 to Y254. This is Y in the morning and remember this is Health of Monday. If you'd like to talk to us and ask some questions about what we're going to be discussing today, please remember that you can do so on hashtag Y in the morning and hashtag Health of Monday and that you can do that on our social media handles that is on Facebook and Twitter, Y254 channels as well as Instagram, Y254 underscore channel, and we're also on DSTV in our channel 376. If you'd like to watch a repeat of this interview, you can do so at 2 p.m. later on in this afternoon. Remember today is World Autoimmune Disease Day where we raise awareness for various autoimmune diseases and we have a wonderful person who's on set with us today and is actually an expert in this particular area. He is a physician as well as a rheumatologist and his name is Dr. Eugene Ganga. He's not only a physician and a rheumatologist, he is an advocate for student athlete. He'll explain a little bit more about that later and also he coaches and mentors with the University of Nairobi basketball team. Thank you for having me. Yes, so please tell us a little bit about the coaching and mentorship before we discuss the rheumatology. Okay, so currently I help coach and mentor the University of Nairobi team and Nairobi school because I've learned there's a lot of issues with the boy child, so just a way of giving back to society. So apart from empowering them with the basketball skills, we also take them through some mentorship program. Okay, I see. All right, thank you. Well today, you know, you're a physician and a rheumatologist. Can you please explain to our viewers what a rheumatologist is and then we can dive right in. What does a rheumatologist do? So rheumatology is a field that is not well understood especially in this part of the world. What the basically, what a rheumatologist's first of all is you first do undergraduate, come a doctor, then do your master's, do internal medicine, then you specialize now in rheumatology. So rheumatology basically looks at connective tissue diseases, musculoskeletal diseases. Some of the examples of things we deal with things like arthritis, back pain, diseases like lupus, muscle diseases, amongst many other conditions. Okay, all right, thank you for bringing up lupus because as much as today is World Autoimmune Disease Day and we're going to be focusing on a particular autoimmune disease that we know as well as rheumatology. Can you say these words? That we know well as arthritis but an autoimmune form of it and actually this whole month we're going to be celebrating world lupus month. Yes, it is. Okay, and there's a connection between the two you said. Yes. Hi of us, maybe we can dive right in. What is the difference between normal arthritis and autoimmune arthritis? So I think to make it clearer, it's basically, let's go to the basic of the science. Okay. When we say autoimmune, what basically mean is that the body is unable to recognize between yourself and a foreign object. So the natural response of the body is to attack a foreign object. For example, like an infection. Yeah, so the body's response to attack it but when you have autoimmune conditions, the body cannot differentiate the two. So it ends up attacking also your body. So you can manifest in very many conditions can affect your joints, muscles, blood vessels, heart, like best practically any part of your body. Right. And that is the science of it. Yes, that's the science of it. So in terms of the difference between the two, okay, with arthritis, we usually have two types. There's the auto inflammatory, the autoimmune, sorry, and the non-autoimmune. So for most of our viewers, they are more, more likely to do the non-autoimmune. So the non-autoimmune is more common in the elderly. We call it osteoarthritis. So basically, the science would give a very simple explanation is that the grease in the joint runs out. So there's a lot of friction. From the friction, you get arthritis, arthritis basically is joint pain versus autoimmune, which is different in that when your body is unable to recognize your normal joint from a foreign object, it attacks now your joint. And now this one is now more common in the younger age group now. I see. Yes. And more common in the younger age group because we do tend to link arthritis to an older age group. When you hear the word arthritis, you think of the senior members of society, the older people. But nowadays, I was also surprised to learn that it's something that's affecting our youth. Yes. Yeah. So, you know, we're going to take that angle when we're discussing because this is a youth channel. And please remember once again, if you are a parent and you are interested in what we're discussing or you've got a child that is going through what we are discussing, please reach out to us on hashtag, help on Monday and hashtag why in the morning and send your questions to us. Tafadali, please let's continue. What are some of the, you said that this is what we're recognizing children. Yes. What are some of those signs that parents can look out for? Maybe the first thing is maybe to define arthritis. Arthritis is basically a joint pain. Okay. And it can be caused by all sorts of things. So, basically, the first you will sign especially the younger age group for babies and children is a bit difficult. But you probably notice the other work with a limp, some unexplained fatigue, unexplained fevers, unexplained joint pains here today, tomorrow they are okay. When you get first adolescent age group, it's a bit no more defined because the patients are more advanced. I'll tell you now, it's just not as painful or swollen or the back as issues. There's one particular arthritis we call ankylosine