that a crowd was present for my ridicule, but my moment of vindication was mostly a private affair. Dear God life can be so unfair!

I must admit that I have been reading and watching a lot of news concerning Covid-19 lately. Part of the reason for this is that so many medical updates keep on arising concerning testing, and many of my colleagues on the front-line worldwide are providing a lot of useful advice that might prove helpful in our local battle with the disease. Another reason is to see how countries are dealing with the economic push-back from the virus, and to get a sense of what stimulus measures might be needed to protect the citizenry from the economic ravages of the virus. However, the last bit consists of the debacle-prone US response (with all its bells and whistles) and, surprisingly, tales of conspiracy theories and what not. Just recently, I caught a segment on Fox News whereby Dr. Oz was talking about possibly getting children in the US back to school after a Lancet (Medical Journal) study had shown that such a move came with a 2-3% chance of increasing the total US mortality statistics. This is of course par for the course when it comes to Fox News recently, and though they keep on emphasizing how precious human life is, it a repetition of their stance that some amount of human life sacrificed for the sake of the economy might not be such a bad thing. However, policing a news media outlet is not my duty; as a trained medical practitioner, my job is to at least make sure that people are getting sound medical advice wherever they choose to consume it from, and especially that is being delivered by a sound medical professional.

Now, rightly so, Dr. Oz drew a lot of condemnation for his comments and ended up having to apologize. This is not the first time that he has been forced to walk back his comments as he was actually brought before a congressional hearing to account for claims he had made on his television show about certain weight-loss regimens. For those who may not know it, Dr. Mehmet Oz is a renowned Cardiovascular Surgeon who is a media sensation who got a big push by being endorsed by Oprah Winfrey. His skill is unquestioned in the field of cardiovascular surgery where he is known to be an innovator; however, it is his media sensationalism that typically gets him into a lot of trouble.

I remember chatting with a group of my high school alums on Whatsapp and I remember being peeved at a suggestion by one of my friends that they needed to be hearing more from doctors in the national discourse during this period of Covid-19. That remark set of a powder keg in the group that drew the ire of the health practitioners. This came against the background of disdain and distrust that Kenyans have continued to hold towards doctors and nurses since a massive 100+ day strike in 2017 which was meant to address issues of poor renumeration and working conditions, and inadequate functional capacity. The politicians of course turned things around and made it seem like it was purely a salary push by a money-hungry lot, and consequently medical professionals and institutions were lambasted by the citizenry. Long story short, hearing my friend calling on the medical professionals to start waxing lyrical was like opening up an old wound. In retrospect though, having had some time to calm down, I can admit that my friend was right. People do need to be hearing from sensible medical professionals at a time like this. The amount of sensationalism, hoaxes, "miracle-cures" and conspiracy theories is proof of that.

I think that people understand even less about the practice of medicine these days. In the old days, people were awed about the profession, but nowadays the prevailing sentiment might be that the internet has bridged the divide between clinicians and patients. It is therefore useful to understand the typical career path of your typical medical doctor. In Kenya, there'll be 5-6 years of medical school (post-secondary), followed by a 1 year internship rotating in 4 major departments; from there you can expect 3 - 5 years of specialty training, and after that you add on as many Fellowships as you want, and you can aim towards being a professor, etc.
Now, since I am going to discuss Dr. Oz, I'll give you a glimpse into the American path of ascension.

• 4 years of a pre-medical degree
• 4 years of a medical degree
• *Residency Program
• Fellowships

*The 1st year of the residency is pretty much just an "internship" (semantics). Unlike the Kenyan experience, American doctors do their internships specifically in their field of interest. Surgeons have a surgical internship, physicians do an Internal Medicine internship, etc.   
    

