David Silverstein: Chief Justice Zach Chesoni's death left me fighting to save my career

Throughout my career I have been lucky enough to enjoy harmonious professional and personal relations with my Kenyan medical colleagues.

The one exception happened in 1999 when my patient Chief Justice Zacchaeus Chesoni succumbed to a fatal cardiac arrest in the hospital’s ICU. I was charged with mishandling the case.

Once the facts were made plain, I was fully vindicated. It was a long time ago, but the anguish I experienced is still vividly etched in my memory.

Zach Chesoni was a personal friend who had been my patient since September 1975 when he had presented at Kenyatta National Hospital with vague complaints of chest pain. On examination I detected a leakage of the aortic valve.

At the time there was no echocardiogram machine in Kenya.

His heart size was normal. He had no symptoms other than mild chest discomfort, which was clearly of muscular origin and related to stress. The following year he came back complaining of significant chest pain. An X-ray and fluoroscopic examination – the only diagnostic tools then available to me – showed considerable dilation of the aorta. It was an aortic aneurysm.

Left untreated, it would kill him.

I was worried and told him he needed surgery. He wasn’t happy at this prospect. I understood how he felt, but I feared that if he didn’t agree to the procedure, his time on earth was limited.

Zach told me he had a relative who was a resident physician at the Mayo Clinic in the U.S. and he would like to go there. He asked me to call Charles Njonjo, then the attorney-general, and explain the situation to him.

Charles listened patiently as I explained that Zach’s rapidly expanding aneurysm might rupture. It was a surgical emergency which we couldn’t yet manage in Nairobi.

He immediately assured me that not only would his office cover Zach’s expenses, but I should move quickly. I was hugely relieved.

Zach flew at once to the Mayo Clinic where my diagnosis was confirmed. Dr Dwight McGoon, a famous pioneer in cardiac surgery, performed an aortic valve replacement as well as a resection of the aortic aneurysm.

On Zach’s return to Nairobi, I put him on the blood thinner warfarin together with a beta-blocker, often used not only as an anti-hypertensive but also to prevent further aortic aneurysms.

He recovered well, and I didn’t see him again for a review for nearly 15 years. By then he was head of the Electoral Commission, which was overseeing Kenya’s first multiparty elections in 26 years.

It was a momentous event for the country and stressful for everyone.

We now had echocardiography available. When I examined the images, I was alarmed to see Zach had developed a very large sinus of valsalva aneurysm at the base of his aorta. It measured eight centimetres.

Urgent intervention

When an aneurysm grows beyond four or five centimetres there is a grave risk of a rupture or further dissection of the aortic wall.

I wrote Zach a letter urging him to return to the Mayo Clinic for surgery immediately and faxed a copy to his son Solomon, a doctor doing postgraduate training in the States. For reasons I never understood Zach never made the trip.

Perhaps he feared going under the knife once more. Possibly his finances were a problem. He had a strong sense of duty and loyalty to President Moi.

He may have hesitated to leave his important post at this critical juncture in Kenya’s political evolution. He also kept his visits to me to a minimum. I suspect he thought that somehow he could tough it out.

I repeated Zach’s echocardiogram two and a half years later in May 1994. The aneurysm had grown to nine and a half centimetres. I was very clear his heart condition needed urgent intervention.

Unfortunately Zach ignored this. Five months later he was back in my office. At his request, I approached President Moi, who sanctioned an operation at government expense.

Still my friend chose not to go abroad. We occasionally encountered one another at State House events. Zach would greet me with a big smile. ‘Daktari, I’m still alive!’ I didn’t have the heart to tell him he was laughing in the face of death.

By April 1997, the aneurysm measured ten centimetres. I wrote at his request to the head of the public service:“I strongly recommend that Justice Chesoni goes overseas for further consultation and intervention”.

Once again Zach did not go. He did come in for regular reviews, and I tried to keep his blood pressure as low as possible in order to keep the shearing pressure of the ballooning blood vessel to a minimum.

