My Luo name is Akinyi. It means baby girl born in the morning.
Our days under the tent are numbered. The cloth tape that has secured the plastic diaphragm to my stethoscope is becoming frayed at the edges.
I lost the rubber ring that seals it together in India four weeks ago.
Dave convinced me to spend another morning rounding on patients. I am not quite sure how he managed to do so- seventeen months and counting on the wards seems more than enough.
Nonetheless, we rounded with 2 other doctors this time, making the experience much more rewarding. But the cases we saw were not any less tragic.
As we walked from bed to bed, thumbing through the paper charts that vaguely resembled the blue exam books we used in college, a woman in the corner began make grunting noises and banging her right arm against the mattress repetitively. She was clearly having a seizure. The doctors we were with didn’t bat an eye.
Her forlorn husband used her paper chart to fan her and swat the flies away from her face.
She was still seizing by the time we got to her bed. I asked about rectal diazepam or any IV benzodiazepine to use as needed.
They didn’t have any in stock. She was receiving IV phenobarb daily.
“She now has stage 3 bedsores. I am afraid that is what will eventually put her down.”
She at various points in the last 2 weeks had been treated for crypto and toxo and now they were considering giving her anti-TB treatment and steroids. And in the end what may kill her is becoming septic from her bedsores.
One of the medical officers suggested “home care,” or hospice. In the end they knew that the husband would not agree.
Some things are not any different at all.
We spent a total of 4 hours seeing 30-40 female patients on 20 beds, often in pairs as many women shared the twin size mattresses. I learned that when antimalarials failed to break a fever or if the smear was negative, the next course of action was to check titers for Brucella, in addition to Typhoid, though the titers for the latter are often not very specific. Blood cultures are the gold standard to diagnose both, but those are not readily available of course.
Pneumonias are treated with “x-pen and gent” or crystalline penicillin and gentamicin. Diarrheal illnesses are treated with chloramphenicol and metronidazole. With the exception of metronidazole and penicillin, none of these drugs are ones we use in the states given their side effects and sometimes irreversible toxicities.
The patients with psychiatric illnesses are not separated from those with medical illnesses. Schizophrenia is not uncommon.
One young 14 year-old girl was admitted for chronic abdominal pain that she seemed to develop right around exam time; Julie, one of the doctors, kindly asked her questions about abuse at home and at school, both of which she denied. In the end they decided she was clinically depressed.
One of the last patients we saw suffered from TB lymphadenitis and chronic anemia, with a hemoglobin of 7.5. (Normal values are above 12.) She was also diagnosed with “somatoform disorder” because she had a habit of “complaining about everything” and asking for blood transfusions daily.
If only those doctors knew how good they had it.
At the end of rounds we quickly wrote up several discharge summaries and then proceeded to draw blood from several patients; the nurses and lab technicians were having some dispute over lab draws so the medical officers had to take it into their own hands.
The women in my life have a habit of burying the name of a God or a Saint in their sigh. It sounds like an exasperated plea, but in reality it is just an acknowledgement of The Way Things Are. An acceptance of sorts.
And so I find myself frequently sighing “Ai, Ramarama,” just as I have heard my mother do so nearly every day for the last 30 years.
*
Acres of sugarcane surround our home in Rongo. The house itself clearly was once beautiful, but years of neglect have worn it down. Brown water stains grow ominously on our plastered walls, windows with a few panels of cracked glass are constantly left ajar letting a number of winged creatures gravitate towards the lights in our living room, in spite of our vain attempts at shutting them closed with waxy dental floss. On our front lawn sheep and chickens and sometimes cows lazily graze and peck on wet grass and rarely seek shelter, even when sheets of rain pour heavily down.
There are a few empty plastic bottles and aluminum chip bags scattered around, sullying the otherwise breathtaking pastures.
We lose power almost nightly. Sometimes the blackouts last the entire night, well into the next morning and so we walk around our house with our headlamps until it is time to crawl under our mosquito nets. On several occasions we were told that the blackouts were not limited to our district- it seemed that the whole country had been affected, as there are a handful of power supplies that provide electricity for the entire nation.
Only once have we run out of running water, when the tank across the lawn was likely empty. So we washed our hands in the rain.
We read voraciously and browse the internet longingly. The last few nights we decided to complete a few of the Chronicle’s online crosswords. It is the only game that Dave and I have ever played where we were not competing….probably because neither one of us is very good at them. It is a good thing that the New York Times crosswords cost money, sparing us some embarrassment over our general ineptitude.
Time has passed by.
To think that we had arrived here less than four weeks ago. It was dark, we had spent hours on many a backroad from Kisumu to Rongo, a vain attempt to shorten the drive.
We had no idea where we were.
I feel so sad to leave. It is a chronic problem with me.
*
We spent the last weekend in Kisumu. I woke up at 4am on Sunday morning because my allergies there were terrible. I was hoping the Benadryl would kick in soon, but in the meanwhile, I checked out the Big Game scoreboard online. Dave woke up not long after to watch the last ten minutes.
Outside, the roosters crowed heralding dawn and the guard dogs howled in response, signaling the end of the night and their shift.
The morning’s cantata opened with the pure singular intonation of the local imam, calling all to prayer.
I soon heard several cars honking on the otherwise quiet streets of Milimani. I walked out onto the balcony of the flat and saw several fancy cars filled with Aunties and Uncles, one of which was decorated in marigolds and chrysanthamums. It was not the kind of Indian wedding party I was accustomed to. I tried hard to spot the bride and groom, but the cars were packed full, matatu style.
Later in the day, we had lunch at a local ex-pat hangout where we noticed several Indian men walk in, their foreheads anointed with fresh red kumkum. They had clearly just come from temple. They sat down, lit cigarettes and ordered cold Tusker, a Kenyan lager, on this day of rest.
Dave and I ourselves toasted our Cal victory with a Tusker malt and a Savannah cider from Stellenbosch, South Africa. (The socially responsible South Africans made it a point of labeling the cider with a warning: “Alcoholism is dangerous to your health.”)
Go Bears.
*
And now time to wax poetically, as if I haven’t done so enough. We leave Nairobi on Thanksgiving.
There are a few things in my life that cause me enormous happiness and gratitude.
Running by large bodies of water. There is nothing like feeling the soft land fall swiftly beneath your feet as you breeze past the Bay or the Hudson, and the promise of the Bridge looming large ahead of you…and then safely behind you. It is the only run I allow that is not a loop. There and back.
Driving across the Bridge. Take your pick- The Bay, Golden Gate, Tappan Zee, GW. I really don’t know what it is. Part of it may be the sheer expanse, the feeling of being suspended over water, the gentle bob of the cables and the constant movement.
But the other part of it may be the excitement of experiencing something new.
And the promise of returning home.
Asante sana and Erok Amano to all of you in my life. You continue to inspire me every day and I am grateful.
Wednesday, November 25, 2009
Sunday, November 22, 2009
"Sometimes Sandwiches Are Nice."
“But I like mayo,” the girl with the dreads and Peace Corps t-shirt lamented. They too were making sandwiches for dinner that night.
We were shopping for groceries in Nakumatt Mega City, a supermarket in Kisumu of industrial proportions where you can find pretty much everything from washing machines to peanut butter….but apparently not mayonnaise.
We had found our kinsmen.
Dave and I had just commented that we could count the number of Americans we had seen since arriving in Kenya on one hand. It was perhaps too generous of a pat on the back for traveling so far off the grid.
We had a hankering for sliced cheese. It had been a while.
And so we are coming to the end of our trip here. Our days of cooking channa and dal are numbered and we are trying to minimize the number of food items we buy, opting instead for quick fix “white bread” solutions. Though we have enjoyed our time here, we continue to yearn for home. I attribute part of this ailment to mefloquine, which wakes me up early in the morning after experiencing absurd dreams about parents of friends turning into zombies and loved ones dying strange deaths….not to mention the dreams of poisonous snakes crawling on our bed.
So the thought of a sandwich seemed comforting.
My mother, who has been known to put tabasco sauce in her ramen noodles “because otherwise it has no taste,” has also stated, on more than one occasion, that “sometimes, sandwiches are nice.”
Agreed. Sometimes sandwiches ARE nice.
*
These days I am desperately trying to hang on to and learn as much as possible….and trying in some way to give something back. I visited Dave’s clinic site last week and spent a morning rounding on patients in the ward with him. We saw several obtunded patients, all of whom had HIV. My general impression was that they either were in status epilepticus (ie a seizure that would not break), but of course we had no EEG to confirm, or they had severe cerebral edema from their toxo/tuberculoma/lymphoma or whatever space-occupying mass we could not diagnose because we couldn’t obtain toxo serologies for what they were worth, nor did we have a CT scanner or a neurosurgeon. Though these patients were unresponsive, they did have some focal neurologic signs- a unilateral positive Babinskis, unilateral clonus. I could have used a refresher on my neurology skills.
I could have used a great many things that day.
It was unclear to me who was actually rounding on these patients, but I soon found myself writing orders alone. Dave and I split up the ward.
There are days when there aren’t any doctors rounding on these patients. The nurses, who clearly are quite adept, handle everything on their own.
Not all of the patients were so sick. Some just had good old pelvic inflammatory disease/endometritis from their “septic criminal abortions.”
Fantastic.
It was by far one of the most depressing days I had had since arriving in Kenya.
On a brighter note, the lady who was failing her ARVs who I thought might have had a DVT came back feeling remarkably better. Her leg looked far less swollen and was not nearly as painful. I hardly think it was the Aspirin I had prescribed her...in retrospect, I wondered if she just had a plain old ruptured Baker’s cyst.
Tincture of time….what better place to test the efficacy of this panacea.