spondylitis. It's very common in the younger age group because what happens is that you find a patient wakes up in the morning and the back is stiff. The back is stiff. Yes. And the back is stiff. It means you can be stiff for about even 30 minutes. You're just in the bed. Just in the bed. So, once your body, like a slow engine, as you warm up and everything there, the pain now disappears. So, usually another thing which can help especially the younger age group because where we teach, we tell our students to differentiate between what is autoimmune pain versus non-autoimmune pain. So, the autoimmune pain is basically pain that's worse in the morning and gets better with activity. Okay. And that is what is more common with the younger age group versus the older one, when you get the wear and tear, is pain that is worse with activity. Meaning that you'll be, maybe we walk the whole day at the end of the day when you have to rest. That's when the pain does what? Substance. Yes. Apart from that, especially the younger age group, sometimes we get some unusual presentations for arthritis. Some certain heart conditions can put you at risk developing arthritis. When you have diseases like lupus which is basically a systemic disease can come with also arthritis also. Yeah. Wow. All right. We'll touch on lupus just a little bit later on. Maybe we can still continue to talk about, since you've said what arthritis is, we've separated the difference between normal arthritis and autoimmune arthritis and how it may affect people of different ages. You know, when I was doing some research yesterday, I learned that when it comes to places like the U.S., they have particular statistics that they've taken and right now they're standing at, I think it was 300,000 youth, 300,000 children basically that are carrying specifically autoimmune arthritis. Excuse me. Unfortunately here in Kenya, I don't think we have specific numbers that we're working with and we'll talk more about how to reduce those numbers but for now, the numbers that we do have, are there any, how can I say, apart from this particular day to raise awareness, are there any organizations that are catering to dealing with children with this or is it just, you know, you just have to vote for the doctor and he'll refer you? Unfortunately, in terms of rheumatology in Kenya, we are still very, very, I'll put it in the storage. For example, the number of rheumatologists in Kenya are less than 10, serving a population of about 40 years. The number of rheumatologists in Kenya are less than 10? Yes. Wow. And that is the major, the major drawback because in order to raise awareness, you also need to improve the personnel. Another shocking statistic is that there's only one public hospital where you have arthritis you can be seen, which is Kenyatta. So it means that if you have arthritis, the only place you can access, apart from Kenyatta, will be a private hospital. There are some of the issues we have with arthritis. I'll give an example like for the children arthritis. There's a paper which we did some research on arthritis in children and a lot of them were coming late, meaning that there have been so many doctors. By the time the landing on us is late, sometimes one year, even two years, that's in the children. In the adults, the exact figures about 60, 70% were coming after a year, a year and a half, which is surprising. So it means that I think awareness on the ground is not the best. And also too, we need to empower our, need to empower our upcoming doctors. Another shocking thing is that if you look at the universities that teach medicine, apart from University of Nairobi and maybe not even at my university, there are only hospitals that have actually got a rheumatology sitting there. The other teaching universities that teach medicine have no rheumatologies there. So you can see there's a really, there's a big shortfall in terms of that. In terms of organizations, nothing so far, there have been a couple of initiatives. There's one called Uwezo Initiative. So basically Uwezo Initiative was an initiative of some fellows from Sweden, England and Kenya. So the idea was they were trying to empower the local clinicians, so they organized workshops for the doctors, for the physiotherapists, and also for the patients. And it's something which has been started. So we're hoping at the time it can be able to pick up and hopefully at least help in terms of managing these conditions better. Okay, I see. And speaking of managing conditions, but actually that's really sad because it looks like there's a really big gap both in physicians and both in nursing awareness. There's just a huge gap everywhere when it comes to arthritis in every single form. And we'll talk about ways we can change that, but speaking of how to manage this disease, specifically autoimmune arthritis, a young person that is watching right now, maybe, that is undergoing or a loved up parent who has a child that is undergoing, what are some of the ways they can manage the pain? Because you did say that it's joint pain normally, and we have the joints in our wrists and our elbows, our knees, and it could be anywhere. And then it can even affect your organs up to some point. How can they manage this pain? So usually management, what I do with my patients, the first thing is education. Because for a lot of parents, they find it very hard to imagine that their 14-year-old child has arthritis. And that usually is the biggest problem because they'll see you, move to another doctor, another doctor, eventually a witch doctor. My child does not have arthritis. Can not have arthritis. So usually the first thing is empowering the patient, empowering also the parents. About