An echocardiogram now showed the aneurysm at ten-and-a-half centimetres. Besides his blood thinner, he was also on five antihypertensives including a beta-blocker.

Zach would come by almost every week on Friday afternoons when I was off duty just to have his blood pressure checked by the nurses. Then came his last visit and the ensuing nightmare that started in August 1999.

It began 24 August when he came to me with pain in his left knee. As he had a history of gout and his white-blood-cell count was mildly elevated, I suspected this was a recurrence.

On examination I found it to be warm and swollen. But my chief concern was his low blood pressure, which consistently measured at 90/60 mmhg.

One reading was 80/70. I urged him to come in for hospital admission. He categorically refused until his wife Mary convinced him to go.

I gave him an injection of diclofenac, a nonsteroidal anti-inflammatory drug, and put him on a dosage of the same compound three times a day.

When I visited him that evening, he was alert and keen to go home. His blood pressure had come up to 110/70. It was a good sign, but I still wanted to keep him in the hospital for another twenty-four hours. He was, after all, Kenya’s chief justice.

Extra caution seemed reasonable. The next morning he looked even better. His white-cell count was within normal limits. He had no fever. He was in excellent spirits and cracking jokes.

By this time the press was beginning to wonder why the chief justice was still in hospital. Zach and Mary told me they were growing weary of the reporters’ constant inquiries. They asked if he could go home.

I told them that out of an abundance of caution I wanted to keep him until his blood pressure reading was consistently at 100/70 or higher for twenty-four hours.

This probably meant one more day of hospitalisation.

Zach was disappointed but reluctantly agreed. Channa, who was soon to become my wife, had recently returned to Nairobi on a break from her work in Portland, Oregon.

Neck stiffness

We had accepted an invitation by the owners of Chui Lodge in Naivasha to celebrate my birthday there. I told Zach about our plans and reassured him I would be available at all times on the phone. Dr Mark Joshi, a consultant cardiologist, would be in attendance as well as those employed in my practice.

Zach said he was fine with that as “no one is indispensable”. I wondered whether he was referring to himself or to me. As Channa and I left town, I was confident of Zach’s excellent care and continued recovery.

The next day Channa and I drove to Lake Bogoria Hotel at the invitation of President Moi. En route, I called Dr Jimmy Mbogori, who worked for me. He reported Zach was somewhat confused.

His white-cell count was normal, but Mbogori had noted some stiffness in his neck. Out of concern the onset of his confusion and neck stiffness might be a brain haemorrhage caused by the blood thinner warfarin he was taking or some sort of meningitis, Mbogori had transferred Zach to the high-dependency unit where he could receive a higher level of care.

A subsequent CT scan had ruled out any bleeding. Zach’s blood oxygen was low, but his chest X-ray was normal and a repeat 2D echocardiogram showed no change in his heart function.

After reviewing the patient again, Joshi and Mbogori provisionally concluded that Zach may have developed encephalitis from an unknown cause.

A lumbar puncture produced xanthachromic (yellowish) CSF (cerebrospinal fluid) that usually is associated with a subacute bleed. With bacterial meningitis you expect to see an elevated white-cell count in the CSF, visible as pus. Zach’s white-cell count, however, was surprisingly low which suggested that he was not able to mount a defence or else the infection was very recent.

Another consideration was a nonbacterial infection such as viral or fungal meningitis. This was why we were monitoring the patient’s neck.

Neck stiffness is a common symptom of inflammation of the lining of the brain (meninges), the hallmark of meningitis. There had been no neck stiffness until then.

However, the gram stain, revealing gram-positive diplococci bacteria, firmly established that Zach was infected by bacterial pneumococcal meningitis, one of the most common forms of bacterial meningitis.

Given this diagnosis, Jimmy Mbogori, in conjunction with my colleague Shem Musoke, immediately started Zach on Rocephin (ceftriaxone), the drug of choice for bacterial meningitis in 1999. It continues to be commonly used to this day.