Her viral load was not back yet. I so desperately wanted to change her regimen, but yet again had my hands tied.
The rest of my time has been spent doing chart reviews and auditing and giving a few “CMEs” (continuing medical education lectures) here and there. (My audience is everyone from the other medical officer to the “office messanger/cleaner.”)
I have created a database of 4 “conditions” and looking at chart documentation and treatment plans for each. The most impressive of these is probably the diagnosis of upper respiratory tract infections, “URTIs,” for which many clinical officers indiscriminately prescribe antibiotics. So I am hoping to help them determine which patients merit antibiotics, which could probably use watchful waiting and which could use “further evaluation”- namely either a chest xray or sending sputa for AFB to rule out TB. It is hard in this land of tuberculosis, where every other person has a “cough”…or even back pain for that matter.
It is a bit hard for me to do this review, as my time here is so short. Moreover, the clinical officers here are amazing, but they are often limited by time. They each see as many as 30-40 patients a day in Rongo, largely because effective decentralization has not taken place yet. The process of “decentralizing” basically means rolling out ARVs to peripheral (more remote) sites and mentoring other clinicians in HIV management so that patients don’t have to travel so far. This also means that as more peripheral sites start running, fewer patients will be coming to the Rongo clinic, relieving some of the burden for the clinical officers and perhaps ensuring better care for those patients who do remain at the site. In the month that I have been here, Rongo has managed to open up three other sites.
The other part of the Rapid Results Initiative (RRI) is also to try to get as many HIV negative young men circumcised as possible. Most days the clinical officers who perform these surgeries stay as late as 9pm.
Primary education became compulsory in Kenya in 2002. Because it takes 6 years to create 1 doctor, and because there are about 300 medical students per class in the only 2 medical schools in the country, the government established this baccalaureate degree to create what we would probably call “mid-level providers” as an attempt to rapidly scale up health care delivery in areas where there are no doctors. The clinical officers don’t have as much basic science training and do not read “the literature” as much as we do. And to some extent they are less comfortable with uncertainty than we are, and less likely to stray far from their protocols. But they truly are masterful clinicians, far better than I in many ways.
The work is truly remarkable. I feel so fortunate to have witnessed and been part of a model of international health care delivery that is clearly doing so much good in the community it serves. They have taken the global health catch phrases “scale up” and “rolling out” to an entirely new level for me.
Everyone here works so hard.
It is inspiring. But I continue to be conflicted.
We were shopping for groceries in Nakumatt Mega City, a supermarket in Kisumu of industrial proportions where you can find pretty much everything from washing machines to peanut butter….but apparently not mayonnaise.
We had found our kinsmen.
Dave and I had just commented that we could count the number of Americans we had seen since arriving in Kenya on one hand. It was perhaps too generous of a pat on the back for traveling so far off the grid.
We had a hankering for sliced cheese. It had been a while.
And so we are coming to the end of our trip here. Our days of cooking channa and dal are numbered and we are trying to minimize the number of food items we buy, opting instead for quick fix “white bread” solutions. Though we have enjoyed our time here, we continue to yearn for home. I attribute part of this ailment to mefloquine, which wakes me up early in the morning after experiencing absurd dreams about parents of friends turning into zombies and loved ones dying strange deaths….not to mention the dreams of poisonous snakes crawling on our bed.
So the thought of a sandwich seemed comforting.
My mother, who has been known to put tabasco sauce in her ramen noodles “because otherwise it has no taste,” has also stated, on more than one occasion, that “sometimes, sandwiches are nice.”
Agreed. Sometimes sandwiches ARE nice.
*
These days I am desperately trying to hang on to and learn as much as possible….and trying in some way to give something back. I visited Dave’s clinic site last week and spent a morning rounding on patients in the ward with him. We saw several obtunded patients, all of whom had HIV. My general impression was that they either were in status epilepticus (ie a seizure that would not break), but of course we had no EEG to confirm, or they had severe cerebral edema from their toxo/tuberculoma/lymphoma or whatever space-occupying mass we could not diagnose because we couldn’t obtain toxo serologies for what they were worth, nor did we have a CT scanner or a neurosurgeon. Though these patients were unresponsive, they did have some focal neurologic signs- a unilateral positive Babinskis, unilateral clonus. I could have used a refresher on my neurology skills.
I could have used a great many things that day.
It was unclear to me who was actually rounding on these patients, but I soon found myself writing orders alone. Dave and I split up the ward.
There are days when there aren’t any doctors rounding on these patients. The nurses, who clearly are quite adept, handle everything on their own.
Not all of the patients were so sick. Some just had good old pelvic inflammatory disease/endometritis from their “septic criminal abortions.”
Fantastic.
It was by far one of the most depressing days I had had since arriving in Kenya.
On a brighter note, the lady who was failing her ARVs who I thought might have had a DVT came back feeling remarkably better. Her leg looked far less swollen and was not nearly as painful. I hardly think it was the Aspirin I had prescribed her...in retrospect, I wondered if she just had a plain old ruptured Baker’s cyst.
Tincture of time….what better place to test the efficacy of this panacea.
Her viral load was not back yet. I so desperately wanted to change her regimen, but yet again had my hands tied.
The rest of my time has been spent doing chart reviews and auditing and giving a few “CMEs” (continuing medical education lectures) here and there. (My audience is everyone from the other medical officer to the “office messanger/cleaner.”)
I have created a database of 4 “conditions” and looking at chart documentation and treatment plans for each. The most impressive of these is probably the diagnosis of upper respiratory tract infections, “URTIs,” for which many clinical officers indiscriminately prescribe antibiotics. So I am hoping to help them determine which patients merit antibiotics, which could probably use watchful waiting and which could use “further evaluation”- namely either a chest xray or sending sputa for AFB to rule out TB. It is hard in this land of tuberculosis, where every other person has a “cough”…or even back pain for that matter.
It is a bit hard for me to do this review, as my time here is so short. Moreover, the clinical officers here are amazing, but they are often limited by time. They each see as many as 30-40 patients a day in Rongo, largely because effective decentralization has not taken place yet. The process of “decentralizing” basically means rolling out ARVs to peripheral (more remote) sites and mentoring other clinicians in HIV management so that patients don’t have to travel so far. This also means that as more peripheral sites start running, fewer patients will be coming to the Rongo clinic, relieving some of the burden for the clinical officers and perhaps ensuring better care for those patients who do remain at the site. In the month that I have been here, Rongo has managed to open up three other sites.
The other part of the Rapid Results Initiative (RRI) is also to try to get as many HIV negative young men circumcised as possible. Most days the clinical officers who perform these surgeries stay as late as 9pm.
Primary education became compulsory in Kenya in 2002. Because it takes 6 years to create 1 doctor, and because there are about 300 medical students per class in the only 2 medical schools in the country, the government established this baccalaureate degree to create what we would probably call “mid-level providers” as an attempt to rapidly scale up health care delivery in areas where there are no doctors. The clinical officers don’t have as much basic science training and do not read “the literature” as much as we do. And to some extent they are less comfortable with uncertainty than we are, and less likely to stray far from their protocols. But they truly are masterful clinicians, far better than I in many ways.
The work is truly remarkable. I feel so fortunate to have witnessed and been part of a model of international health care delivery that is clearly doing so much good in the community it serves. They have taken the global health catch phrases “scale up” and “rolling out” to an entirely new level for me.
Everyone here works so hard.
It is inspiring. But I continue to be conflicted.
Just Call It Dave
Dave speaks again:
Only four days until we head back to the states. The time has sped by and it has been too short a trip. On the other hand, there have been many moments in which I have been very aware of not being in the US, moments when I have missed home terribly. I’ve missed family and friends, and good coffee, and so many of the things we take for granted at home.
Lest I forget, a few things should be noted:
Matatu’s- basically small Toyota minivans, which are one of the main modes of transport here. There is always room for one more on the Matatu. Unless there are two people hanging outside the open sliding door, it is not full. I’ve been taking one to Migori from our flat outside Rongo, everyday for work. It can take 30 minutes or over an hour. In the bay area, traffic is the main frustration for a commuter, but here, you can be held up by a truck hauling sugar cane, by a stop for the conductor to bribe a policeman, by cows or sheep on the road. Sometimes for no apparent reason, the matatu stops, everyone gets out, and then you all board another matatu and continue on as if nothing out of the ordinary had happened.
We bought vegetables for dinner a few days ago at a little stand near our house. The grand total for a huge bag of kale (~ 1 to 2lbs) and four tomatoes? 30 shillings, or about 22 cents.
Nobody really eats lunch. They have 1 or two chappatis with or without a boiled egg, as well as tea. With the exception of soda, there are few processed foods here. People eat a fair amount of vegetables as well as ugali of course.
There is definitely a middle class here and the vast majority of people that you see on the street appear healthy and well fed. There is paradoxically more and less poverty here than you expect.
The government hospital in which I’ve been working, is underfunded and there are some days when no clinician does rounds on the inpatient ward. Even when we, or others, are there to see the patients, there are overwhelming frustrations. We can’t get CTs or MRIs. The imaging is limited to plain films, essentially. Even basic labs, though dutifully ordered, are often not done. You end up making your best assessment based on history and your exam and treating empirically. (There is currently a disagreement between the nursing staff and the lab over who is responsible for drawing blood, so most often, it is not drawn at all.) When it’s necessary, the doctors or clinical officers draw the blood themselves.
