I am an orthopedic surgeon, fellowship trained in trauma, practicing in a private hospital in Wisconsin. I have returned from Kenya, Africa after a trip to witness firsthand the impact the SIGN program has had on this country. I have traveled to Kenya in the past as a medical student. In 1993 I spent 6 weeks in a mission hospital in a small town, Maua. Having traveled in this country before, I did have some expectations of what I might encounter.

During my previous trip I found the people to be generous, open, warm, and optimistic. This has not changed. I experienced these qualities repeatedly. This included a friendly conversation with the matatu driver on my trip from Maua to Embu. This young man is working 12 hours per day making the trip to and from Maua and Embu. He is “thinking big” and wants to return to school to make a better life for himself. Young men on other trips always made an effort to make me comfortable and help me navigate to my next destination.

I met countless people in hospitals who interrupted their busy days to sit and talk with me and tour their facilities. Dr. Kariuki is the District Medical Officer of Health for the district including the town of Maua. His title is impressive and his responsibilities are immense, but this is a young man who has only recently finished medical school and an internship and has no formal training in hospital administration. He is currently the only doctor in this district hospital and must be available 24 hours per day. His wife and child live in Nairobi which is 5 hours travel by public transportation. Despite the enormous demands on his time, Dr. Kariuki spent several hours showing me his facility as well as the mission hospital Maua Methodist Hospital.

After meeting this young man I started to get a feeling for how daunting the problems are for the medical community. On my previous travels, I understood that Kenya was a resource poor country. I saw that this had an impact on the delivery of medical care. I did not, however, understand the scope of the problem. It is pervasive, affecting every level of care.

The most obvious impact of the scarcity of resources is the facilities. Embu district hospital is a referral hospital with busy inpatient wards. Despite this, there is only one theater and another room for emergency c-sections and overflow. These rooms are shared by all the surgical services including general surgery, neurosurgery, gynecology/obstetrics, and orthopedic surgery. This is the first impediment to providing care. Orthopedic surgery is allocated one day each week to do all urgent and elective cases. Emergency cases are only those that are life threatening.

The next obvious hurdle is a lack of equipment. Despite improvements in the availability of basic materials, implants for orthopedic cases are not available through the hospital, but must be provided either by the surgeon or in most cases by the patient. A routine, unstable ankle fracture is often treated non-operatively unless the patient can procure the necessary implants. If the patient’s family is able to obtain what is needed, access to the operating room often delays the case for weeks. These delays lead to hospital wards full of patients waiting to have traumatic injuries appropriately fixed. Most of these patients that are waiting to be fixed have injuries that we would consider urgent of emergent, including femur and tibia fracture.

What is less obvious, but also has a significant impact on the delivery of health care is the low morale among the hospital staff. Operating personnel often work long days without adequate breaks. Food is not available for meals. Despite demanding conditions, the staff is poorly compensated and often do not feel rewarded for their efforts. This lack of motivation leads to low efficiency and productivity.

The SIGN program has had an impact on several of these obstacles. My host was Dr. Soren Oliver Otieno. He completed his orthopedic training in Uganda and returned to Kenya being assigned to Embu district hospital. He is a very competent and motivated surgeon. Arriving in Embu equipped with enthusiasm, skill, and donated SIGN instruments and implants, Dr. Otieno has started to see a change in the delivery of orthopedic care. While the facilities are the same and the availability of something as basic and necessary as anesthesia is still wanting, having the SIGN instruments and implants has made a difference.

Patients now have readily available implants that are provided free of charge. This makes access to the operating room in a more timely manner possible. The SIGN implants work. Patients who would have been bedridden for months in traction are now up with crutches in less than 48 hours and discharged from the hospital in less than a week. Hospital personnel see this first hand. Participating in something so dramatically positive has been motivating to staff. This permeates through the hospital and has improved efficiency.

The SIGN program has not solved all the problems. Patients are still transferred to Embu having languished in traction for 10-12 weeks. More seasoned surgeons are still reluctant to accept different methods and continue to use more expensive ineffective treatments. Providing free implants can create a sense of entitlement. Despite the limitations and hurdles, Dr. Otieno continues to provide the best care possible and through his efforts to train other surgeons, he is having an impact on the entire region.