The aim of medical training is to start you off with as wide a base of medical knowledge as possible, and then whittle that down to the things required only for your area of specialty. Back in the day there were people who dabbled across the field of medical specialties, but nowadays - short of someone being a genius - such broad focus is discouraged. True Story - I remember being blasted for showing lack of focus during a surgical specialty interview at a local medical university. Why? you might ask. Because I had listed that I had performed independent research on Phytoremediation on my curriculum vitae (CV); the same CV further states that

"I aim to become an experienced doctor specializing in surgery, with a view towards
practicing and teaching medicine while infusing my practice with environmental
consciousness to enhance the focus on preventive medicine."

The Plastic Surgeon on the panel had a look of disbelief on his face; it was like this was blasphemy!

Therefore, applying this logic to Dr. Oz, who got his joint MD and MBA degree in 1986, the man has been a PURE SURGEON since 1986! This is not the kind of individual you want to be getting your principal Covid-19 findings from (media sensation or not).

The above 2 images have been part of a meme sent out by many of my medical colleagues, but I think that only the medical field is in on the joke. This is the grim reality: most of the specialist medical professionals do not have the skills to deal with this Covid-19 pandemic; but if we cannot keep the numbers of severely sick down to a level where the healthcare system can adequately handle the numbers, then every medical practitioner will eventually need to be drafted to help with the situation. They'll just have to be retrofitted and adapted to the situation.

If this post wasn't already too long I would've delved into the reasons why medicine is not the homogeneous field most people tend to think it is. There is a lot of direct antagonism going on that is the subject of much comedic gold.

• Surgeons vs. Anaesthetists, where surgeons believe it is the joy of an anaesthetist's day to cancel a scheduled surgery for the flimsiest of excuses. Anaesthetists in turn believe that surgeons will steam-roll through any procedure without considering the risks. (It's the relationship portrayed in the title cartoon!)
• Orthopedic surgeons being of questionable IQs (despite the research)
• Those who are not good enough to be surgeons become... (I once remember a surgeon toss this gem in jest at his accompanying scrub nurse)
• Doctors vs. nurses
• A surgeon only sees a surgical solution to a problem. A physician only sees a medical solution to a problem (typified by my experience with my Consultant)

All this aside, the best results in our profession (and its allied fields) are usually achieved when we have a healthy dose of respect for everyone and their training. The best approaches are always multi-disciplinary. Therefore, next time your relative with Diabetes/Heart Disease/Lung Disease etc. shows up for an elective surgical procedure and another doctor gets called in for a specialized consult, please understand that the hospital is not simply trying to pad your hospital bill; what they are trying to ensure is that the elective surgical procedure doesn't end up degenerating into a complicated affair with death as an outcome.

This pandemic is stressful for everyone, more so the medical fraternity which finds itself faced with a new enemy for whom our typical treatment regimens don't seem to be working. Despite that, we are soldiering on, and we are looking for our fellow (not-so-flamboyant) colleagues to provide answers. We are listening to the Researchers (Virologists, Pathologists, Epidemiologists, Biotechnologists), Infectious Disease Specialists, Intensivists, Critical Care nurses, Respiratory Therapists, Psychiatrists/Counselors etc. to help us chart the way forward. Their work will eventually filter down to the other medical professionals and inform our practice, and finally down to the general population.   

Now, more than ever, it is important for people to interrogate their sources of information. It has taken the medical field forever to get down to the level of Evidence Based Medicine wherein we have to let the efficacy of the science guide our practice. We are not witch-doctors after all! This level of supervision has not made its way to streaming and social media, and thus all manner of dubious claims are being made about this disease and its treatment. We have no way of policing all these dubious claims, but I would ask people to exercise restraint in dispersing all this pseudo-science. Sars-Cov-2 is out in the open and it will be studied intensively for many years to come, then we will finally have the truth; until then, for all these medical pundits making all these claims, remember to assess their backgrounds with the following lens

1. Researchers trump Classical Doctors
2. Internal Medicine specialists trump Surgical Specialists
3. Alternative Medicine specialists are pretty much at the same level as the typical civilian
4. Not every PhD has the acumen to discuss medical issues
5. Always look for conflicts of interest. The person is certain to be selling their dubious miracle cure as they tear into the conventional medicine, i.e. Miracle Mineral Solution (MMS) which is just INDUSTRIAL BLEACH; otherwise, look for them to be espousing a particular agenda
6. Check for reports about them being called out by their professional peers or censured by medical regulatory boards. This kind of behaviour is always a continuum       