Kenyans are very religious. The country is majority Christian. It seems that many folks here assume that everyone else, including visitors, are believers as well. I haven’t been subject to active proselytizing, but during our weekly Friday morning meetings, things are begun and ended with a prayer. Last week, the gentleman giving the thought of the day spent about ten minutes explaining how to get into heaven. He emphasized leading a good honest life, and at this point we were in full agreement, but then he transitioned to a finale about belief in Jesus as the lord and savior, and his conviction that the only way into heaven was through Jesus. This is at a morning meeting for a secular, university affiliated, non-profit. I asked one of my colleagues later that day, “Are there any Muslims in the staff?” I don’t know any among the staff I’ve met, and if there are, perhaps they don’t mind the lecturing. In the end, though, this is not my country, and “when in Rome”, or something like that.
Yesterday we went to the impala sanctuary. I was skeptical, “why would I go to what is essentially a zoo, when a few weeks ago I saw animals in their natural habitat?” However, it was actually fascinating. We saw a hyena, which was enormous, much bigger than I expected, and very funny looking. We also saw baboons, monkeys, jackals, and a leopard. There was also an ostrich, and I know we’ve all seen pictures, and I’m sure most of you have seen one in a zoo, but I have to say, it remains one of the most bizarre animals I’ve ever seen. I couldn’t get over it. The neck is long, and flexible, and you can see the esophagus just under the surface of the skin, accentuated when it swallows and food travels downward. The neck moves in a more serpentine than avian manner.
The End
Only four days until we head back to the states. The time has sped by and it has been too short a trip. On the other hand, there have been many moments in which I have been very aware of not being in the US, moments when I have missed home terribly. I’ve missed family and friends, and good coffee, and so many of the things we take for granted at home.
Lest I forget, a few things should be noted:
Matatu’s- basically small Toyota minivans, which are one of the main modes of transport here. There is always room for one more on the Matatu. Unless there are two people hanging outside the open sliding door, it is not full. I’ve been taking one to Migori from our flat outside Rongo, everyday for work. It can take 30 minutes or over an hour. In the bay area, traffic is the main frustration for a commuter, but here, you can be held up by a truck hauling sugar cane, by a stop for the conductor to bribe a policeman, by cows or sheep on the road. Sometimes for no apparent reason, the matatu stops, everyone gets out, and then you all board another matatu and continue on as if nothing out of the ordinary had happened.
We bought vegetables for dinner a few days ago at a little stand near our house. The grand total for a huge bag of kale (~ 1 to 2lbs) and four tomatoes? 30 shillings, or about 22 cents.
Nobody really eats lunch. They have 1 or two chappatis with or without a boiled egg, as well as tea. With the exception of soda, there are few processed foods here. People eat a fair amount of vegetables as well as ugali of course.
There is definitely a middle class here and the vast majority of people that you see on the street appear healthy and well fed. There is paradoxically more and less poverty here than you expect.
The government hospital in which I’ve been working, is underfunded and there are some days when no clinician does rounds on the inpatient ward. Even when we, or others, are there to see the patients, there are overwhelming frustrations. We can’t get CTs or MRIs. The imaging is limited to plain films, essentially. Even basic labs, though dutifully ordered, are often not done. You end up making your best assessment based on history and your exam and treating empirically. (There is currently a disagreement between the nursing staff and the lab over who is responsible for drawing blood, so most often, it is not drawn at all.) When it’s necessary, the doctors or clinical officers draw the blood themselves.
Kenyans are very religious. The country is majority Christian. It seems that many folks here assume that everyone else, including visitors, are believers as well. I haven’t been subject to active proselytizing, but during our weekly Friday morning meetings, things are begun and ended with a prayer. Last week, the gentleman giving the thought of the day spent about ten minutes explaining how to get into heaven. He emphasized leading a good honest life, and at this point we were in full agreement, but then he transitioned to a finale about belief in Jesus as the lord and savior, and his conviction that the only way into heaven was through Jesus. This is at a morning meeting for a secular, university affiliated, non-profit. I asked one of my colleagues later that day, “Are there any Muslims in the staff?” I don’t know any among the staff I’ve met, and if there are, perhaps they don’t mind the lecturing. In the end, though, this is not my country, and “when in Rome”, or something like that.
Yesterday we went to the impala sanctuary. I was skeptical, “why would I go to what is essentially a zoo, when a few weeks ago I saw animals in their natural habitat?” However, it was actually fascinating. We saw a hyena, which was enormous, much bigger than I expected, and very funny looking. We also saw baboons, monkeys, jackals, and a leopard. There was also an ostrich, and I know we’ve all seen pictures, and I’m sure most of you have seen one in a zoo, but I have to say, it remains one of the most bizarre animals I’ve ever seen. I couldn’t get over it. The neck is long, and flexible, and you can see the esophagus just under the surface of the skin, accentuated when it swallows and food travels downward. The neck moves in a more serpentine than avian manner.
The End
Tuesday, November 17, 2009
Saying Grace.
I married a Jewish carpenter.
The Prodigal Son?
“We are very blessed that it is the first time a white man has stepped into this church.”
I felt my face grow warm and my eyes become moist. I glanced over at Dave who clearly looked uncomfortable.
It was so hard for me not to feel angry. It was so hard for me not to wonder what was wrong with these people.
Leave it to my husband, who relentlessly tirades against the fallacy of religion to befriend a pastor on a matatu and not only get invited to attend his church, but also serve as the guest of honor.
The white doctor and his wife.
After several gentle reminders from the good doctor, they eventually recognized me as not only his wife, but also his colleague. I am not foreign to such assumptions, which occur as often in Berkeley as they do here. So the fact that it was hard for them to comprehend that I too was a doctor did not bother me nearly as much as the race issue.
They made a special lunch for us. They killed a chicken that morning, bought sodas and cooked rice and chapattis instead of the traditional ugali in anticipation of our arrival. Though we were scheduled to have lunch with the coordinator of the Rongo clinic later that afternoon, we accepted graciously.
“Our god saved the people of Israel. Our guest is from Israel and the United States. He is the Juice (Jews).”
The church itself was an unadorned hut that had about 10 rows of wooden planks that served as pews. I didn’t see a cross anywhere. The service itself was beautiful; the hymns and chorales were uniquely African, with drums made of sheepskin and rhythmic clapping and ululations abound. The children sang a song about AIDS, after Dave and I said a few words “of inspiration” on the subject.
The Pastor had confided in us earlier that he actually wanted to study medicine, but had only received a C+ in high school biology, and though his second choice was to pursue teaching, the church that had raised him after his parents died in an accident would only support him if he went to theology school. And thus he became ordained.
He was anything but insincere.
If he and his “evangelical” weren’t so obviously kind and clearly filled with love and goodness, I would have continued clenching my teeth and seething silently. But there is something to be said about men and women of God. When they are true, they do exude a certain sanctity of being, a certain pureness of heart. It is hard to be angry with someone who is, to put it simply, so honest. So sincere.
I have just finished reading American Pastoral and Dave is more than half way through. Philip Roth is merciless in his caricature of a Jewish Johnny Appleseed and the myth of the American frontiersman.
Maybe we all look for coherency in chaos….a coherency that is sometimes manifest as Johnny Appleseed. Or The Bearded White Man with Hazel Eyes. Or the Blue-skinned God with a Peacock Feather in His Hair.
Post-colonial Africa. Chaos and Coherency.
But in the end, to shamelessly quote Larry David:
“Whatever Works.”
**************************************************************
We spent the weekend around Rongo, visiting the homes different staff members of the clinic. The homes we visited were simple and clean, the meals we ate were warm and filling, the babies we played with were fat and friendly.
We always said a prayer just before a meal.
Everyone has something to say about the politics and about the post-election violence. It is still very vivid in everyone’s memory.
“It was very scary. Very scary! We had to ration our food, we could only eat two meals a day for a while.”
“I cannot stand these politicians. Do you know how much they make? Our president makes over 2.5 million Kenyan Shillings!”
That translates into about $375,000. About 1.5x what President Obama makes. The average clinical officer makes about 30,000 Ksh a month- less than $1000. Imagine feeding a family of 3 with that kind of money, let alone a family of 5.
And that is if you have a college education.
“When my brother’s kid developed hydrocephalus, I sent them to Nairobi to get evaluated. The child eventually got a shunt, but it cost 29,000 Ksh! They couldn’t afford it so the hospital refused the release them unless we paid. It cost me nearly a month’s salary, but we did it, but the grace of God, and now the child is healthy!”
By the end of the weekend, our bellies were tight and our hearts were full. But it is still tough to feel like we are part of the community. And it is hard not to feel homesick.
There are a number of ex-pats who live in this part of Kenya. It is how I had previously envisioned doing international work- living in the country where I would set things up for at least a couple of years, and bringing my family with me.
I honestly am not sure if I am really cut out for that kind of work. But I can’t imagine any other way.
We watched a documentary on these two incredible guys from Lwala, a small district in Nyanza, who managed to go to college and med school in the States and have subsequently set up this clinic in their village. Their parents died from HIV. The narrator wondered aloud if these guys would move back there permanently or if they would continue their charitable work from abroad.
It is hard to go back.
“It is hard to leave.”
*********************************
“I think this was a bad batch of lidocaine,” the clinical officer said to Dave. They were on their third circumcision of the day and noticed the men wincing and covering their eyes more than usual.
After work we went for our first run in over two weeks. About 2 minutes along the winding dirt path, we heard the first high-pitched “Mzungu! How are you!?” We soon were being chased by several children, some barefoot, others with flipflops, all under the age of 10.
Dave rolled with it gracefully. Every so often he would turn around and growl at them and they would scream and giggle in delight.
I laughed wheezily. I am still not completely over this bug.
We have been cooking every night. Dave is becoming an expert on dal with kale.
I have found refuge at Mama Pauline’s, about 500 yards from our home. I buy Cadbury’s chocolate from her every couple of days. It gives me great comfort to have a place from where I can obtain my daily sweet tooth fix. She is round and kind.