the patient because a lot of, like especially the teenagers, teenagers are a bit difficult because there's a lot of issues in terms of acceptance. Why am I taking medicine at this young age? Other things that what would my friends think about when I'm taking medicine? So empowering them, isn't it, is something which we need to do. And one of the things which I tell my patients is that if, because most of the coffers I've attended, the leading doctors in arthritis for the youth are actually patients. So they started as patients and became doctors and became leading. And so the, the kids were driving because they've been through it. They've been able to make it. So that's some of the things I used to empower the patient. So in terms of medicine, there are a number of options that are available and number, number, number of options depending on the cause. Usually education is very important because people go on Google. Like one of the drugs we use is called methotrexate. It was like for the rheumatoid arthritis and patients come and tell you what, doctor, I went to the chemist and the chemist was very telling me that this is for cancer or something. Yes, it can be used for cancer. I'm not disputing, but in the doses for cancer, but the arthritis are very different. In fact, when children, the doses are what? Are very different. The other options you can give, the drug called chloroquine, it used to be used in all this for malaria. By the way, yeah. You can use it, you can use it both, right? Yeah, yeah. The problem with us Africans, you misused it. No, I would say that everybody has malaria. So eventually the bug would resist and so the drug was withdrawn, but research has shown that it can be useful there. The drug called surfacilazine can be used. The regular painkillers can be used on and off. Once they will give them steroids. The steroids is only for a short duration of time so as to corrode inflammation, but the main steroids I've mentioned and then there's some newer drugs that have been introduced in the market. They're expensive. We call them biologics or designer drugs. So the sum, the cost usually is the prohibitive factor. There's one that costs about 200,000 every two months. 200,000 per what? Every two months. It's another about 85,000 every month. But those are usually for patients who can afford and maybe who have failed the standard treatment. Oh my goodness. Wow. 200,000. Many can afford that. Actually, I think a handful can afford that. Yeah, and that's why I've been trying because like in the 80s and 90s, the HIV medicine was very expensive and the gays who really pushed were the patients. Yeah. Look now cancer. The gays who are pushing for cancer are who? The patients. So you've been trying to encourage your patients that you guys need to push. Yeah, push. Because if you push a lot of these drugs, I'll give you for example, like one of the drugs that is used in cancer, so used in arthritis. But if you go under an HF, you can't get it for arthritis, but you'll get it for what? For cancer. And that that costs like about 250,000. So I think going forward, I think trying to petition the government show that the people are here and they need this medicine, something which might help at least lower the cost because arthritis is very expensive. Yes, actually sounds very expensive. And speaking of medication as a way to manage pain, is there anything else people can do apart from exercising? I know you said that some people go to a witch doctor. Because you know you, because in your mind, you are convinced that this is a disease for old people. By the time a 14 year old has it, I mean rogua or something, you know. But I think simply put joints are joints. Yes. Whether joints are an old person or they're a young person, a joint is a joint. And when the lubrication at the joint, I guess gets severed somehow, arthritis will come at any age. It's not a matter of witchcraft. Yes. You said medicine. Is there exercise, you know, that people can do? Because sometimes I've seen they limp, literally. And I'm asking myself, how will they get the energy to do exercise or even hydro? Hydro therapy and the rest. So in that particular aspect, there's something we have called rehabilitative exercises. And this mainly is to do physiotherapy and occupational therapy. So physiotherapy is basically when you've come, it's like rehab, being taught how to work again. There's a flexibility of the joint, strengthening of the joint. So that's what physiotherapy is. Occupational therapy is a bit different because you're trying to restore function. Like for example, like if I'm like a cook, how can I use my hand when it's deformed? So that's what occupational therapy is. Unfortunately in Kenya, we have physios and occupational therapies, but in terms of the equipment they have in like most of the districts, most of the counties, sub counties are not up to up to par. So usually we need to encourage our patients to maximize their physiotherapy. Apart from that, exercise is good. And from research, they've been able to show that if patients who have been regularly exercising tend to recover faster from arthritis. Secondly, it delays the onset of arthritis also. And third can actually be able to prevent what some of these arthritis. Apart from that, the exercises diet is important. We run away by a lot of high refined sugars. So these high refined sugars over time can actually have been shown being placated in some of these autoimmune conditions. So we need to be able to eat more healthy food, more fruits, more vegetables, meat or the high meats should be taken down. Because apart from causing the usual autoimmune can also cause gout, which is becoming a problem, especially in the