This current sensationalism of medicine reminds me of that time when "The DaVinci Code" movie graced the movie screens. I remember that it was touted to have made a lot of people lose their Christian faith, and I wondered if watching it would have been detrimental to my own; then I watched it and I felt bamboozled. I remember at one point the author (Dan Brown) randomly included "The Peace of Westphalia" and used it to make a nuanced argument. I wouldn't have known anything about that incident if it hadn't been for the boring "Church History" lessons (my apologies Mr. Borruso) that I'd had to take while I was in High School, and thus I could see that the author was merely sensationalizing historical incidents that most people are not aware of.

The same exact thing is playing out with medicine right now. To tell you the truth, medicine - just like History - is very boring! Let me clarify, studying/reading medicine is extremely boring! You better thank a scientist who is able to take the time to truthfully summarize a lengthy research paper into snippets that you can digest because reading them is hard work! Being boring notwithstanding, it does not give us practitioners of science the right to mislead people. Always remember that

"The most dangerous untruths are truth slightly distorted." 

Therefore, as a medical practitioner, I will do right by my patients or anyone who needs some clarification. Honesty, Discipline, Empathy and fortitude will get us through the rigours of this pandemic. However, despite the readily available stream of information from social media and video streaming services, we all still have a responsibility to practise patience and critical thinking. There is no need for panic.

God Bless

 

 

Empathy

As far removed as I am from my internship days, every once in a while a specific memory pops into my mind from way back then. This one specific memory has been popping up from time to time; perhaps it's relevant for the times we're in. So here goes.

During the latter part of the Internal Medicine rotation, I remember early one evening, as I was almost leaving, I ended up being called to attend to a patient. This patient was neither in the ward nor in the casualty area; rather, he was at the TB clinic area, which was an Outpatient clinic where TB patients usually showed up for follow-up as they went about taking their medication. This was something that the clinic was able to handle so well without involving the other doctors, so it was something of a novelty for me to be called in to the clinic. I got there to find a young man - probably in his early 30s - flanked by another gentleman who looked to be in his 60s.  The elderly gentleman then proceeded to tell me a story. The young man was his son (I'll refer to him henceforth as *ALEX), and was a prospective patient; having been diagnosed with Pulmonary Tuberculosis (PTB) a while back, Alex had been started on treatment for the condition. Unfortunately, he was also an incorrigible drunkard, and his usual modus operandi had consisted of initially taking the TB medication (which doctors refer to as RHZE) then somewhere along the way - probably once his symptoms would subside - he would go back to his drunken ways and stop taking the medication.

Let's get a little technical here: the treatment for TB consists of 4 medications: Rifampicin (R), Isoniazid (H), Pyrazinamide (Z) and Ethambutol (E). You start off taking all 4 for 2 months (RHZE), then switch to 2 drugs - Rifampicin and Isoniazid (RH) for the remaining 4 months. There are variations to this dosing, but this is the simplest one for run-of-the-mill PTB. People should be aware that these drugs do have a whole bunch of side effects, most common of which is liver toxicity and injury.

So, by the time I encountered the young man, he had basically defaulted on taking his medication on 4 separate occasions. During that time, he had gone on to infect 3 other people in his village area; thus, he had been served with an eviction notice by his chief (and the villagers) that if he was found within the village, he would basically be beaten and burned to death! Father and son had thus ended up moving to the township area to stay with a relative as a stop-gap measure, and they had come to the TB Clinic in order to get him started on treatment. Because Alex was a serial defaulter, an option that has usually existed is for such patients to be institutionalised in a prison facility where it can be ensured that they take the full course of their medication. I remember making a call to the nearest prison facility, but they insisted that they were in no position to accept such a risky individual; the prison was already overcrowded, and imprisoning someone suffering from TB was a recipe for disaster.