Whatever Works.
*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~
Dave's Story
“Hi, I’m Johnson.” Thus began our intro to Kenya, off the beaten track. I accepted his offer to attend their church service this Sunday. I was a little nervous since he was just some random guy I met on the matatu (bus), but he gave off a good vibe.
Tara and I took the matatu to Uriri and then phoned Johnson by cell. After we met him we got on motorcycle taxis and started off. It was at least 15-20 minutes down a winding dirt path. We were in the boonies.
Of course they had to serve us tea before the service (along with white bread margarine sandwiches, which were better than they sound). Although, I introduced her as Dr. Tara (since they insisted on calling me Dr. Dave) she was initially, the Dr’s wife, then Tora, then Dr. Tora (which in my head, given the circumstances, became Dr. Torah).
The service was in Luo ( a local language) and parts were in English. There was always translation into the other language.
The heart of the message, seemed to be, put your trust in G-d, and if you put your trust in him you will have health, prosperity, and general success in life. Pastor Johnson, who is extremely mild and soft spoken, was transformed, during his service, into a shouting, gesticulating, pentacostal-ish madman. The minute the sermon was over, though, he was back to meek, unassuming, pastor Johnson.
The singing was beautiful, though, I couldn’t help thinking of Paul Simon’s Graceland. The harmony was breathtaking. Tara and I gave a “sermon”, wherein we discussed transmission and prevention of HIV, as well as the fact that with treatment, people can expect to live long lives.
Although they told us that our speaking was very important, the Pastor, and the evangelist, both hammered home the HIV/AIDS message and, in the end, were probably much more convincing than we were.
At the meal afterwards we were served, Chapattis (a staple here; Tara has been asked a few times, “Have you had Chapattis before”), rice, and a stew with the chicken that had been slaughtered on account of our visit. I could hear its brothers and sisters happily clucking and crowing in the yard outside. I was referred to, a number of times, as, “the first white man” to visit the church, which was altogether awkward no matter how you interpret the statement.
Other choice moments were when Tara was offered chicken, though she and I had earlier explained that she doesn’t eat meat. Earlier, that news had elicited a small amount of shock among the assembled parishoners. A second explanation of vegetarianism seemed to produce exactly the same amount of shock as the first. They also asked, “They say that when all the Jews (which they sometimes pronounced “juices”) return to Israel, that that will bring the second coming.” “Are you going to go back to Israel?” “Well, I went, and it’s very beautiful, but I didn’t stay.”
They were very hospitable, and kind. And hopefully the parishoners benefited in some way from our “sermon” and hopefully they learned and experienced as much from us as we from them.
The Prodigal Son?
“We are very blessed that it is the first time a white man has stepped into this church.”
I felt my face grow warm and my eyes become moist. I glanced over at Dave who clearly looked uncomfortable.
It was so hard for me not to feel angry. It was so hard for me not to wonder what was wrong with these people.
Leave it to my husband, who relentlessly tirades against the fallacy of religion to befriend a pastor on a matatu and not only get invited to attend his church, but also serve as the guest of honor.
The white doctor and his wife.
After several gentle reminders from the good doctor, they eventually recognized me as not only his wife, but also his colleague. I am not foreign to such assumptions, which occur as often in Berkeley as they do here. So the fact that it was hard for them to comprehend that I too was a doctor did not bother me nearly as much as the race issue.
They made a special lunch for us. They killed a chicken that morning, bought sodas and cooked rice and chapattis instead of the traditional ugali in anticipation of our arrival. Though we were scheduled to have lunch with the coordinator of the Rongo clinic later that afternoon, we accepted graciously.
“Our god saved the people of Israel. Our guest is from Israel and the United States. He is the Juice (Jews).”
The church itself was an unadorned hut that had about 10 rows of wooden planks that served as pews. I didn’t see a cross anywhere. The service itself was beautiful; the hymns and chorales were uniquely African, with drums made of sheepskin and rhythmic clapping and ululations abound. The children sang a song about AIDS, after Dave and I said a few words “of inspiration” on the subject.
The Pastor had confided in us earlier that he actually wanted to study medicine, but had only received a C+ in high school biology, and though his second choice was to pursue teaching, the church that had raised him after his parents died in an accident would only support him if he went to theology school. And thus he became ordained.
He was anything but insincere.
If he and his “evangelical” weren’t so obviously kind and clearly filled with love and goodness, I would have continued clenching my teeth and seething silently. But there is something to be said about men and women of God. When they are true, they do exude a certain sanctity of being, a certain pureness of heart. It is hard to be angry with someone who is, to put it simply, so honest. So sincere.
I have just finished reading American Pastoral and Dave is more than half way through. Philip Roth is merciless in his caricature of a Jewish Johnny Appleseed and the myth of the American frontiersman.
Maybe we all look for coherency in chaos….a coherency that is sometimes manifest as Johnny Appleseed. Or The Bearded White Man with Hazel Eyes. Or the Blue-skinned God with a Peacock Feather in His Hair.
Post-colonial Africa. Chaos and Coherency.
But in the end, to shamelessly quote Larry David:
“Whatever Works.”
**************************************************************
We spent the weekend around Rongo, visiting the homes different staff members of the clinic. The homes we visited were simple and clean, the meals we ate were warm and filling, the babies we played with were fat and friendly.
We always said a prayer just before a meal.
Everyone has something to say about the politics and about the post-election violence. It is still very vivid in everyone’s memory.
“It was very scary. Very scary! We had to ration our food, we could only eat two meals a day for a while.”
“I cannot stand these politicians. Do you know how much they make? Our president makes over 2.5 million Kenyan Shillings!”
That translates into about $375,000. About 1.5x what President Obama makes. The average clinical officer makes about 30,000 Ksh a month- less than $1000. Imagine feeding a family of 3 with that kind of money, let alone a family of 5.
And that is if you have a college education.
“When my brother’s kid developed hydrocephalus, I sent them to Nairobi to get evaluated. The child eventually got a shunt, but it cost 29,000 Ksh! They couldn’t afford it so the hospital refused the release them unless we paid. It cost me nearly a month’s salary, but we did it, but the grace of God, and now the child is healthy!”
By the end of the weekend, our bellies were tight and our hearts were full. But it is still tough to feel like we are part of the community. And it is hard not to feel homesick.
There are a number of ex-pats who live in this part of Kenya. It is how I had previously envisioned doing international work- living in the country where I would set things up for at least a couple of years, and bringing my family with me.
I honestly am not sure if I am really cut out for that kind of work. But I can’t imagine any other way.
We watched a documentary on these two incredible guys from Lwala, a small district in Nyanza, who managed to go to college and med school in the States and have subsequently set up this clinic in their village. Their parents died from HIV. The narrator wondered aloud if these guys would move back there permanently or if they would continue their charitable work from abroad.
It is hard to go back.
“It is hard to leave.”
*********************************
“I think this was a bad batch of lidocaine,” the clinical officer said to Dave. They were on their third circumcision of the day and noticed the men wincing and covering their eyes more than usual.
After work we went for our first run in over two weeks. About 2 minutes along the winding dirt path, we heard the first high-pitched “Mzungu! How are you!?” We soon were being chased by several children, some barefoot, others with flipflops, all under the age of 10.
Dave rolled with it gracefully. Every so often he would turn around and growl at them and they would scream and giggle in delight.
I laughed wheezily. I am still not completely over this bug.
We have been cooking every night. Dave is becoming an expert on dal with kale.
I have found refuge at Mama Pauline’s, about 500 yards from our home. I buy Cadbury’s chocolate from her every couple of days. It gives me great comfort to have a place from where I can obtain my daily sweet tooth fix. She is round and kind.
Whatever Works.
*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~
Dave's Story
“Hi, I’m Johnson.” Thus began our intro to Kenya, off the beaten track. I accepted his offer to attend their church service this Sunday. I was a little nervous since he was just some random guy I met on the matatu (bus), but he gave off a good vibe.
Tara and I took the matatu to Uriri and then phoned Johnson by cell. After we met him we got on motorcycle taxis and started off. It was at least 15-20 minutes down a winding dirt path. We were in the boonies.
Of course they had to serve us tea before the service (along with white bread margarine sandwiches, which were better than they sound). Although, I introduced her as Dr. Tara (since they insisted on calling me Dr. Dave) she was initially, the Dr’s wife, then Tora, then Dr. Tora (which in my head, given the circumstances, became Dr. Torah).
The service was in Luo ( a local language) and parts were in English. There was always translation into the other language.
The heart of the message, seemed to be, put your trust in G-d, and if you put your trust in him you will have health, prosperity, and general success in life. Pastor Johnson, who is extremely mild and soft spoken, was transformed, during his service, into a shouting, gesticulating, pentacostal-ish madman. The minute the sermon was over, though, he was back to meek, unassuming, pastor Johnson.
The singing was beautiful, though, I couldn’t help thinking of Paul Simon’s Graceland. The harmony was breathtaking. Tara and I gave a “sermon”, wherein we discussed transmission and prevention of HIV, as well as the fact that with treatment, people can expect to live long lives.
Although they told us that our speaking was very important, the Pastor, and the evangelist, both hammered home the HIV/AIDS message and, in the end, were probably much more convincing than we were.
At the meal afterwards we were served, Chapattis (a staple here; Tara has been asked a few times, “Have you had Chapattis before”), rice, and a stew with the chicken that had been slaughtered on account of our visit. I could hear its brothers and sisters happily clucking and crowing in the yard outside. I was referred to, a number of times, as, “the first white man” to visit the church, which was altogether awkward no matter how you interpret the statement.
