Emergencing: A Strategy for Knowing What Others Can Know But Cannot Tell

By Macharia Waruingi

This book is an attempt to explain how we can be effective in our work in global health. I used the emerging grounded theory design to investigate the paradoxical increase in the incidence of disease and poverty that exist at a time when there is increasing investment for fighting the diseases and poverty. I learned that failure to acknowledge tacit knowledge within local communities in developing countries leads to ultimate failure of many global health projects, creating a relevance paradox. We can overcome these problems in global health, and indeed other social problems by developing a skill for emergencing the more that people can know, but cannot tell. Emergencing is a theoretical model of knowledge emergence for effectiveness in our actions. Although the substantive area of study was global health, emergencing as a process of creating, and innovating, applies to all types of settings. Emergencing helps us to go beyond thinking outside the box, to thinking where there is no box.

• Language: English
• Publisher: Lulu.com
• Release date: Mar 29, 2011
• ISBN: 9781257198139

Book preview

INDEX

List of Tables

Table 1

Table 2

Table 3

Table 4

Table 5

Table 6

Table 7

Table 8

Table 9

Table 10

Table 11

Table 12

Table 13

Table of Figures

Figure 1

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Figure 11

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PART I

THE PROBLEM

CHAPTER 1

THE SOURCE

Growing up on the slopes of Mt. Kenya (the Slopes), I heard stories about Kenyatta National Hospital. You were sent to Kenyatta, mahututi, Swahili word for at the point of death. After working on coffee for days and nights on end, I could hear remarks among the grown-ups, I am a case for Kenyatta. After more than a hundred hours of working on coffee beans, you did not have the strength to stand up. You ate in bed. You were tired to the point of death.… from extreme work.

In reality, you were sent to Kenyatta at the point of death… from extreme disease. You did not hear about people being sent to Kenyatta otherwise. You had to be at your point of death if you were to be admitted in Kenyatta. Otherwise, how could the hospital cope with a flood of patients coming from the four corners of the country? Kenyatta was the national referral hospital for Kenya. Health professionals around the country referred every difficult case in a country of 32 million people to Kenyatta. Although my mother and her friends joked about being a case for Kenyatta after weeks of hard labor on coffee, being admitted in Kenyatta was no laughing matter. (I was admitted mahututi to Kenyatta, at one point. I know, it is no laughing matter.)

I have found that life has an interesting way of dealing with me. The stories I heard about Kenyatta growing up on the Slopes left me thinking: Kenyatta is the last place I would want to be. At the age of 15 or so (no one maintained the age book in my village, as far as I know), I was admitted to Kenyatta, mahututi. For what seemed like an interminable period of time (this could have been a week, I do not remember how long, I stayed there), I shared a bed with different patients. The first day I had an elderly looking man. He could have been in his 30s, but he seemed as if he was in his 70s. He slept with his head on one end of the bed, and I on the other end.

My bedmate was too sick to talk. He could not stand. He could not sit. He vomited blood all night. His skin was cold and dry. He was very thin. On the second day, the nursing staff removed his body. He had died during the night. I was too sick to know or register what was happening. After that the hospital staff brought other patients to the very crowded ward. Everything was a blurr. I remember vaguely about sharing bed with other patients. I remember getting an intravenous line. I remember unpalatable porridge like substance given to us for food. More than anything else, I remember the smell.

An overwhelmingly choking pungency issuing from a hundred or so un-bathed humans crammed into a space created to accommodate only 32 people. The smells of human excrements, bodily secretions, combined with the scent of the disinfectant solution to produce an unbearable stench. I was too sick to care. So was everyone else in the ward. When my aunt came to visit, she thought that I was going to die there. She convinced the doctor to discharge me. She took me to her house, bathed, and fed me warm soup. She then went to the market and came back home with medicines. I recovered slowly. I have never forgotten the smell. That was my first encounter with Kenyatta.