With that option off the table, I called the Internal Medicine Consultant. He was very categorical that the patient was high risk, possibly suffering from MDR (Multi-Drug Resistant) TB, and thus there was no way he could be placed in our regular ward. I broached the idea that perhaps the patient could be placed into our TB isolation ward (our old Amenity Ward) while we tested him to confirm that he was in fact suffering from MDR-TB, but my consultant categorically refused. "Send him to Homa Bay" was the only solution I was given.
Now Homa Bay does in fact have a facility that can serve MDR-TB patients, but you needed to first have a confirmatory test (Gene Xpert) which confirms infection with a drug resistant strain of TB. Without that confirmatory testing, I worried that I would be sending the patient on a long journey only for him to be turned away once he arrived at the Homa Bay facility. In addition, if he was in fact infectious, he risked infecting an even larger number of people if he used public means to travel to that same facility.

My hands were tied in the matter, and I remember relaying this to Alex's father. This had been a surreal experience, sometimes so comical that a chuckle almost escaped my lips (damn that morbid medic sense of humour!). I was not expecting to see his elderly father almost break down into tears at the hopelessness of the situation! Contrasting that with Alex's laissez-faire attitude, this felt like a case where a careless man deserved to get his comeuppance. Sadly though, there was a family that was being inconvenienced by this man's carelessness, and that had to factor in there somewhere. Eventually, in contravention of my consultant's advice and against my better judgment, I ended up having Alex housed at the amenity ward so that he could have Gene Xpert testing early the next morning. I think my stomach was in knots that night as I thought about the prospect of having admitted a high-risk patient; worse still, if my consultant had found out, my goose would have been cooked. 

My elation was palpable on the next day when I eventually found out that he was suffering from "garden variety" TB. This meant that he could be treated at our facility. I hoped that the idiot would finally stick to his treatment for the prerequisite 6 months this time around, but, alas, I don't know how the story ended.

Seems like ever since this COVID-19 popped up, it really is the only infectious disease that's being talked about. In a most ironic twist, it has thankfully reminded people that hand hygiene and cough etiquette are matters of utmost important. You'd have thought that a high prevalence of TB and Cholera (among other things) would already have clarified that fact! After this is all said and done, we'll probably have the most hygiene-conscious generation of individuals ever.

The sad thing about being smack in the middle of this pandemic is that we can't even be 100% sure of the transmissibility of this virus. The asymptomatic carrier may have an extremely large role to play in spreading Covid-19. An oft-quoted line of wisdom with regards to Influenza used to suggest that you are most infectious before you start to show flu symptoms (might be more true for Influenza B than A). This same line of reasoning seem to hold true for Covid-19, and a pre-symptomatic or asymptomatic carrier might just go about shedding a lot of viral particles without being any the wiser.

I keep thinking back to how my response to this virus changed as the situation has evolved. Even while at the clinic, initially I wasn't afraid to shake hands. At that point, before seeing a patient, I would casually glance at their notes and only don a surgical mask if the patient exhibited respiratory symptoms. From there, it evolved to no handshaking, having the surgical mask on at all times, and eventually progressed to preferentially donning the N95 mask. I went from looking at my scrubs as benign items that I was confident to walk into the house while wearing (at the end of a shift), to germ-infested items that are tracking this nasty virus to my humble abode each day.
In case you might not have guessed it, a lot of your doctors and nurses are the biggest hypochondriacs out there. It started out during medical training when we were exposed to a whole bunch of medical conditions in the literature. Sometimes we could feel the lecturer diagnosing us with the rarest conditions on the spot; but because we stoically kept quiet, I think we eventually just overcame our worries and fears to continue with our chosen careers. It does of course help that once we begin actually practising medicine, we discover that "Common things occur more commonly"; and in case something uncommon jumps out at us, between our hands-on practice and help from peers and superiors, we can usually fashion a suitable response to the task at hand. Truthfully speaking, Covid-19 has a lot of us worried. There are no standard treatment regimens as of today for the disease, and there is no vaccine in sight until next year (at the most optimistic estimate). The disease remains a really theoretical concept for the ordinary mwananchi, but we in the medical field can physically visualize the downward spiral for an affected patient. We've encountered these effects with other diseases, but never on scale that's potentially this massive!