Other choice moments were when Tara was offered chicken, though she and I had earlier explained that she doesn’t eat meat. Earlier, that news had elicited a small amount of shock among the assembled parishoners. A second explanation of vegetarianism seemed to produce exactly the same amount of shock as the first. They also asked, “They say that when all the Jews (which they sometimes pronounced “juices”) return to Israel, that that will bring the second coming.” “Are you going to go back to Israel?” “Well, I went, and it’s very beautiful, but I didn’t stay.”
They were very hospitable, and kind. And hopefully the parishoners benefited in some way from our “sermon” and hopefully they learned and experienced as much from us as we from them.
Friday, November 13, 2009
Kenyan Pastoral
"Karibu Sana! Be proud to be here my friend! Karibu Kenya!"
“Being proud” to be in Kenya meant that instead of moving towards a less crowded matatu, we would suck it up and share seats in the already packed Toyota minivan. Usually the matatu conductors try hard to make sure every seat is taken- 4 in the rear, 3 in the middle 3 rows and 4 (including the driver) in the front- but this conductor was exceptional in his ability to squeeze 20 people (not including himself) and at least 2 chickens in.
Dave and I looked at each other and shrugged. He passed me the gallon of water he had been carrying and climbed in the back. I shared my seat with a young woman who was holding a live chicken in her arms. On the other side of me was a younger boy, also with a smaller chicken resting calmly on his lap. I myself was holding my backpack and the gallon of water on my lap.
It was to be their dinner for the evening. We drove the 5 or 6 miles to our home, past rolling hills of sugarcane and millet. When we came to our stop, I motioned to the woman that I needed to get out. She stood and the chicken squawked for the first time.
Karibu sana. We were finally feeling welcome in Kenya.
*******************************
Though I have reached a point where I am seeing patients completely on my own, I find the work becoming harder and harder.
An elderly woman came in and I noticed that she was clearly failing her regimen. She had been failing it ever since she started it nearly a year ago and she was recently diagnosed with cryptococcal meningitis. (The diagnosis is never made via lumbar puncture, only by serum cryptococcal antigen which in reality suggests disseminated crypto.) She was on her “intensive (induction) phase” phase of po fluconazole- IV ampho/flucytosine of course is not an option.
I was not the only one to have noticed that she was failing her regimen. One of the clinical officers had assigned her to adherence counseling again, to start ABC/TDF and lopinavir/r. She had faithfully completed the course, but had not yet started the new regimen.
The one thing we were waiting for was the viral load. (Resistance testing is not an option.) I wasn’t sure of the point of testing a viral load, but apparently there have been “1 or 2” cases where the patients who appeared to have immunologic failure to the regimens had undetectable viral loads. And so the protocol was to check the viral load before changing the regimen so as not to waste a second line treatment.
I sighed, frustrated by the situation.
The assistant coordinator and one of the best clinical officers at the site smiled at me ruefully. “I realize that those are isolated cases, but that is the way it is.”
By the time she saw me, the patient’s biggest concern was her left leg. It was exquisitely painful to touch and swollen. The skin looked shiny and felt cool. Her pulses were completely intact and the swelling was not localized to a joint but her entire leg.
Definitely not cellulitis or a septic joint or even gout, though the allodynia was striking. Deep vein thrombosis or a deep abscess, I thought. But why?
I looked her. She was 68, but looked like she was well into her 80s. Thin, wasted. Possibly from her advanced HIV. Possibly from some other occult malignancy which would predispose her to blood clots.
“Is there a place I could send her to get an ultrasound of her leg?” I knew even before I asked what the answer would be.
“There is, but she would have to pay. And it would be in Kisumu.”
When we order chest xrays, the patients travel 30km to obtain them and then bring the plain films back for us to read. I worried that the ultrasound would be the same way, and that was not something I could do with any kind of certainty. Moreover- even if we did find a clot, then what? Start her on coumadin? Or lovenox which has better efficacy in malignancies? Right.
So I wrote her a prescription for Aspirin 325mg, hoping that it was something she could afford, and told her to come back in a week so that we could consider switching her ARV regimen, after the viral load came back.
She lives in Rwanda.
There are no data as far as I know that Aspirin will do anything for her venous thromboembolism.
She will return in a week. Hopefully.
********************************
One of the things I love the most is listening to people talk about their families. I love hearing about road trips with sisters and
Skyping with low-tech mothers and fathers that carve field hockey sticks for their daughters on junior varsity.
And I love watching the interaction between family members. Functional and dysfunctional. A bit voyeuristic? I won’t lie- I think this need “to watch and be a part of” is part of the reason I joined this profession. Or rather, the reason I stuck around.
The human condition. The human stain.
Most of the patients who come to our clinic are women, which was surprising to me given the statistics that women are largely underdiagnosed. Every once in a while I meet a young, loving couple, both HIV positive with their children who are negative because they enrolled early enough to prevent vertical transmission.
You hear of grandmothers taking care of their HIV positive grandchildren all too often, but I saw far more of that in New York and New Haven than I do here. In Kenya, HIV affects all generations, all socioeconomic classes, all tribes and ethnicities. I see as many well-dressed English-speaking daughters who bring their mothers in as I do peasant farmer fathers who bring their daughters in.
It is devastating. But in some weird way it also offers me hope. We created the system we have today largely because of wealthy young politically active gay men who would not wait to die from red tape.
Karibu Kenya. Welcome. Be proud to be here.
“Being proud” to be in Kenya meant that instead of moving towards a less crowded matatu, we would suck it up and share seats in the already packed Toyota minivan. Usually the matatu conductors try hard to make sure every seat is taken- 4 in the rear, 3 in the middle 3 rows and 4 (including the driver) in the front- but this conductor was exceptional in his ability to squeeze 20 people (not including himself) and at least 2 chickens in.
Dave and I looked at each other and shrugged. He passed me the gallon of water he had been carrying and climbed in the back. I shared my seat with a young woman who was holding a live chicken in her arms. On the other side of me was a younger boy, also with a smaller chicken resting calmly on his lap. I myself was holding my backpack and the gallon of water on my lap.
It was to be their dinner for the evening. We drove the 5 or 6 miles to our home, past rolling hills of sugarcane and millet. When we came to our stop, I motioned to the woman that I needed to get out. She stood and the chicken squawked for the first time.
Karibu sana. We were finally feeling welcome in Kenya.
*******************************
Though I have reached a point where I am seeing patients completely on my own, I find the work becoming harder and harder.
An elderly woman came in and I noticed that she was clearly failing her regimen. She had been failing it ever since she started it nearly a year ago and she was recently diagnosed with cryptococcal meningitis. (The diagnosis is never made via lumbar puncture, only by serum cryptococcal antigen which in reality suggests disseminated crypto.) She was on her “intensive (induction) phase” phase of po fluconazole- IV ampho/flucytosine of course is not an option.
I was not the only one to have noticed that she was failing her regimen. One of the clinical officers had assigned her to adherence counseling again, to start ABC/TDF and lopinavir/r. She had faithfully completed the course, but had not yet started the new regimen.
The one thing we were waiting for was the viral load. (Resistance testing is not an option.) I wasn’t sure of the point of testing a viral load, but apparently there have been “1 or 2” cases where the patients who appeared to have immunologic failure to the regimens had undetectable viral loads. And so the protocol was to check the viral load before changing the regimen so as not to waste a second line treatment.
I sighed, frustrated by the situation.
The assistant coordinator and one of the best clinical officers at the site smiled at me ruefully. “I realize that those are isolated cases, but that is the way it is.”
By the time she saw me, the patient’s biggest concern was her left leg. It was exquisitely painful to touch and swollen. The skin looked shiny and felt cool. Her pulses were completely intact and the swelling was not localized to a joint but her entire leg.
Definitely not cellulitis or a septic joint or even gout, though the allodynia was striking. Deep vein thrombosis or a deep abscess, I thought. But why?
I looked her. She was 68, but looked like she was well into her 80s. Thin, wasted. Possibly from her advanced HIV. Possibly from some other occult malignancy which would predispose her to blood clots.
“Is there a place I could send her to get an ultrasound of her leg?” I knew even before I asked what the answer would be.
“There is, but she would have to pay. And it would be in Kisumu.”
When we order chest xrays, the patients travel 30km to obtain them and then bring the plain films back for us to read. I worried that the ultrasound would be the same way, and that was not something I could do with any kind of certainty. Moreover- even if we did find a clot, then what? Start her on coumadin? Or lovenox which has better efficacy in malignancies? Right.
So I wrote her a prescription for Aspirin 325mg, hoping that it was something she could afford, and told her to come back in a week so that we could consider switching her ARV regimen, after the viral load came back.
She lives in Rwanda.
There are no data as far as I know that Aspirin will do anything for her venous thromboembolism.
She will return in a week. Hopefully.
********************************
One of the things I love the most is listening to people talk about their families. I love hearing about road trips with sisters and
Skyping with low-tech mothers and fathers that carve field hockey sticks for their daughters on junior varsity.
And I love watching the interaction between family members. Functional and dysfunctional. A bit voyeuristic? I won’t lie- I think this need “to watch and be a part of” is part of the reason I joined this profession. Or rather, the reason I stuck around.
The human condition. The human stain.
Most of the patients who come to our clinic are women, which was surprising to me given the statistics that women are largely underdiagnosed. Every once in a while I meet a young, loving couple, both HIV positive with their children who are negative because they enrolled early enough to prevent vertical transmission.
You hear of grandmothers taking care of their HIV positive grandchildren all too often, but I saw far more of that in New York and New Haven than I do here. In Kenya, HIV affects all generations, all socioeconomic classes, all tribes and ethnicities. I see as many well-dressed English-speaking daughters who bring their mothers in as I do peasant farmer fathers who bring their daughters in.