younger age group, which should not be the case. Yeah, amongst other things. Of course. All right. And we've learned quite a bit about arthritis today and the difference between normal arthritis and autoimmune arthritis. Do you mind touching a little bit on the connection? Since this is world lupus month, the whole month, could you maybe touch on the connection between lupus and autoimmune diseases? So lupus is a type of autoimmune disease. Lupus, if you go back history, what it means is wolf bite. Wolf bite? Yeah, wolf bite. That's what it means. So that bite here. So the initial people, I think when the first patients in the 1800s or whatever time it was, they'll get scar here. So then lupus name came from there. So lupus is a very interesting disease because it's very common amongst ladies. I think the ratio is about 9 to 1. Age group is about 15 to about 55. And it's a systemic thing. So arthritis or joint issues is one of them. Muscle is one of them. Heart is another one. Tummy issues. Brain issues. Blood is another way. So you can present in very many forms. I saw someone maybe falling here. Yes, even falling here. So some of the symptoms which the patient pick up will be one weight loss and explained fevers, feeling just fatigue, this unexplained fatigue. Other things will get mouth ulcers. They get a cheek, a rush around the cheek. Others who are very unfortunate can present with kidney failure. Some who are very unfortunate. Those who have seen other unfortunate fellows who have been diagnosed as mad can present as psychosis. It affects your brain that much. Yes. And then another which is for ladies especially, these unexplained pregnancy losses. I remember as a patient I once saw who had lost I think six pregnancies. Her husband had left her. I don't know what the having issues. She was pregnant with the seventh one. Unfortunately she lost the seventh one. I haven't seen her since then. Her husband left her. And that's another thing about this. She still has the lupus. She still has the lupus but I don't know where she is. I haven't seen her in a while. Some of the things you know, some of these autoimmune conditions, a lot of stigma associated with it. And I like that right now people are coming out and talking about the lupus. Maybe I can mention a few people who the youth might relate to. Yes, please. Like Nick Cannon. Nick Cannon is a comedian. He has lupus. For him, he has lupus nephritis. I mean kidney. He had kidney issues. He had to go for dialysis and all that. Selena Gomez, the same kidney. She even had to go for a transplant. They replaced her kidney. Lady Gaga. Yes, has lupus. With all that energy. And her, in fact, if she goes back, I think either her mom and her family had lupus. Tony Braxton also has lupus. I think she passed out one day in some interview or something. They went for a test. It had affected her heart. This is a rapper called Trick Daddy. Trick Daddy, sorry. Trick Daddy now is the, he has one aspect of the skin. We call it the square lupus. You can see it's a very common thing. And I like that he's coming out. Yes, yes, yes. And I noticed you used past tense. This means that they've been cured of it? Not exactly. You see the cure is a bit difficult because a lot of these autoimmune conditions, we still are understanding and we still do not know what exactly causes. We just know that if you are, it's more likely to be ladies. Okay. People who smoke, we take alcohol. I've heard like a lot of viral infections. It's a family history, but we don't really have one particular cause we say like for malaria, we say it's a malaria bug. If it's a type of bug, so treating is a bit easy. But for lupus, it's a bit difficult. And just to show you how difficult it is to treat lupus is that in the last 50 years, there's only been one drug, one new drug for lupus, the last 50 years. In the last five decades, there has been one new drug that has been reduced into the market. So basically it's been the same drug the whole time. And it's so damn expensive. About $2 million a year, the whole cause. Yes. It's not available in Kenya by the day. It's not available in Kenya, but we still have women here that need it. Yes. Yes. Yes. We still have it. So what we do is, like the poor lupus, it has, it's, I call it like a hydra. A hydra meaning that it has very many faces. So my face may be the heart, another may be the kidney, another may be the skin. So there are some treatments that are there and if you're able to talk with your doctor, they're able to tailor make the treatment according to what you have. And most of the time they do well on the standard treatment. There are some extreme cases where you may be required and able to go to the country to then access those particular drugs. But the main issue is that most of these patients come when they are very late. So even the standard treatment may not be effective. I see. Okay. Oh, wow. And now that you've talked about the connection between lupus and autoimmune diseases, I hope our viewers are trying to catch up and continue to understand. Maybe you can discuss with us a little bit how, when it comes to autoimmune diseases, maybe how here in Kenya, we can change the numbers of what, yes, we don't have specific numbers. We have no idea how many people have autoimmune diseases. Like in America, we know it's 300,000 young teenagers that have it. But here in Kenya, we still don't know. Still, nonetheless, we'd still like to reduce those numbers. In what ways can we do that apart from raising awareness? So I think the first thing is that we clinicians also, we need to do research. I think that's the most important thing. Like if you're, I'm sure you try googling lupus in Kenya, there are not very few