I also keep thinking back to a few of the patients that I'd been encountering in the previous months. I was - initially - particularly annoyed at the patients who'd travelled from hotspots; instead of quarantining themselves off for the agreed 2 week period, they were breaking quarantine to come into the clinic to seek reassurance. Practically all of them were asymptomatic, but they still worried that they had possibly put their families/loved ones in danger and worried about the fallout. They wanted to have themselves tested, but the truth of the matter was that only government labs were conducting the testing, and due to scarcity they were only really testing patients with marked respiratory symptoms coupled with a positive travel history or contact with a Covid-positive individual.

I can understand their fears. For the longest time I have had 2 fears concerning this condition:

1. Suffering the most severe symptoms
2. Unwittingly spreading it to others

I daresay that if all I was going to encounter was the typical flu symptoms - with the assurance that I'd be immune thereafter - I'd rather get it over with (same way parents used to opt for their kids to get exposed to Chicken pox). All I could do was reassure them that they had an 80% chance of being on the good end of this condition. Until such time as they would develop severe symptoms, I advised them to simply continue with their quarantine schedule whilst monitoring themselves.

Lately, however, I've developed a 3rd fear that stems from our government's response. As a matter of policy,

"Until the Ministry of Health establishes the existence of sustained community transmission, all confirmed positive Covid-19 cases identified should be monitored closely at a HEALTH FACILITY ISOLATION ROOM...Once sustained community transmission has been established, home management of mild cases should be encouraged."

 *Interim Guidelines on Management of Covid-19 in Kenya (PDF Page 13) - Available for Download here

I'm of the opinion that because we have under-tested thus far, we have already reached the level of sustained community spread. This is the reason that I'm all for random mass testing of the general population because it will push the number of confirmed cases up exponentially, which will in turn escalate the government's response; ideally, this should mean home care for Covid-19 positive individuals with mild symptoms.

The government's understanding of the situation and its "playbook" keeps changing as time goes on. After a recent webinar by medical professionals, I feel like the government might choose to accommodate a Chinese solution, meaning isolation of POSITIVE people, whether they might be asymptomatic or mildly symptomatic. If that's the course they follow, picture a whole bunch of people who might at most only require Paracetamol, cough syrup and bed rest being isolated away from the general population in designated facilities like hospitals, stadiums and high schools.

I also appreciate that the government also needs to do contact-tracing of those individuals that have possibly been exposed to a confirmed Covid-19 patient. Defining the extent of the disease's spread is important, but I believe that we also need to safeguard the dignity of our citizen's who've been inadvertently exposed to this disease. These contact-tracing officials riding gung-ho into a neighbourhood in the name of carrying out their duties risk panicking residents, or even worse turning the infected/affected into pariahs within the community (like Alex in my initial story). Ironically, to quote Donald Trump,

We cannot have the cure be worse than the problem

    
Life will go on for most of us beyond this virus. We cannot afford to "burn" people in the community in the name of protecting everyone else. Despite how crazy things might be around us, we must retain our humanity through the whole experience.

I really sympathize with the government as well. It can't be easy charting a course in the chaos with all the differing opinions about their approach (though I suspect they're having a much easier time than the United States). I can respect that they've chosen to have people wear masks like the CDC recommended (but not the WHO), but hate that they've left us at the mercy of hoarders and quacks supplying the goods. Have they even stockpiled enough masks for healthcare (and affiliated) workers in this same period? Then there's the problem of indiscipline among Kenyans. In much the same way that overseas travelers failed to self-quarantine, it can be postulated that Covid-19 positive patients are unlikely to self-isolate of their own volition (as recent reports of mischief would suggest).