It is devastating. But in some weird way it also offers me hope. We created the system we have today largely because of wealthy young politically active gay men who would not wait to die from red tape.
Karibu Kenya. Welcome. Be proud to be here.
Monday, November 9, 2009
Finding Swine on the Famished Road
Diarrhea and vector-borne illnesses be damned. I come to Kenya and I get slammed hard by that wretched little bugger, the flu.
It didn’t matter that the multiple vaccinations I had received a month ago rendered my immune system excited and inflamed and ready to fight not only Yellow Fever and Typhoid, but also Meningococcus, even though I was unlikely to travel anywhere near the Meningococcal Belt. (Our beloved travel medicine clinic doc can be very convincing- though I did put my foot down to the rabies vaccine. Even though I had been considering going for a run or two out here, I was willing to take my chances with the stray dogs.)
Two weeks later I also received the seasonal flu vaccine. The novel H1N1 vaccine came out just a couple of days before I left, but- and don’t hate me for saying this- I was suffering from vaccine-fatigue. And honestly, I am neither pregnant nor immunocompromised in any way, so why bother? I mean does the vaccine really reduce nasal carriage and risk of transmission, or is only risk of acquisition?
I have been taking my Mefloquine religiously, and put on 40% Deet on occasion, usually when lady Anopheles and friends decide to have a party in our house every once in a while.
I put out my hand sanitzer on the folding table every day, and use it in between patients religiously. One sweet elderly patient saw the bottle on the desk and motioned towards me, a nonverbal request asking if she could take some. She looked at the bottle closely, shrugged her shoulders and proceeded to take a palm full and rub it all over her body as though it were cologne.
Pride comes before a fall. I can count on one hand the number of times I have gotten sick while traveling and during residency.
In spite it all, the flu hit me. Hard. And of course it hit me hardest on our trip to Masai Mara Game Reserve. Dave and I thought carefully about the one “indulgence” we were going to allow ourselves and in the end it was a toss up between a game drive and a flight to Mombasa on the other side of the country. In the end we were glad to have spent the money on this very touristy adventure.
But for most of the trip I felt like the emaciated cows on the savannah whose hardened faces would stare emptily at me while chewing endlessly on dry cud. The Masai were even trying to graze their cattle within the confines of the national park because the land is just so dry.
I did manage to enjoy our game drives regardless. We saw 4 of the 5 big five- lions, elephants, rhinoceros and water buffalo. Our lovely driver-guide took us within inches of some of these intimidating creatures, including a close up of two mating lions. They were lazily lounging on the grass, yawning in synchrony, their majestic bodies stretched out long and large. And then, without any verbal cues, they rose together, and began their play. It was amazing.
*************************************
I went to work the next morning in spite of my better judgment. My original plan was to not do any direct patient care and focus on some chart reviews and perhaps leave a bit early. Such was not the case. We were short several clinical officers and the chart pile was sky high. By the end of the day, I was hypoglycemic and febrile again and Dave had to rescue me. He put his foot down and gave away a couple of my charts to the other clinical officers.
So I previously extolled the evidence-based protocol driven system that I have found here, but of course it is far from perfect. The evidence for cotrimoxazole in all patients with HIV (regardless of CD4 count) is fairly convincing, especially in children, though in certain studies there is some suggestion of waning efficacy after a period of time, likely due to non-adherence and increased resistance.
The issue of adherence is fascinating in and of itself. Though we have a decent selection of ARVs (AZT, 3TC, d4T, NVP, Lopinavir/r, and apparently even Tenofovir), our limited stock makes it crucial that patients commit to adherence. So they have to undergo a three-week counseling session before they start, and if they fail the counseling sessions then they are just plain out of luck. The guidelines are fairly strict with respect to CD4 count and WHO staging- I have even seen a clinical officer defer placing a patient on ARVs with a CD4 of 260, as 250 is the cutoff. In the States we also use the rate of decline as another marker, in addition to increasing the cutoff to 350. I did convince this clinical officer to have the patient come back in another month to recheck the CD4, as I was convinced that it would eventually meet her criteria.
Ah lists and protocols. Protocols and lists. Peter Pronovost would be having a field day out here.
The issue of whom to test for malaria is also rather tricky for me. In an otherwise healthy population, those who would be at risk for developing clinical malaria are children, pregnant women and those from non-endemic areas. Of course HIV confers an increased risk for complications, but the extent of these complications depends on whether the malaria in the area is “stable” or “unstable.” I have met several patients who presented with complicated malaria- which makes me suspect that the malaria prevalence waxes and wanes, perhaps with the different seasons. Yes, even in equatorial Africa there are seasons.
To smear or not to smear? This is what I have been asking myself for the last couple of days. Clinically, everything I am experiencing- myalgias, rhinorrhea, a nasty cough, low grade fevers and rigors- all smell of influenza.
But after all, I am currently in Africa.
Thoughts?
It didn’t matter that the multiple vaccinations I had received a month ago rendered my immune system excited and inflamed and ready to fight not only Yellow Fever and Typhoid, but also Meningococcus, even though I was unlikely to travel anywhere near the Meningococcal Belt. (Our beloved travel medicine clinic doc can be very convincing- though I did put my foot down to the rabies vaccine. Even though I had been considering going for a run or two out here, I was willing to take my chances with the stray dogs.)
Two weeks later I also received the seasonal flu vaccine. The novel H1N1 vaccine came out just a couple of days before I left, but- and don’t hate me for saying this- I was suffering from vaccine-fatigue. And honestly, I am neither pregnant nor immunocompromised in any way, so why bother? I mean does the vaccine really reduce nasal carriage and risk of transmission, or is only risk of acquisition?
I have been taking my Mefloquine religiously, and put on 40% Deet on occasion, usually when lady Anopheles and friends decide to have a party in our house every once in a while.
I put out my hand sanitzer on the folding table every day, and use it in between patients religiously. One sweet elderly patient saw the bottle on the desk and motioned towards me, a nonverbal request asking if she could take some. She looked at the bottle closely, shrugged her shoulders and proceeded to take a palm full and rub it all over her body as though it were cologne.
Pride comes before a fall. I can count on one hand the number of times I have gotten sick while traveling and during residency.
In spite it all, the flu hit me. Hard. And of course it hit me hardest on our trip to Masai Mara Game Reserve. Dave and I thought carefully about the one “indulgence” we were going to allow ourselves and in the end it was a toss up between a game drive and a flight to Mombasa on the other side of the country. In the end we were glad to have spent the money on this very touristy adventure.
But for most of the trip I felt like the emaciated cows on the savannah whose hardened faces would stare emptily at me while chewing endlessly on dry cud. The Masai were even trying to graze their cattle within the confines of the national park because the land is just so dry.
I did manage to enjoy our game drives regardless. We saw 4 of the 5 big five- lions, elephants, rhinoceros and water buffalo. Our lovely driver-guide took us within inches of some of these intimidating creatures, including a close up of two mating lions. They were lazily lounging on the grass, yawning in synchrony, their majestic bodies stretched out long and large. And then, without any verbal cues, they rose together, and began their play. It was amazing.
*************************************
I went to work the next morning in spite of my better judgment. My original plan was to not do any direct patient care and focus on some chart reviews and perhaps leave a bit early. Such was not the case. We were short several clinical officers and the chart pile was sky high. By the end of the day, I was hypoglycemic and febrile again and Dave had to rescue me. He put his foot down and gave away a couple of my charts to the other clinical officers.
So I previously extolled the evidence-based protocol driven system that I have found here, but of course it is far from perfect. The evidence for cotrimoxazole in all patients with HIV (regardless of CD4 count) is fairly convincing, especially in children, though in certain studies there is some suggestion of waning efficacy after a period of time, likely due to non-adherence and increased resistance.
The issue of adherence is fascinating in and of itself. Though we have a decent selection of ARVs (AZT, 3TC, d4T, NVP, Lopinavir/r, and apparently even Tenofovir), our limited stock makes it crucial that patients commit to adherence. So they have to undergo a three-week counseling session before they start, and if they fail the counseling sessions then they are just plain out of luck. The guidelines are fairly strict with respect to CD4 count and WHO staging- I have even seen a clinical officer defer placing a patient on ARVs with a CD4 of 260, as 250 is the cutoff. In the States we also use the rate of decline as another marker, in addition to increasing the cutoff to 350. I did convince this clinical officer to have the patient come back in another month to recheck the CD4, as I was convinced that it would eventually meet her criteria.
Ah lists and protocols. Protocols and lists. Peter Pronovost would be having a field day out here.
The issue of whom to test for malaria is also rather tricky for me. In an otherwise healthy population, those who would be at risk for developing clinical malaria are children, pregnant women and those from non-endemic areas. Of course HIV confers an increased risk for complications, but the extent of these complications depends on whether the malaria in the area is “stable” or “unstable.” I have met several patients who presented with complicated malaria- which makes me suspect that the malaria prevalence waxes and wanes, perhaps with the different seasons. Yes, even in equatorial Africa there are seasons.
To smear or not to smear? This is what I have been asking myself for the last couple of days. Clinically, everything I am experiencing- myalgias, rhinorrhea, a nasty cough, low grade fevers and rigors- all smell of influenza.
But after all, I am currently in Africa.
Thoughts?
Thursday, November 5, 2009
Chappatis and the little Chickpeas.
Three days of chappatis and channa masala for dinner.
I am craving fruit.
