Jeruto* was a 35-year-old lady who was referred to us from a mission hospital in her village. She came bearing a referral letter stating that she had a difficult delivery and ended up with a vesico-vaginal fistula. The fistula was obviously quite severe because she was completely incontinent of urine and had to be nursed in a catheter and in addition, wear adult diapers.
Jeruto was admitted in the private room because she had to stay in hospital with her six-week-old daughter. Being the medical student assigned to the team responsible for her care, I spent the afternoon talking to her to get her full medical history as part of the admission process. This was part of my learning session.
Jeruto’s history was heartbreaking. She narrated how she had delivered her first five babies at home uneventfully with the help of a traditional birth attendant. When her sixth baby was due, she found out that her trusted birth attendant had been taken ill and was hospitalised. Left stranded, she opted to go to the local mission hospital for help.
She reported that she was told her labour had complicated and she required a caesarean section to ensure the safe delivery of her little one. She reluctantly agreed to the procedure and was wheeled off to theatre even before her husband arrived. The whole process was extremely intimidating for her as she had never spent a night in a hospital bed. Even more daunting was that the doctor attending to her was white and she could not communicate with him as he only spoke in English. She had to use the nurse as a translator.
She reported she woke up in the ward several hours later and was told she had delivered a bouncing baby girl. She was allowed to breastfeed her at about midnight and she was grateful for this was her first daughter. They noted that although she had expected some bleeding after delivery, she could not explain why her bed was soaking with urine.
The next morning during the doctor’s rounds, she reported to the team about the urine incontinence with great apprehension. She was then told that she had developed complications in theatre. She had bled uncontrollably, and to save her life, they had to do an emergency hysterectomy (removal of the uterus) so as to stem the bleeding. The nurse translated to her that the urine incontinence was a complication of the extensive surgery and that it would be addressed at a later date after she had recovered.
Jeruto was speechless. She had to go home with a urinary catheter in place to help manage the incontinence. It kept her fairly dry, but she still leaked a bit. It was incomprehensible. Meanwhile, she also noted she had unexplained hot flushes and insomnia. She counted the weeks diligently awaiting her review. At the hospital, the doctor noted that the incontinence had not subsided and he referred her to our hospital for further care. What the doctor never told Jeruto was that during surgery, not only had they taken out her uterus, they had also removed her ovaries, effectively rendering her menopausal at 35 years. This was the reason for her hot flushes, insomnia and anxiety. He did put down this detail in the referral note but with no explanation of why this had been done. However, he never told Jeruto in person. She only found out about this when I asked her about it while seeking clarity.
Jeruto was now angry! All of her 52kg was shaking in rage. She felt betrayed and conned by the health system. She cried hot tears of fury. I was so stunned I could only hold her as she sobbed in agony. She cursed God for letting her traditional birth attendant fall ill on that fateful day. She had no faith left in the health system yet she had to put up with it to correct the mess we had all created.
Jeruto had a successful fistula repair and went home to raise her beloved daughter. She underwent a lot of counselling to enable her to find peace. She had to take hormones for the next 15 years to manage the early menopause complications and allow her to live a normal life. She is now ready for menopause to take its course because she is now 50. She may have adjusted but my mind has not, all these years later.
Jeruto’s surgery was done by a general surgeon instead of a gynaecologist. The hospital claimed that at that particular time, the resident gynaecologist, who was a foreigner, was away on leave. Therefore, because Jeruto’s surgery was an emergency, the surgeon was deemed to have done the best he could in the circumstances, even though it resulted in complications.
I still wonder why the hospital did not feel compelled to engage a gynaecologist on temporary basis for the duration their own was away. Why did the surgeon have to remove Jeruto’s ovaries during the surgery yet this is not necessary to arrest the bleeding? Was it because he had no idea of the damage he caused? Could the bladder injury that resulted in the fistula have been avoided if a qualified person had done the surgery? Did Jeruto suffer from the affliction of “poor medicine for poor people” that is the bane of the Third World?
Mission hospitals have always bridged the gap for many years in places where the government had failed to reach. Most of these missions were supported by foreign doctors who were offering services on a charitable basis.
To this end, these doctors practised with minimal supervision from the government, especially in very remote areas. For the most part, they did a tremendous job of giving hope to the people. However, a few apples have existed too. Unfortunately, the harm they may have caused comes to light only in extreme incidents like in Jeruto’s case.
I am glad that the Kenya Medical Practitioners and Dentists Council has put in place mechanisms that rigorously assess the suitability of all foreign doctors and all Kenyan doctors, trained outside of East Africa, to practice in Kenya. Further, the council now has full jurisdiction over all health facilities and should endeavour to ensure that they abide with practice standards that safeguard all patients, irrespective of their socio-economic backgrounds. Good medical care is a right for all Kenyans.