As fate would have it, years later, I found my way back to Kenyatta….this time not as a patient, but as a medical student. Yes, who would have thought! OK, I am here at the University of Nairobi. After two years of slogging through the basic sciences of human anatomy, biochemistry and physiology in The College of Sciences in serene Chiromo Campus on Riverside Drive in Westlands, Nairobi, I am transferred to The College of Clinical Sciences in Kenyatta National Hospital Campus in Upper Hill, Nairobi. This campus housed the Medical School.

The transition from serene Chiromo Campus to Kenyatta National Hospital/Medical School Campus was a culture shock of sorts. Chiromo is couched in a lush green wooded area next to the Nairobi Arboretum, in an upscale neighborhood. Life was easy in Chiromo, everything was clean; fresh air, great food. Everyone seemed happy, in the lush green campus…. except for the continuous assessment tests coming at the end of every week.

Kenyatta was crowded; too many people everywhere. The place was dusty, with many high rise buildings crammed in a small space. The halls of residence seemed very old and dilapidated, compared to the halls in Chiromo. Utilities were dysfunctional. Water was available sporadically, and many times we had to go to another hall to take a shower. The kitchen was disorganized and the dining hall was rarely cleaned. The place was visibly crying for cleaning and maintenance in general.

I noticed many beautiful sport utility vehicles (SUVs) parked next to the Medical School Halls of Residence Kitchen building. The SUVs bore logos of UNICEF, WHO, CARE, UNIFEM, and similar international agencies. I wondered what SUVs were doing parked next to the kitchen. I learned that the SUVs were decommissioned from terminated projects. The programs that imported the vehicles had come to an end, and the sponsors had moved on to other things. The vehicles were dumped. The area next to the kitchen building was a graveyard for SUVs whose projects had come to an end. These were functional cars abandoned by their owners because they did not need them anymore. The owners were done to with their projects. They parked the cars up, and abandoned them. Many of these cars were in good condition. The university could not use them, because among other administrative problems, there was no money for gasoline and maintenance. The SUVs were parked for live. For the next three years, I witnessed addition of more almost new SUVs to the pile, as more projects came to close.

I also noticed that international project sponsors did not only abandon the vehicles next to the medical school kitchen. Also abandoned were hundreds of patients who were enrolled in short to medium term health programs. The sponsors of the programs, would leave abruptly and go back to where they came from (mainly Europe and United States) leaving hundreds of patients stranded. At the introduction of a new disease program, the sponsors would employ local doctors, medical students, nursing students to go out and recruit patients. Many of the projects involved a heavy research component, as a part of clinical trials on infectious diseases. Other projects were community based campaigns against diseases of public health concern such as tuberculosis, or acquired immunodeficiency syndrome. Patients would travel hundreds of miles from their villages, at enormous costs, coming to Nairobi seeking care provided in various projects at Kenyatta National Hospital. As far as I can remember, all the projects lasted one to two years, after which period the sponsors returned home, leaving the patients stranded in the city.

As medical students, we started clinical clerkship in Kenyatta hospital in third year of medical school. During clerkship, we attended the ward rounds in the morning with the attending physician and the resident physician, and the nursing staff. The morning rounds involved reviewing patients admitted to the ward in the previous 24 hours. The resident worked all day, and all night, admitting patients to the ward. During a 24 hour period, the resident admitted about 120 patients into a ward with bed capacity for 32 patients. The work of the nurses was incredibly difficult. They did not have room to keep the patients who kept coming throughout the night. At the end of a 24 hour period there were patients everywhere in the ward. Some on the floor, multiple patients on the same bed, sometimes three or four patients on a bed!

We did not have medical supplies to take care of such a huge volume of patients. We recycled disposable gloves by boiling. We did not have intravenous solutions for volume support. We sent families to go out and buy intravenous kits from pharmacies down-town. Many a time the patient would die of dehydration before the family could return with the intravenous kit and fluid. Family members did not have cash needed to buy these supplies. Intravenous fluid was just the beginning of a list of supplies needed, which ranged from pain killers to antibiotics, to anti-hypertensives, to anti-cancer