data. But over time, the number of publications that come in, like you have some publications on lupus, I have a couple, is one on rheumatoid arthritis that are there. So I think for doctors is to publish, when you publish or write an article concerning lupus or rheumatoid arthritis or some autoimmune condition, it goes to the internet. So it means there's a number there. And that is what we need to tell, if you go to the government, this is there and we show them the evidence, it makes sense. Other things about arthritis is one to the stigma. The stigma is something which is a bit difficult because I've heard, maybe I can give you the story, there's a lady who has rheumatoid arthritis. So she came with her sister. So chat, chat, chat, she goes away. A few months later, the sister comes back, the sister now, the two sisters come. Now the first lady had rheumatoid arthritis, the sister a few months later develops what? rheumatoid arthritis. In the midst of talking, I'm wondering how, you know, because where I studied, people would come as couples, come husband, wife, husband, wife. So I asked them, how come you guys are not coming with the husbands? They told me that when the first lady got rheumatoid arthritis, the husband bolted. So she would come with her sister. So when the sister got rheumatoid arthritis, guess what? The husband also did what? Left her too. So I think stigma, I don't know. It's that bad. It's that bad. And there's another, the previous story you mentioned as well, the lady with the six miscarriages. So it's stigma. Sorry, before you go further, what are they seeing in this stigma that makes them literally take to heal and run? What are they seeing? What have they heard? What is it that people are saying about arthritis? I'll give you, for example, like lupus. When lupus comes the first time, I very say we are lupus. The first thing to think about is HIV or cancer because it has, it's very similar. The symptoms. Symptoms. It is very, very similar. So that's the first thing people think about. Other issues about, you know, this disease is bad because a lot of the patients tell me that people think I'm lazy because there are some days they just can't wake up. They can't because that day the disease is just bad. They are fatigued, joint pain, so you see for the, for this guy is wondering, you look okay. Why are you in bed the whole time? So those are some of the issues about the stigma and then also witchcraft and all that. I know a lot of these people really don't understand about it. Like there's a very special disease called scleroderma. Called what? Scleroderma. So basically it means thick skin. So you have like a skin that is hard like leather. Wow, leather skin. Very tight. Very, very tight. So imagine that to a layman. What's the first thing they'll think about? It's just witchcraft. So I think stigma is something which we need to deal with. Another thing I think is empowering our doctors. We are trying, at least another rheumatologist is increasing and at least information is getting out there. So I think that's something which we need to do. Another thing is trying to involve government in terms of management of this disease. Because a lot of people don't understand that we actually have guidelines for motor arthritis in Kenya. They released like last year by the, this is an organization called Atrumah Society of Kenya. The guys who were like, we are the rheumatologists who came together. So we came up with a guideline which would help at least with rheumatology. Unfortunately, we didn't get any government input. Unfortunately. Wow. That shows you the things that. Yes, lack of interest. Kenya, we are a react kind of government. When this go bar is going to do what? We react. We kind of wait until things have gone haywire. We're like, oh, let's do something. Let's do something about it. Wow. And then the patient support groups, like where I started, the patient support groups do a lot. They do a lot. So they're the ones who actually fund the research. How do they fund the research? They usually organize campaigns to raise money, concerts. They even have shops where you would like, there's a Luper's UK good for shop for Luper's UK find the rubber bands, t-shirts, shirts, everything is there. So you can buy whatever you're buying goes towards what? That particular. Yes. That's what I think going for something which we can, we can do the guesswork is driving the, the change for the management and even some of them when they go to conferences and even teach doctors about the disease, because who better to teach the disease than a patient. I see. I love how you brought up. There's two things I'd like to talk about which I feel could have help a little bit. You know, yes, the foundations for all this, but you know how, for example, in the supermarket, how you finish paying for your things. And just as you've paid for your stuff, this little thing, tin bucket things where you put loose change, come on, like three Bob or something you don't need, you can put there for donating. And most of the time it's for children's homes or something like that. I feel maybe for some supermarkets, they can change the initiative a little bit take some of the proceeds and take them to diseases that are not well documented, maybe like mental health or lupus or autoimmune diseases. Another thing I think it would be really interesting to take a step towards is PSAs. A lot of the times when you're watching, like this is a channel, I think it's called ETVA or something. I don't think it's a Kenyan channel. I think it's South Africa. But when they're, when they're break time, they don't have announcements. And even if they do, they're quite few. But they have facts, for