We have a powder-keg of a mess on our hands, but there is always hope if we empathize with those that we mean to protect. Worldwide, Covid-19 is showing us that traditional inflexible systems cannot work. Just like the fictional human society in Star-Trek, we might be forced to abandon concepts like "profit" and "individualism", and just work together to confront a common unseen enemy, if at least only for the moment at hand. At a countrywide level, our politicians need to make sensible policies for the citizens they govern. Despite all the buzz about Kenya being a middle-income country, they know that we are still a fledgling developing country with a vast vulnerable population. Their policy needs to acknowledge that and put in place measures to safeguard the most vulnerable; ignoring this will only lead to revolt.

At the local level, there needs to be public health education on a massive scale. People need to feel entrusted with the knowledge and acumen to fight this disease. They also need to be reminded that with all the RIGHTS that they exercise there are also congruent RESPONSIBILITIES. The only way we come out of this any better is by abandoning the inefficiency and bad habit that have failed us in the past; we need to empathize and we have to be better. Our very survival depends on it.

God Bless  

2020

I was hoping to have started 2020 better than this. For starters, I have totally procrastinated and abandoned this blog for quite some time. I've missed writing up a couple of movie reviews, and then the knockout punch came with the demise of one of my favourite artists - Lyle Mays. Being the glue that held the Pat Metheny Group together, I'd hoped that they would eventually bless us with another album that could stand the chance of eclipsing their 2005 Magnus opus "The Way Up". Sadly, we won't get that opportunity. However, Pat Metheny released a new album "From This Place"in February, which, it turns out, is the first album I've ever pre-ordered. I'll be sure to talk about that in another post.

However, another matter has us occupied altogether. Seems like Mother Nature turned on us in the  starkest of ways, unleashing on us the ongoing COVID-19 pandemic. Now, as a clinician, my mind is always prepared for this kind of an incident (at least in theory); when we had a teen die of Acute Respiratory Distress Syndrome (ARDS) secondary to the flu at a local hospital last year, we braced ourselves for what we thought might be the next big thing. It really took till the end of 2019 for us to develop the challenge that we've always felt lurked out there.

It would behoove me to blame Mother Nature for this specific occurrence; also, unlike conspiracy theorists, I DO NOT believe that this new virus (SARS-CoV-2) is a bioweapon. It's very insidious, and once you pair that with it's ability to "return-back-to-sender" you understand that it makes for a very dreadfully poor bioweapon. The problem here is that wildlife trade that going on in parts of China. Let me clarify that this is not me launching an attack on people's food choices, vast as they may be. While we're on the subject, I remember that (while I was in med school) one of my Mandarin Language teachers used to recite a long held gem of wisdom about food choices in Guangdong (Southern China)

"If it moves on the ground, apart from bicycles and cars, and if it flies with the exception of airplanes, then it is considered edible".

I have paraphrased it slightly, but that was the general gist. Though it was uttered in jest, living in China basically exposed us to a fair share of "exotic" delicacies. Digging into the history of the country reveals that some of these cuisine options came about in times of hardship, and we can't begrudge them that part of their past.

What is problematic, however, is how those animals are handled prior to slaughter. We've known for a long time about zoonoses/zoonotic diseases that can spread between species because we sometimes end up as unwitting sufferers of such conditions. This continues to be a relevant matter as we encroach further into other environments like forests, caves, etc. that we've been relatively isolated from. The wildlife trade in China actually complicated things a bit because by all admissions all manner of animals were held in pretty close proximity to each other; this created the perfect petri dish for a zoonosis to spread between the species, and maybe along the way it run into a multiplier species that set off this whole issue. Due to the fact that we are in the middle of a pandemic all this is a matter of speculation. Consensus seems to suggest that the virus probably originated within Bats, but the missing link in the chain prior to it making its way to humans is still a matter of research (people have suggested a Pangolin).