As soon as Channa and I arrived at Lake Bogoria late that afternoon I phoned Jimmy Mbogori, who briefed me on Zach’s condition.

There had been some early reports, mostly out of the U.S., of the pneumococcal organism’s resistance to penicillin and, more rarely, to drugs such as ceftriaxone.

In the remote possibility that Zach’s infection was resistant to the ceftriaxone, I also started him on vancomycin, another antibiotic.

I called President Moi to update him on his chief justice’s status and to inform him I would be driving back to Nairobi at sunrise to be at the patient’s bedside.

Sometime after midnight, I was called because Zach’s blood oxygenation was falling. I had him transferred to the ICU. He was intubated, which meant inserting a tube through the mouth into the wind pipe, and then put on a ventilator.

Channa and I rushed back to Nairobi as quickly as we could. When I arrived, I saw at once that Zach had responded well to our treatment. I was mildly relieved.

The next day his chemically induced paralysis (necessary at times for adequate ventilation) and sedation were stopped. After two days Zach was well enough to receive visitors, one of whom was President Moi.

It was about this time that Dr John Matseshe, a gastroenterologist and Zach’s cousin, flew in from Illinois.

He at once presented himself to the media as the man in charge of the chief justice’s treatment. Matseshe provided the reporters with daily updates, explaining that the patient was responding well to his (Matseshe’s) treatment.

I thought this was inappropriate, but as he was Zach’s close relative. I didn’t think it wise to call him on it. My responsibility was to the patient not Matseshe.

Zach was indeed doing well. The various bacteria cultures showed he had contracted a meningitis due to a very sensitive pneumococcus.

When subsequent cultures came back indicated that penicillin was effective, I stopped the ceftriaxone and vancomycin and put him on penicillin. Zach continued to improve and I was able to take him off the ventilator by September 1.

The next day, we removed his endotracheal tube. Zach was fully alert and able to carry on a conversation with me. It was clear he had recovered. His kidney function had returned to normal.

Plans were made to move him out of the ICU to the ward. His cousin, the gastroenterologist, continued to assure reporters that under his splendid care the chief justice was making excellent progress.

Sudden collapse

By Friday, September 3, Zach’s vital signs were normal and stable so Channa and I went to our farm in Naivasha for a relaxing weekend before her return to Portland.

I left Dr Luke Musau in charge. He was a consultant anaesthesiologist who had been doing intensive-care work in my practice for the previous five years. I also asked Dr Joshi to be available for any cardiological problems should they arise.

They understood that, if Zach’s condition deteriorated, I would be able to return within two hours during the day and, as travelling on Kenyan roads in the dark can be dangerous, first thing in the morning should a call come at night.

Nothing of concern transpired until 2am Sunday morning when Zach spiked temperatures of up to 40º C and developed difficulty breathing.

He was returned to the ICU at once and put back on a ventilator. The lumbar puncture was repeated. There was no evidence of any further meningitis infection.

I worried about the possibility that some bacteria had seeded his artificial aortic valve or possibly even set up shop in the aneurysm itself. If that was the case, he would be at high risk of a fatal rupture of the aneurysm.

Dr Matseshe telephoned me shortly afterward to inform me he believed an urgent echocardiogram should be done. I didn’t think this would alter the treatment available to us in Nairobi in 1999.

Nevertheless I asked Mark Joshi to perform one. Zach’s echocardiogram was unchanged from the previous one. He was put on new antibiotics to cover the possibility he had developed a new infection. By dawn he was stable once more.

Then came his sudden collapse. At 11am, as I was driving back to Nairobi, Luke Musau rang to say Zach’s heart rate had suddenly plummeted and his heart had stopped.

I had been stuck on the road having encountered a horrendous traffic jam caused by an accident.

When I got the call, I was still finding my way to the hospital using circuitous back roads. I got to the ICU five minutes after efforts to resuscitate Zach Chesoni from his second cardiac arrest were abandoned.