Even the distant memory of the watered down ridiculously large but fruitless oranges in our *tropical* yard in Berkeley makes me salivate. At least I won’t be in need of Food by Prescription any time soon, the milk-based meal we prescribe for the chronically malnourished. I have seen some kwashiorkor and marasmus in my brief time here, but not as much as I had thought given the recent drought and consequent famine. Kenya usually has two rainy seasons, but this year did not receive the much-needed one in April. We are in the middle of the second one, which is offering some relief, though in general April rains are what brings harvest.
I am seeing quite a few children, which is not as daunting as I thought it would be. I am gaining some sense of the malnourished versus the dehydrated versus the happy baby. Dave is far more comfortable in this area than I, and though I am more familiar with adult and pediatric HIV than he, I often ask for his expert opinion on the little chickpeas. It is nice having your own personal consult at home.
The thing that strikes me the most about the little gremlins is not their huge eyes or shy smiles that envelop their faces or the fact that they can create a playground from just about anything- a slide out of a broken bench, a trampoline out of their mothers’ thin bellies. The thing that strikes me the most is their given names. Everyone has a Christian name, a Luo name and a Surname. (Barack Obama Sr’s father converted to Islam; most Luo are Christian.) I have had the privilege of meeting little Tony Blair Achieng Odhiembo and little Steve Biko Adhiembo Ochieng.
Funny enough, I have yet to meet a Barack Obama, but I do on occasion see our president’s face on a fancy belt buckle or on a piece of bubblegum wrapper.
Kids are amazing. But sadly, many of them have not been tested, and the staff at the clinic are trying to make sure that every patient brings each child under 15 in to get tested. They are finding that though these parents are in care, many of their children are dying at home. And so in addition to voluntary counseling and testing (VCT- which they are planning on modifying significantly), the clinical officers have instituted a “provider initiated testing and counseling” (PITC) protocol to leave no child behind.
Today we drove out to another clinic site, in an even more remote area- so remote that I would not have access to chappatis and tea for the day. I saw a 9 month-old baby that weighed 5kg. Though he had good skin turgor, he was undoubtedly failing to thrive. He could sit, but not pull himself up to stand just yet.
(Granted, my understanding of developmental milestones may be a bit skewed. My friend Nessy’s baby weighed 9kg at 4 months, and could take a few steps by 9 months. Though she is a strong little Norse baby, I realize that she is a bit precocious, but realistically, not too far off the mark.)
And he was fussy, according to mom, who was at the clinic by herself. Her husband had not gotten tested yet, nor had his second wife.
She was feeding the child with breast-milk and porridge, or “mixed feeding,” which is strongly discouraged. The porridge that is used lacks nutrition and apparently can irritate the GI tract and cause mucosal damage, thus making the child more prone to infection from the breast milk. And though breast milk is also discouraged, it is preferable to use only breast milk if formula (or clean water to mix the formula) are unavailable.
It didn’t matter- the child’s PCR was positive. Since the Kenyan guidelines call for initiating ARVs regardless of the CD4% or WHO stage for all children under 18 months, he was to start ARVs.
“But, Doctor, you see, we cannot start the mother on ARVs because her CD4 is too high. So if she continues to breastfeed, she will continue to re-infect or super-infect the child.”
(Please know that I never introduce myself as Doctor- not in the States, and definitely not here. I usually state my full name when introducing myself- which most people miss the first time I say it- followed by something along the lines of, “one of the doctors/medical officers working here.”)
So the two clinical officers I was working with were asking me what they should do about initiating ARVs in the infant who was still breastfeeding. Right-o.
Though I was familiar with some of the evidence regarding breastfeeding, I was most definitely out of my element. And I knew that my dear husband would not be of help here either. I could not phone a friend.
I paused for a moment and cleared my throat. “Um, well, technically, the mother would only be transmitting wild-type virus as she is treatment-naïve, and so I don’t think we should withhold treatment for the child just because he continues to breastfeed. And after all, the child has thrush and is failing to thrive.”
My dear friend and clinical officer Mercy nodded in agreement. She understood I was saying, which emboldened me.
“I think we should just start the treatment. It will essentially also serve as post-exposure prophylaxis.”
So we gave the child the full monty, RLS (Resource Limited Settings) style: albendazole, amoxicillin, CTX, MVI, Food by Prescription, and Abacavir, 3TC and Nevirapine.
All brought to you by your friendly neighborhood pharmaceutical, Cipla. Made in India. Cipla is the king of manufacturing combination therapies, including Triomune (3TC/d4T/NVP-the standard regimen here in Kenya for adults) and Candid-A, hydrocortisone/clotrimazole cream. I can’t believe that Pfizer did not corner the market on the latter- I mean come on!
In all honesty, I am not sure if that child is going to make it, regardless of what we try.
On a less somber note, Dave too spent the day off-site, riding around in a minivan with a large megaphone playing reggae music in between shouting the merits of circumcision. As in “This is a public service announcement. Please free yourself of the foreskin! Reduce your and your partner's risk! Disrobe the little guy!”
Or something like than in Kiswahili.
For the first time since we got here, I have cooked dinner (you got it- Chappatis and Channa, and maybe a little scrambled egg here and there) and am waiting for Dave to come home. Please don't worry about my loneliness- keep in mind that my ancestors come from a country that now has over a billion people, and Kenya seems vastly underpopulated to me. It is a bit horrifying to think that a third of the population in some areas has been ravaged by this virus.
I am craving fruit.
Even the distant memory of the watered down ridiculously large but fruitless oranges in our *tropical* yard in Berkeley makes me salivate. At least I won’t be in need of Food by Prescription any time soon, the milk-based meal we prescribe for the chronically malnourished. I have seen some kwashiorkor and marasmus in my brief time here, but not as much as I had thought given the recent drought and consequent famine. Kenya usually has two rainy seasons, but this year did not receive the much-needed one in April. We are in the middle of the second one, which is offering some relief, though in general April rains are what brings harvest.
I am seeing quite a few children, which is not as daunting as I thought it would be. I am gaining some sense of the malnourished versus the dehydrated versus the happy baby. Dave is far more comfortable in this area than I, and though I am more familiar with adult and pediatric HIV than he, I often ask for his expert opinion on the little chickpeas. It is nice having your own personal consult at home.
The thing that strikes me the most about the little gremlins is not their huge eyes or shy smiles that envelop their faces or the fact that they can create a playground from just about anything- a slide out of a broken bench, a trampoline out of their mothers’ thin bellies. The thing that strikes me the most is their given names. Everyone has a Christian name, a Luo name and a Surname. (Barack Obama Sr’s father converted to Islam; most Luo are Christian.) I have had the privilege of meeting little Tony Blair Achieng Odhiembo and little Steve Biko Adhiembo Ochieng.
Funny enough, I have yet to meet a Barack Obama, but I do on occasion see our president’s face on a fancy belt buckle or on a piece of bubblegum wrapper.
Kids are amazing. But sadly, many of them have not been tested, and the staff at the clinic are trying to make sure that every patient brings each child under 15 in to get tested. They are finding that though these parents are in care, many of their children are dying at home. And so in addition to voluntary counseling and testing (VCT- which they are planning on modifying significantly), the clinical officers have instituted a “provider initiated testing and counseling” (PITC) protocol to leave no child behind.
Today we drove out to another clinic site, in an even more remote area- so remote that I would not have access to chappatis and tea for the day. I saw a 9 month-old baby that weighed 5kg. Though he had good skin turgor, he was undoubtedly failing to thrive. He could sit, but not pull himself up to stand just yet.
(Granted, my understanding of developmental milestones may be a bit skewed. My friend Nessy’s baby weighed 9kg at 4 months, and could take a few steps by 9 months. Though she is a strong little Norse baby, I realize that she is a bit precocious, but realistically, not too far off the mark.)
And he was fussy, according to mom, who was at the clinic by herself. Her husband had not gotten tested yet, nor had his second wife.
She was feeding the child with breast-milk and porridge, or “mixed feeding,” which is strongly discouraged. The porridge that is used lacks nutrition and apparently can irritate the GI tract and cause mucosal damage, thus making the child more prone to infection from the breast milk. And though breast milk is also discouraged, it is preferable to use only breast milk if formula (or clean water to mix the formula) are unavailable.
It didn’t matter- the child’s PCR was positive. Since the Kenyan guidelines call for initiating ARVs regardless of the CD4% or WHO stage for all children under 18 months, he was to start ARVs.
“But, Doctor, you see, we cannot start the mother on ARVs because her CD4 is too high. So if she continues to breastfeed, she will continue to re-infect or super-infect the child.”
(Please know that I never introduce myself as Doctor- not in the States, and definitely not here. I usually state my full name when introducing myself- which most people miss the first time I say it- followed by something along the lines of, “one of the doctors/medical officers working here.”)
So the two clinical officers I was working with were asking me what they should do about initiating ARVs in the infant who was still breastfeeding. Right-o.
Though I was familiar with some of the evidence regarding breastfeeding, I was most definitely out of my element. And I knew that my dear husband would not be of help here either. I could not phone a friend.
I paused for a moment and cleared my throat. “Um, well, technically, the mother would only be transmitting wild-type virus as she is treatment-naïve, and so I don’t think we should withhold treatment for the child just because he continues to breastfeed. And after all, the child has thrush and is failing to thrive.”
My dear friend and clinical officer Mercy nodded in agreement. She understood I was saying, which emboldened me.
“I think we should just start the treatment. It will essentially also serve as post-exposure prophylaxis.”
So we gave the child the full monty, RLS (Resource Limited Settings) style: albendazole, amoxicillin, CTX, MVI, Food by Prescription, and Abacavir, 3TC and Nevirapine.
All brought to you by your friendly neighborhood pharmaceutical, Cipla. Made in India. Cipla is the king of manufacturing combination therapies, including Triomune (3TC/d4T/NVP-the standard regimen here in Kenya for adults) and Candid-A, hydrocortisone/clotrimazole cream. I can’t believe that Pfizer did not corner the market on the latter- I mean come on!