Regardless of the way in which this thing came into existence, the rate at which it has been able to spread so prolifically has accentuated just how much of a "Global Village" the world has really become. We saw it take root in China, and watched as it spread first to adjacent Asian countries, then made its way across the world to everyone's doorsteps. It's not unrealistic to say that it surprised everyone, but what has come to the fore is that some people have been better at dealing with this situation. The fact that Italy, Spain and France have taken quite the walloping despite their remarkably high level of healthcare is a truly sobering fact. The United States' response has, however, proved to be quite the conudrum; coupled with its late response, its president's "unique" personality, bipartisan distrust and its administrative composition, we are being treated to widespread confusion on a massive scale. In hindsight, Trump and the Republicans might be forced to admit that their "hack-and-slash" treatment of measures already put in place by previous administrations might very well be the country's undoing. Also, maybe they also need to accept that this is not a problem that can be dealt with from a strictly "capitalistic" point-of-view; this virus will not bend to accommodate our inclinations, and therefore our systems must ideally be molded for the best outcomes. 

The US, however, is not an isolated incident; here in Kenya we are suffering something similar, but on a smaller scale. Granted, this COVID-19 situation is a one-of-a-kind occurrence, and better equipped countries have also found themselves overwhelmed, what is going on in Kenya is a mess of our own making. The government won't outright admit it, but there was a particularly slow response to closing of our borders when you consider that a China Southern plane was allowed to bring 239 passengers from mainland China in late February before China had gotten control of the pandemic on its end. When pressed for answers, government officials only seemed to focus on the fallout of failing to let the economy progress in business as usual fashion; it's also likely that they feared retaliation from China if we didn't allow their flights into Kenya (I fear that our overwhelming debt owed to the Chinese doesn't give us much room to negotiate). It must be poetic justice to note now that China has its COVID-19 situation under control, it has forthright banned foreigners in possession of valid visas from returning to the mainland; they are basically doing the right thing to safeguard their borders and prevent importation of the virus back into their country.

We are currently waiting for the COVID-19 pulse to hit the country. Thus far the government has locked down the borders, stopped all international flights as of midnight March 25th (with the exception of "evacuation flights"), put in place "social distancing" measures and has initiated a dusk-to-dawn curfew (7pm - 5am); recently, concerned that 81% of confirmed cases were within the vicinity of Nairobi, they've initiated a lockdown of the Nairobi Metropolitan area to prevent the virus from spreading to the rural areas where it is felt that it might be particularly passed on to grandparents and similarly aged individuals.

The government is perhaps scared to admit its folly in this matter. A lot of medical professionals (myself included) will openly admit that the virus has already achieved nationwide sustained community spread. The numbers of confirmed cases remain low because of one factor alone: testing. This is a scientific endeavour, and the only real way for us to quantify how well we are doing in this situation is by our ability to measure the situation. The truest measure is to pinpoint the infected and to keep the infection from spreading. If we wait too long, there are other quantities of measure that will start to surface - Deaths! Ideally, we cannot afford to wait that long. The government thus far, because of the shortage of testing kits, is stuck testing those people it had forcibly quarantined as well as the symptomatic cases that are coming in to hospitals; this comes to an average of ~300 tests in a day.

I applaud the government for what they have done thus far, and for where they are headed. However, they need to set their sights higher. They already lost the first battle to keep the virus out of our borders, and we have to move on. People were not busy sitting in Nairobi as we awaited the government's "Will-it/Won't it" decision to place the country under lockdown; people already panicked and traveled beforehand to the rural areas. As insidious as this virus is (in comparison to something like Ebola), we have no idea what a COVID-19 sufferer looks like. A majority of people will suffer anything from no symptoms to mild symptoms. That is a vast range including anything from a seemingly normal person to simple upper respiratory tract symptoms (coughing, sneezing, runny nose, itchy eyes/ears/nose, loss of taste and smell, sore throat and voice hoarseness) to flu symptoms (fever, headaches, malaise, chills and rigours, muscle and joint aches, nausea, diarrhoea and vomiting).