Zach’s son Solomon Chesoni and his cousin John Matseshe were there at the bedside.

I offered my condolences, and they thanked me for my efforts. I shared my concerns about Zach’s aneurysm and aortic valve and their possible role in his death. I said a post mortem was essential to establish the cause of death.

Clearly it wasn’t meningitis as the infection had cleared. They said they did not want a post mortem.

My friend Zach Chesoni was buried at his farm six days later.

Malpractice accusation

I had a busy day and didn’t get a chance to take a break. When I stopped by to see Aaron and Jeremy at their mother Jackie’s house, I found Jackie and her sisters listening to the news.

They looked up when I walked in. Was I okay? There was concern in their eyes. Something was definitely amiss.

Jackie’s sister Angela led me outside and explained. Thousands of mourners had turned up for Zach’s funeral.

It had been covered on national television and radio. John Matseshe had given a eulogy. In front of President Moi, the entire Kenyan judiciary, most of the cabinet and a strong representation of Western Kenya dignitaries, he had accused me of malpractice in treating his late and beloved cousin.

I was stunned.

I was at a loss to understand why Matseshe had lashed out in this manner, but I was pretty certain I needed a lawyer.

I called Charles Njonjo and asked my friend if the brilliant and wellrespected Byron Georgiadis would be the right lawyer to represent me.

The Oxford-educated Georgiadis, sometimes referred to as the “silver-haired Perry Mason of East Africa”, had a long string of wins to his name in high-profile cases. Charles believed he would be a solid choice even though he had recently retired from full-time practice. I called him at home that evening. To my relief he agreed to take the case. His first piece of advice was to keep quiet and leave the speaking to him.

The following day, coverage of the funeral was splashed across the front page of the Sunday Standard under the headline, “Wrong medicine killed Chesoni – family doctor”.

Matseshe was quoted as saying that Zach “…would be alive today if the disease that killed him last week had been diagnosed on time.”

The Standard went on to reveal the Chesoni family had decided against an autopsy because Matseshe “…was by the bedside, and the family knew what the top judge had died from.”

At the request of the Nairobi Hospital Medical Advisory Committee, Dr Samuel Gathua, a consultant chest physician, drew up a detailed review of the Chesoni file with findings that absolved me of professional misconduct.

In my heart of hearts I thought this would be the end of the matter, but I was wrong.

The next morning, the Nairobi Hospital’s Standards Audit and Ethics Committee issued a statement pointing out that Chesoni had received the correct diagnosis and treatment and regretted the family had declined a post mortem.

The relentless Matseshe called his own press conference and stoked the fires of doubt by refuting the hospital’s statement.

Coincidence

The following week, the board ordered a preliminary-inquiry committee to review the matter and prepare a report. That pleased me.

It would give me an opportunity to refute the allegations. By this time I was angry and ready to do battle.

I had rehearsed my presentation for the investigators and was buoyed up by the many letters of support I’d received from patients and friends.

George Anyona, a high-profile MP, raised a question in parliament about Zacchaeus Chesoni and Cecil Miller, a prior chief justice.

In a weird coincidence, Miller had died of meningitis under my care exactly ten years earlier to the day.

Anyona asked the government to institute judicial inquiries into the causes, circumstances and conditions of the deaths of the two late chief justices. Then came another shock.

The East African ran the frontpage headline, “Chesoni probe points finger at Silverstein”.

Meanwhile, the Medical Practitioners and Dentists Board was forming a tribunal to determine whether I had violated professional ethics in the treatment of the chief justice.

If the answer was yes, I risked losing my licence. The timing of the tribunal coincided with the introduction of new members to the board. Several had been appointed by the health minister. Others were elected in a secret ballot.

Campaigning for positions on the board was commonplace and considered appropriate. What was unusual and unwelcome on this occasion was the promise from a group of candidates that if elected, they would ensure that Dr Silverstein was found guilty and that an African doctor would be selected to care for President Moi.