example, about Africa. So it'd be like, Oh, did you know that the Rift Valley is this and this and that? And in my head, I'm thinking not, not who cares, but can we use this platform for something more important, like no offense. But some of the facts I read, and I'm like, Hey, I knew that. And I'm sure not the only one who knew that. Can we now use this to raise awareness? Can you throw some facts about mental health? Can you throw some facts about young people having arthritis or lupus or something? And I feel like we just need to really, really take every single initiative and exploit every single space we can possibly exploit. And the people who are raising awareness, I'm so proud of them. Shout out to you guys, by the way, great job. Yes. And they should continue pushing. And if there's a way I could help, I would love to help. But yeah, these are some of the ways I wish we could. Things need to be publicized. Exactly. Even if it means to be put on TV for 30 seconds, just a fact about autoimmune disease, maybe the next time 30 seconds a fact about lupus or something, then people are like, Oh, so it's not witchcraft or Oh, so my wife was acting funny, like three years ago, it was this thing. But without that, it becomes quite difficult. That's true. That's true. Wow. This has been a great discussion. And maybe we can lastly discuss on how what are the differences because I'm seeing how they deal with it in the West is a bit different from how they deal with it in here. What are some of those differences? And lastly, what can we pick from them? Yeah, when it comes to dealing with autoimmune disease, what can we pick from the West? I think the first thing would be empowering the doctors. We need to have more campaigns and teach our doctors better. Okay. And maybe also improve the infrastructure in terms of we can't just have Kenyatta having the only public rheumatology clinic. Yes. We need to have more out there because imagine if I'm in Wajir or Mandara and I have basically I mean, I've lupus or rheumatology. It means I've come all the way to Kenyatta to be seen, then I go back. So I think that's another thing we need to do also. Like what they've done in the West is like, maybe I'll give the example where I studied, I studied in the UK. They have this, they call it the NHS. It's the National Hospital Service. It's like an NHS in Kenya. But there's a bit more organized and I think better than ours. The receptionist is not using helicopters. I don't think so. So like they are what they do first of all, they really encourage education for the doctors. So from the get go from undergrad, once you finish, if you want to become this particular doctor, you already have your path set out. You go to this hospital, I do this, I do this, I end up being this. And then they are posted anywhere. Then matter whether you're from Wajir, you can go to Nairobi, to Bombasa, that's what they do well. And also in between, they organize short courses like one weekend discuss maybe just lupus, other weekend matter arthritis. And it's from the experts, experts, experts. Another thing which they have done is research. I know in Kenya we really don't look here about research, but there they really do a lot of research. And their research is to improve the quality of life of the patient and to drive down the costs for management. And driving down the costs, if it means that I'm going to spend less on treating this patient and save money, that's what they want. And some of the initiatives they've done is that, take for example a patient has this long-term condition, the caregivers actually can take time off work, take care of the patient, get a salary at the end of the month, taking care of the patient, because they argue that if the patient is in hospital, eat up more money, that's a bad space. But this being at home, being brought to the hospital, which I think is a good thing. Yes. Other things which they have done is how they organize their structure from the undergrad, from the regular doctor, the consultant. So like the rheumatology clinics, how they run them is that you'll see a doctor like about twice or thrice a year. That's what, and usually that's for regular, just for the reviews and everything. In between what they have done, there's the general physician, so what they've done that in each area, you have like a bunch of doctors who manage the common conditions, so they can manage, they do what they refer. But at the rheumatology clinic, they have a nurse. So the nurse are the guys who do most of the work. So the nurse, their job is one to educate you on the disease, educate you on the medicine. Actually, I found it very funny that, you know, in Kenya, we just prescribe medicine till the patient go. So there what they do is they tell you, the drugs are one, two, three, four, five, and then afterwards now you go and decide what you want. Then you start. I see. Wow. Those are amazing ideas I feel like we can pick up. And if there's anyone who is you know, vibing on the same vibration as our doctor over here and feels that there's some of the things we can change, and there's some of the things that we can do to raise awareness on this particular issue. Do remember, it's hashtag health and Monday, hashtag one in the morning. And remember, you can find me on joy underscore muchache. We do have to let this conversation go. It has been a wonderful discussion with you. Thank you so much for coming and raising awareness on this particular issue. And also for raising awareness on this day that has been set apart specifically May 20th for autoimmune diseases. Thank you so much for tuning in. My name is Joy Muchache. Coming up next is Youth and Politics with Hilda Wadidi. Do stay tuned.