I can't help but smile everytime the WHO/CDC adds another symptom to the list. Those of us who treat Cold and Flus on a regular basis recognize that there's nothing unique that distinguishes COVID-19 from regular flus and colds. Between the dust and pollen in the air, we also have seasonal allergies (Allergic Rhinitis) and asthma to deal with. The few people who will develop the characteristic severe symptoms will find themselves in an extremely unlucky position characterized by medical personnel's worst bunch of condition:

1. Acute Respiratory Distress Syndrome (ARDS)
2. Kidney Failure
3. Sepsis
4. Multiple Organ Dysfunction Syndrome (MODS)
5.  Death

This is a unique time in medicine because a lot of us are basically flying blind. Thanks to a bottleneck in testing, we don't know how many infected we are actually dealing with. We have no vaccines and no particularly proven treatments for this specific disease, so we are relying on measures that have saved us in the past and hoping that the experience of countries that have been hard-hit by the pandemic will provide us the answers we need.

However, with hindsight from the past 2 or so months, some measures appear to be better than others.

• Social distancing is helping
• Hand hygiene is DEFINITELY helping
• Decongesting hospitals by keeping the mildly symptomatic people away is the wisest of all options.
• Isolating the infected at home, provided they are stable, goes hand-in-hand with the above mentioned measure.

Some things are still in doubt

• Hydroxychloroquine and Azithromycin are not quite the cures people were looking for. Both drugs have their proponents and opponents in equal measure, but there is nothing conclusive in the water.
• Wearing masks is also just as contentious. The CDC is all for it, but the WHO is against it. And being a long time wearer of surgical masks, I am honestly worried about the quality of masks that are currently in the market. The masks are ill-fitting (*I favour the tie-ons to the elastic banded ones), people are not wearing them the right way, and at upto sh. 100 ($1) per disposable mask, people have been recycling them, thus rendering them useless. *In light of current shortages, hoarding and the exploitative prices, I would pray that the government rescinds this order and looks for a more workable solution

Other things don't even need to be mentioned.

• Walking around with disposable gloves all day is one of the most disgusting habits ever. Saw this introduced at Carrefour for shoppers, and the same shoppers proceeded to take those gloves everywhere. This is an infection control failure.
• Police bundling people into crowded vehicles or cells is a plus for COVID-19 all the way. (at the end of this debacle, we are going to need to have a serious conversation as a country about using police officers with zero PR training and comprehension skills, and equally poor demeanors to enforce important government directives)
• Any religious folk claiming they can heal COVID-19 sufferers should be locked up in their lavish abodes and be forbidden from contacting any of their religious faithful. THERE IS NO TIME FOR THIS KIND OF NONSENSE. Tithes can also be humbly directed to the medical efforts or to feed and take care of the less fortunate in society.

There is still a lingering question concerning the low fatality rates occurring in Africa thus far. People might say that we are probably at an early stage of the infection of the populace, and not quite at the "Critical mass" level. I am silently hoping for a genetic/environmental advantage. Realistically speaking though, we need more testing. Initially, we've been doing PCR testing, but eventually we will move on to rapid kit testing. Eventually, we should get to Serology testing where we detect antibodies. At that phase, we'd be able to know patients in the acute phase, and more importantly those who've already developed long term immunity to the virus. Such testing would obviously push our numbers through the roof, but then it would provide another bit of ammo for us in this fight. Let's not forget that plasma from immune individuals could technically be used to confer passive immunity on direly sick COVID-19 individuals as a stop-gap measure until we are able to produce a vaccine.

It has been quite the crazy start to the year, but I'm hopeful that things will get better. I would like to salute all essential staff at this time, particularly the healthcare and allied professionals: the doctors, nurses, physiotherapists, pharmacists, cashiers, cooks, cleaners, etc. This one pandemic will shine a spotlight on an oft-neglected sector, and will become a rallying call for us to fund it and fix it as much as we can. To ignore it any further is tantamount to disaster.

Be safe and God Bless.