I kept my thoughts to myself and took strength in the knowledge that among the people appointed to the new board by the minister were some very capable doctors with whom I enjoyed mutual respect. Foremost among them was Professor Julius Kyambi, the new chairman.

There was no question that, during this time, the clinic traffic slowed down.

Byron quipped, “When shit gets thrown at you, you get dirty.”

However, for the most part, my patients were very supportive. One patient whom I had pulled through a difficult and long ICU admission for meningitis made an appointment to see me to offer himself as a witness to vouch for my expertise in treating this condition. I was touched.

I wrote letters to leading infectious-disease authorities around the world, providing them with the case history without comment and soliciting their professional response. All replied that from their expert perspective the chief justice’s case was handled in an exemplary fashion.

I was impressed with the way Byron Georgiadis studiously absorbed the material I gave him, drawing on it to write detailed briefings in pencil. I explained to him that Zach Chesoni’s widening aortic aneurysm was much more likely to have killed him than his meningitis, which we’d cured before he died.

Without a post mortem, of course, there was no conclusive proof. We decided it was fruitless to pursue the issue before the tribunal.

Better to keep our arguments as simple and straightforward as possible.

I paid a call on President Moi to explain all that had happened and to reassure him I had done everything correctly and to the best of my ability. He supported me wholeheartedly, saying, he had great faith in me.

“You will remain my doctor,” he said and commended me for taking up the battle rather than asking for political protection.

“Black man in America”

D-Day arrived on February 18, 2000. The tribunal was being held in the University of Nairobi faculty of health sciences boardroom.

When I first came to Kenya, this drab space lit by overhead fluorescent lights was used by the faculty for tea and coffee breaks. Standing in the same room a quarter century later,I managed a little smile at the recollection.

Business that day was procedural. Testimony was scheduled to begin the following Monday.

The 16-member tribunal, led by Julius Kyambi, was at the front table. Their legal team, led by the distinguished Lee Muthoga and Martha Koome, was seated at a separate table.

Muthoga was chair of the Law Society of Kenya. He later served as a judge at the International Criminal Tribunal for Rwanda.

Two decades into the future Koome became the first woman to serve as Kenya’s chief justice. I sat with Byron Georgiadis and his assistant, Fiona Elms, at a third table.

The Chesoni family, including Zach’s widow, sat behind us. Mary, like Zach, had been my patient for many years.

Their attorney was Steven Adere. He had a remarkably loud voice. He must have been nervous going up against a legal legend such as Byron, who had once been his mentor.

My chair was uncomfortable. Everyone else’s appeared to be too. The atmosphere was tense. Byron was the first to speak. In a long preamble, he lectured the room on how such a medical tribunal should be conducted, rather cheekily appropriating the board’s authority to himself.

Byron’s presumption might have rankled some of the tribunal members, but I think he succeeded in setting the tone for the inquiry. And that was his objective. The tribunal began taking evidence at 9 am on Monday morning by which time I had finished my hospital rounds.

First to testify was John Matseshe. Muthoga led him through a series of questions related to Zach’s care and asked for an explanation of the so-called “red flags” that he claimed to have discovered on arrival at his cousin’s bedside.

The witness performed reasonably well until Byron crossexamined him. On the first two allegations against me — that I had delayed a correct diagnosis and overseen incorrect treatment of the chief justice — Byron simply buried the doctor in data drawn from the articles and text books I had provided him.

By the end, he had demonstrated beyond any reasonable doubt that I had performed in accordance with the most up-to-date and highest standards of patient care.

It was a virtuoso performance in which Georgiadis delivered a global and detailed knowledge of the facts, presented in a compelling manner that had the effect of diminishing John Matseshe’s medical knowledge.

Then Byron went after Matseshe’s third allegation which was that I had abandoned my patient without proper medical supervision. Here Matseshe seemed to lose control of himself. His lips were quivering. Sensing the moment, Byron pounced.

“You have a chip on your shoulder, don’t you?” he asked.

