On Rounding in East Africa

Rounds begin on the pediatric wards for Upendo firm 2 at Shoe4Africa Children's Hospital. As the medical student whispers his first patient presentation, nurses rush in with blue canvas partitions, obscuring bed 15. We pause, and I lean to ask the registrar (the equivalent of a pediatric resident in the Kenyan medical system)—What happened? The body bag is zipped, lifted, and carried swiftly past our team into the bustling hallway and out of sight. We've lost an overnight admission, she murmurs, then glances at the medical student to continue.Despite practicing in a country almost 9000 miles from my own, pediatric medicine feels familiar here: the confidence of the registrar, the awkward timidness of the medical student, the quiet anxiety of a mother at the bedside, even the bronchiolitis and gastroenteritis. The culture and content of medicine in East Africa is remarkably similar to Central Texas. The language of medicine is truly universal, I realize here, and transcends society and class.But as I watch that body bag being carried toward the morgue, I am also struck by something here that is foreign to my experience. On Upendo firm 2, I've seen 5 pediatric deaths in 3 weeks. As a pediatric emergency medicine fellow nearing my graduation, I saw 5 pediatric deaths in 3 years—the difference in mortality sticks with me. After finishing rounds, we walk past vast farmland, lush nurseries, vibrant shops, traffic jams caused by cows, and smiling faces. The sting of childhood death juxtaposed against this gorgeous landscape is difficult to grasp but begs contemplation. I am overcome with grief for these families and clinicians. I am angered by the rippling effect of colonization and longstanding systemic racism that disconnects this country from the global economy. I am uncomfortable knowing that I have been taught these inequities but took so long to fully understand them.Back in predeparture training, my feet tapped with anticipation as instructions echoed throughout the lecture hall. Excitement grew while the logistics of visas, vaccines, and travel safety tips were meticulously reviewed by our program leadership. We moved on to a cultural orientation, engaging in mock scenarios to help expose us to a variety of ethically challenging situations. I nodded as my anticipated role was defined as a "hybrid" of both learning under Kenyan medical leadership and supervising our own American medical students. I was a sponge: eagerly absorbing information from recommended readings. We discussed the dark legacy of former colonial relationships on current global health inequities in Africa—the restriction and control of indigenous populations through quarantine measures, the exploitation of local remedies under the guise of "research," and the ignorance of established religion and education systems in delivering what was then known as "Tropical Medicine." Even now, a lingering impact exists through skewed power dynamics, knowledge generation, and even research partnerships. I understood that my country is guilty of a neocolonialist mindset, perpetuating past failures often unknowingly.Determined to shed this way of thinking, I was admittedly nervous. How would I be received as an American physician within this historical context? Would I be useful? What would I ultimately take back? Despite my awareness of this history, would I accidentally perpetuate, or be complicit in, a too-long-legacy of neocolonialism?Back on Upendo firm 2, the registrar's knowledge, capability, and work ethic are astonishing. She starts her own intravenous lines, obtains sedated bone marrow aspirates, and performs lumbar punctures on the general pediatric floor. Her skillset is not unique to her, but remarkably held by all of the other registrars in this facility. She manages complex cardiac pathology, often waiting days for a specialist's recommendation. In my system, we get upset if a specialist doesn't respond within minutes of a phone call. Each day, we round on close to 30 pediatric patients, often 2 to a bed, excluding family members. Most of these children are quite ill and would automatically qualify for a pediatric intensive care unit bed at my home institution. As a former resident, I remember considering a patient panel of 10 quite busy—each with their own room. In this environment, considering my privilege as a physician is sobering. Yet she remains collaborative with me, a foreign doctor who is new to the country and the hospital.The registrar consistently involves me in the workup or management of each patient, considering my input valuable. On a child with generalized edema, she agrees to add a urinalysis looking for signs of new-onset nephrotic syndrome, broadening our differential diagnosis. On another child with bloody stools, she adds my recommendation of an abdominal ultrasound so as not to miss intussusception, while the medical student anchors to bacterial gastroenteritis. This registrar sees me as an asset on this team; I am elated. On the other hand, when we round on other children with conditions such as severe malaria, visceral leishmaniasis, and tuberculous meningitis, I look entirely to her—I learn, and I feel incredibly humbled by what I don't know.The clinical experience is collaborative in a way I read about but could not appreciate until I experienced it myself. The discussion is consistently bilateral, and both clinicians leave rounds feeling edified as physicians. Most importantly, our patients benefit from this relationship. My time spent working with her is not only collegial, but also friendly. She laughs at my attempt to greet families in Swahili and corrects me with a smile. Between patients, she asks what it is like to live in Texas. The chaos of the wards made our relationship initially a bit stiff, and serious. But over time we became quite comfortable, as I would with any colleague in the United States.Minutes after the body bag is whisked away, I hear a mother loudly wailing in the hallway and recognize the universality in the sound. On Upendo firm 2, I see several "rare" diagnoses, unseen in Central Texas. But after listening to this mother grieve, I realized something. The cries of a parent losing their child are just as devastating as anything I've heard in the United States. The death of a child is a wrong, here as anywhere in the world. And, the love of a parent is just as universal.The author would like to thank Dr. Tim Ruttan and Dr. Tim Mercer for their review of the manuscript and UT Austin Dell Medical School and the AMPATH Consortium for this global health experience.