PINCC volunteers arrived on the outskirts of Kibera at the offices of Carolina for Kibera on Monday morning, albeit later than expected because of the ever-unpredictable Nairobi traffic, ready to get to work. For some volunteers this was to be their first experience entering the slum they had only heard about in the various forms of popular media. Apprehension, excitement, curiosity, determination and many shades of emotions in between were apparent on the faces of the volunteers as we prepared to make our way through the narrow paths that would lead us to Tabitha Clinic. Along with donning our rubber boots we carefully forced straight and stoic faces while mentally preparing for what we had only heard about. The residents of Kibera were already in the midst of their day, easily traversing the somewhat treacherous terrain which we nervously (and very slowly) tread. I am happy to report there were no slips during our week of walking in and back out from the clinic despite the heavy rains that made this trek all the more daunting.
Upon arrival to Tabitha Clinic, most of us were struck by the large concrete structure. How they managed to construct this massive building in the midst of small tin-roofed homes, open ditch sewage, millions of residents and muddy streets is a feat I will not even begin to contemplate. We were, as per usual, greeted with enthusiasm and hospitality that far exceeded our expectations. All the staff went well out of their way to be accommodating for the duration of the week, and yet every day I was amazed that this seemed effortlessly to be the case. We walk in and disrupt their routines and their staff roles, and they couldn’t be more welcoming to this ordered chaos. After a brief introduction of the team we would be working with throughout the week, we realized how much assistance we would have available. Community and peer health workers were in abundance and more than prepared to encourage the residents of Kibera to come in and be screened by the PINCC trainees. As we took a tour of this clinic it was a bit jarring to look around and see how well supplied it was. Tabitha Clinic is a CDC site and is also made possible by Carolina for Kibera. Therefore, it is resourced fairly adequately, particularly in comparison to some of the other sites PINCC visits. Since this was the second visit to Tabitha, we were going to try to use the supplies provided by the clinic as they were available. The clinic had their own cryotherapy equipment, but PINCC supplied the LEEP equipment in order to have this service available to clients throughout the week.
For the majority of the trainees this was their first experience working with PINCC. We were all impressed by how quickly they learned and the enthusiasm in which they undertook the training. Many had never performed a speculum exam, and I can personally attest to the fact that by the middle of the second day they were patiently and competently teaching me. The learning that took place within this group was exceptional. Dually noted was the warmth and kindness that radiated from everyone in the clinic. From the clinical officer to the maintenance staff, every person I encountered was contentedly working towards helping this startlingly underserved community. The energy of that goal was palpable from the time we stepped foot in the clinic to the time we took our last steps out. I have not a shadow of a doubt that this is the attitude even when there are no witnesses. What a humbling and honorable experience to have the opportunity to work alongside this dedicated group of men and women.
I couldn’t help but compare the experience at Tabitha Clinic with the experience from the previous week at Bungoma District Hospital. When first walking in Tabitha, it feels a bit closed off compared to the open and spread out layout we experienced in Bungoma. Our “nursing station” was a desk in the middle of the crowded waiting room. Among large numbers of waiting clients and screaming children getting their vaccinations, we began. Despite the lack of personal space and the crowded nature of this room, the volunteers and health workers tried to provide as much privacy as possible while interviewing clients. It was a difficult realization that the simple concept of privacy in these situations is somewhat futile. Asking personal questions and performing cervical examinations are usually tasks that are kept as dignified and as private as possible. However, our idea of patient privacy and confidentiality does not quite align with realistic possibility in Kenyan clinics. Still, we worked with what was available and tried to preserve patient privacy as much as was feasible. It’s just one aspect of the great learning curve we had the privilege of experiencing every day. We had five exam rooms; one of which served as a cryotherapy room and one that was used for LEEPs as needed. The rooms inside the clinic are about the size of a closet and have no source of light except for the natural light peeking through the windows. Conditions were tight, but everyone made the best of it and worked past the small discomforts with ease. Even when, on the first day, the skies opened up and the clinic was under several inches of water, everyone simply slipped on their boots without complaint and carried on with the tasks that needed to be completed before we were able to leave for the day.
The patients we saw during the week spoke a variety of languages, primarily Kiswahili, Luo and English. We had printed materials in all three languages and the community health workers were able to assist with patients that had limited English. Despite the language barrier, the gratitude emanating from every client and staff member was palpable. I suppose some things traverse language, and spoken words become inadequate. Again, such an incredibly humbling and honorable week from start to finish. The patient population coming in for screening tended to be younger than I personally had anticipated. Typically, PINCC recommends screening only for women older than age 25. However, during our week at Tabitha we amended this standard. Because the majority of women are sexually active at an earlier age and a high percentage are HIV positive, the risk of cervical cancer is significant even for women in their late teens or early twenties. Education for these clients was vital and it was encouraging to see such proactive young women coming in to be screened. Despite the fact that the average life expectancy in Kibera is only mid-30’s, alongside the younger population there were also middle-aged women coming in to be screened for the first time. We detected varying degrees of dysplasia and were able to successfully treat many women of all ages.
We had several cases throughout the week where we would have to turn women away for one heartbreaking reason or another. Once cervical cancer is detected, the services PINCC has the ability to provide become insufficient and the woman is encouraged to seek medical attention elsewhere. Sadly, the waiting lists are endless, resources few and financial assistance unavailable. Many women also come to the clinic in the hopes of finding an answer for their breast cancer or their neighbor’s progressing cervical cancer. Not looking for money, but simply for an answer. A pleading look, a desperate grasping of hands and the inevitable walk back out the door into the harsh reality. There is nothing. That is something I hope to never become accustomed to.
Throughout the week we saw anywhere from 30-55 patients a day, and performed several cryotherapies and LEEPs. As the trainees grew in their knowledge base and experience, our confidence in them increased exponentially. By the end of the week we were able to certify two trainees and both were present at PINCC’s first visit. The small number of certifications awarded is due to the fact that PINCC likes to have each learner perform a large number of exams in order to confidently certify someone in VIA. Needless to say this usually does not happen during the trainee’s first experience with PINCC. We encouraged all the trainees present during this visit to return upon PINCC’s third, and perhaps final, visit in September. Based on the skill level and educational development of the trainees, there is sure to be many more certifications earned upon PINCC’s next visit. As we prepared to leave, we were surprised by an impromptu performance by both the Kenyan Boys Choir and the Kenyan Girls Choir. They were incredible and it seemed a very fitting way to end our last day. As we put on our rubber boots to make our way out of Kibera slum for the last time, the energy among PINCC volunteers, Tabitha employees and Kibera residents was tangible. The Friday afternoon activities were in full swing: children out of school, food being prepared along the narrow streets, people going about their business as we inconspicuously left Tabitha, and Kibera, behind. It almost seemed as though nothing had changed since our arrival, and yet, for me, everything had.