“Yes! I have a chip on my shoulder. If you trained as a Black man in America as I did, you would also have a chip on your shoulder.”

Byron immediately fell quiet allowing Matseshe’s words to hang in the air so the panel members could consider without distraction what they had just heard from my prime accuser.

He was holding up a mirror to my detractors, showing them what it looked like to demonise someone for the colour of his or her skin, or the kind of passport they held. It was an old evil with which they were all acquainted.

After Byron had roundly refuted the alleged facts of his accusations, all that was left was anger and Matseshe’s determination to punish me for all that he had endured. His allies on the tribunal, if they were listening, would have to consult their own motives in calling for my head.

The next day it was my turn to be grilled. Byron carefully turned down the heat with a calm and businesslike review of my training and experience. Together we reviewed the history of the Chesoni case. I explained that, when the chief justice had come to me with gout, I had persuaded him to allow me to admit him to the hospital because I was concerned by his very low blood pressure.

I had kept him beyond his expected discharge date because the low blood pressure persisted. The meningitis had been a secondary development. Its diagnosis had been delayed because he never developed the triad of meningitis symptoms — high fevers, mental confusion and a stiff neck — until very late in the course of his illness.

I backed this up with literature as well as with the correspondence I had conducted with authorities in the field.

As I looked around the room, I sensed a lot of people had become noticeably friendlier toward me as they listened to the science and the explanation of how I made my decisions.

Verdict

Doctors Jimmy Mbogori, Luke Musau and Mark Joshi, the colleagues taking care of the chief justice in my absence, were also questioned.

They gave cogent responses consistent in every detail with my testimony. Seven people in all gave testimony.

Zach’s daughter Atsango Chesoni was one of them. She had nothing substantive to say about the medical science at issue but took the opportunity to speak from her heart.

Her sorrow was real, and I was disturbed to have it exacerbated by Matseshe’s accusations. The tribunal concluded Friday morning, and I returned to the hospital.

After evening rounds I left for the synagogue as was my usual Friday practice. On the way, my car phone rang. It was Daniel Yumbya, the tribunal’s secretary.

He told me a verdict had been reached and I was to come immediately for it to be announced. He must have heard the anxiety in my voice for he added, “Just relax.” I reached the health sciences board room around 6.45 that evening.

This was not a court of law so Byron’s presence was not required. The Chesoni family had asked to be notified as well when a decision was made so they could attend.

But after several unsuccessful attempts to reach them, at 9pm Julius Kyambi finally stood to read the verdict. I was innocent of all three charges. I had been vindicated as I predicted, although by a paper-thin margin of nine to seven as I later heard from Julius.

The Ministry of Health constitution required a two-thirds majority to find me guilty. That night I slept well for the first time in months.

There was a strange twist to the affair that didn’t come to light until nearly two decades later. On a trip to Israel with the now retired President Moi in March 2018, I met Zach Chesoni’s son, Jon, who was the Kenyan ambassador there.

Sitting together in an airport VIP lounge at the beginning of the visit, he reminded me of that troubling time. He said that the family had struggled to come to terms with his father’s death. They were in enormous turmoil.

Subsequently, as a young diplomat in Uganda, he had listened to the entire tribunal proceedings and realised the allegations against me were not right.

I had taken excellent care of his father, he said.

He thanked me for keeping Zach alive for as long as I had and for helping to get him admitted to the Mayo Clinic in 1978.

If his father had been heading the tribunal, Jon confided, his sharp judicial mind would have seen through the allegations immediately and dismissed the case out of hand. He would have been unhappy to see the misery I was put through, he added.

Some years later, I was awarded the Order of the Burning Spear, Kenya’s highest civilian award.

Had Zach lived, I believe he would have congratulated me and told me: “Justice has prevailed”.

I miss him to this day.

- Tomorrow in the Daily Nation: President Daniel Moi’s illnesses over the years, handling rumours over his health and dramatic moments during foreign trips