In all honesty, I am not sure if that child is going to make it, regardless of what we try.
On a less somber note, Dave too spent the day off-site, riding around in a minivan with a large megaphone playing reggae music in between shouting the merits of circumcision. As in “This is a public service announcement. Please free yourself of the foreskin! Reduce your and your partner's risk! Disrobe the little guy!”
Or something like than in Kiswahili.
For the first time since we got here, I have cooked dinner (you got it- Chappatis and Channa, and maybe a little scrambled egg here and there) and am waiting for Dave to come home. Please don't worry about my loneliness- keep in mind that my ancestors come from a country that now has over a billion people, and Kenya seems vastly underpopulated to me. It is a bit horrifying to think that a third of the population in some areas has been ravaged by this virus.
Wednesday, November 4, 2009
The Mzungus say Sawa Sawa (okay!)
“That’s not Africa. This is Africa!” This was the second time I was told by a Kenyan that my trip to South Africa so many years ago simply did not count.
Our introduction to “Africa” initially found us on a street in the predominantly Indian neighborhood in Kisumu, where our neighbors were a Sikh Gurudwara and a Hare Krishna Temple (of the ISKON variety). I would smile politely to the aunties and chechis sporting salwars and chunnis; though I saw plenty of them in our neighborhood, I could count on my hands the number that I would see in the town center, less than 2km away. It was striking; after all, they did own almost all of the shops.
It was hard not to compare this to the country with which I was far more familiar. The roads, though similar in their areas of development (or lack thereof), are markedly different. In Kenya, with a population of less than 60 million, you rarely have vehicles racing towards on coming traffic in an attempt to bypass slower cars and autorickshaws (tuk tuks). Instead, you have vehicles politely turn on their right hand signal to notify those behind them of oncoming traffic, lest they try to pass. Such is never the case in the Motherland.
Leave it to us, however, to find the one Indian uncle who could help us find the appropriate adapter for our laptop. After having shorted three other ones, one of which nearly caused an electrical fire, Electronics Uncle came to the rescue.
And then Bao showed up. Good old Bao, who graciously introduced us to Ugali and Stewed Fish at Railway Beach. Though it was his first time at that particular location, after a month Bao was an expert on the Lake Victoria fisherman’s diet. The large Tilapia we were about to eat stared vacantly at me, and I half-joked to Bao that he looked well-nourished enough for me to have the courage to consume. After all, fish tapeworm was more common in the little old Jewish lady eating Gefeltefish than the Luo fisherman eating his catch of the day, right?
“My parents used to tell me to eat the eye so that my eyesight would improve. It didn’t do the trick,” he cracked. “Lasik did wonders though.”
And thus Bao, my dear Vietnamese friend from California, became our cultural guide, showing us the way of all things African. It was sad to see him go, though we had only spent a day with him. He was gracious enough to buy us a box of wine to share the night before he left.
“Just so you know, the only women that frequent the bars in this country are prostitutes.”
Our first two days were spent stocking up for our trip to the bush, buying all the necessities- bread, peanut butter, chappatis and garbanzo beans. We did manage to go to the Kisumu Museum, where among the snake pits and bird sanctuaries was a harrowing photographic exhibit of the post-election violence in January of 2008. Kisumu, hard hit, has some remnants of this unusual period of destruction for a country that hails itself as a safe haven of peace in turbulent East Africa. One notable large burnt down supermarket still barely stands on the corner of Odinga Odinga and Nairobi Roads.
As with any country developed and underdeveloped (the US not excluded), tribalism still runs deep in Kenya. The election violence was split cleanly along those lines, and newspaper headlines still remark that intertribal families were torn apart during those times. The major players involved the tribes of the two running candidates, the incumbent Kikuyu Kibaki, and his opponent, the head of the Orange Democratic Movement and Luo Raila Odinga. Ocampo, head of the International Criminal Court, is currently in Kenya to consider bringing major officials to trial for participating in the violence. It is unclear who these officials are.
The Luo are the predominant tribe in the Nyanza Province, and notably, the tribe of Barack Obama Senior. President Obama visited Kisumu in 2006 and apparently publically took and HIV test with his wife, to demonstrate the importance in this area with an estimated prevalence of 30%.
We soon found ourselves far away from everything outside of Luo. The former estate of the principle secretary, a rustic little bungalow 5 miles outside of the main town of Rongo, replete with 70s style mauve and taupe carpeting and secondhand furniture was to be our new home for the month. Our first night was spent attempting to “bug proof” our humble little abode, screeching our way through cold baths and listening to the mice scamper about the walls.
Dave was just as terrified, if not more, of the variety of six to eight legged critters that paid us a visit that night. If only he had
seen the enormous spiders I had befriended in Achappan’s (my grandfather's) bathroom. “I am bigger than you are,” became my mantra every time I went in, though it would often fail when I would see the creature voraciously grab an ant with its enormous pincers and chuck it down its gullet.
So Dave spent the better part of the evening trying his best to make sure nothing got past our stifling mosquito net.
I burst into tears the moment we walked in after our three hour ride from Kisumu, not because of the sparse living arrangements, but because we were so far away from everything. I had never felt so physically isolated in my life.
The next day we took matatus to our respective clinics. The Rongo clinic was unlike any healthcare facility I had ever seen before, even in India. Our clinic “offices” were canvas tents with three walls, an examining table and a long folding table. It was under these tents that on my first day I tapped a joint and placed the needle in a cardboard sharps container, advised Ceftriaxone, Doxy, podophyllin cream and a derm/urology referral for a man with a fungating penile lesion and a purulent discharge, diagnosed complicated malaria and Kaposi’s Sarcoma in one tachypneic woman who should have been hospitalized but “didn’t qualify” and helped one of the clinical officers place an IV in an woman with respiratory failure (who did qualify, only to die 1 hour after she was placed in the female ward).
The woman with Kaposi’s and malaria was brought in by her father the next day with the chest xray we had ordered to be done in Migori, a good 20km away. It showed bilateral diffuse infiltrates. Her breathing was agonal and she soon passed away.
I couldn’t help but wonder if I should have just started her on therapeutic (oral) Pneumocystis (PCP) treatment with steroids….though it could have been just about anything. Acute Respiratory Distress Syndrome from malaria or any number of infections. Pulmonary Kaposi’s Sarcoma. I also wondered if having a pulse oximeter available would have helped justify an admission.
Was any of this preventable? There is an MSF (Medicins Sans Frontier) center in Homa Bay that provides chemo for Kaposi’s, though antiretrovirals (ARVs) must be instituted before even considering it.
She was noncompliant with her ARVs.
Our tent was open to dozens of waiting patients as we watched her die. Her father and an aide carried her body on a stretcher to the female ward while they made arrangements.
The patients watched without emotion and carried on.
I have no idea what a Luo death ceremony involves, or if it involves anything.
But there were dozens of others doing reasonably well, on and off ARVs. The system was remarkably well run, largely protocol driven by “clinical officers” who probably are the equivalent of nurse practioners in the States. And the protocols, because they are evidence based, work.
One example is the use of Cotrimoxazole (TMP-SMX) in everyone diagnosed with HIV, along with a multivitamin. Though in the States it is only reserved for PCP/Toxo prophylaxis, in the developing world it is used to ward off all possible threats to the HIV infected, including malaria.
After a busy morning, the clinical officer I was with asked me if I knew what chapattis were. And so we had a lovely little break with chapattis and sugary tea (which I had to toss out half way through). All the loneliness that I had felt the previous night melted away with each savory bite of buttered parathas.
The FACES clinics have an elaborate system of monitoring and evaluation, data collection and entry. One small 500 sq foot building houses several laptop computers in the Rongo clinic for this alone. Other similar sized buildings house a “minor theater” (mostly for male circumcisions which have been shown to reduce HIV infection in men), an area for VCT (voluntary counseling and testing), and a laboratory. This laboratory amazes me in its capacity to run hepatitis serologies more rapidly than a lactate. I can’t help but be a little bit suspicious, but perhaps I too have a long way to go before I can put away my notions of the superiority of “my” (western) training in medicine.
Interestingly enough, I am the one of two physicians (medical officers) at the clinic, and so many of the clinical officers ask for my “advice.” The other medical officer essentially finished internship and was spending two or more years in an administrative position before starting postgraduate work (residency). It is a bit unsettling to be asked about diseases I have rarely seen, though I can occasionally speak with some authority.
Dave met me in Rongo after our first day and we walked the 4 miles back to our little bungalow. We both had similar stories to share.
“Fine, Mzungu!” the schoolchildren would automatically exclaim the Kiswahili word for “white person” even before Dave would have a chance to ask “How are you?” Alternatively they would excitedly chant “how are you” over and over again without waiting a for a response.
And I, in amazement, realize that it is only the beginning of my trip with my Mzungu.
Our introduction to “Africa” initially found us on a street in the predominantly Indian neighborhood in Kisumu, where our neighbors were a Sikh Gurudwara and a Hare Krishna Temple (of the ISKON variety). I would smile politely to the aunties and chechis sporting salwars and chunnis; though I saw plenty of them in our neighborhood, I could count on my hands the number that I would see in the town center, less than 2km away. It was striking; after all, they did own almost all of the shops.
It was hard not to compare this to the country with which I was far more familiar. The roads, though similar in their areas of development (or lack thereof), are markedly different. In Kenya, with a population of less than 60 million, you rarely have vehicles racing towards on coming traffic in an attempt to bypass slower cars and autorickshaws (tuk tuks). Instead, you have vehicles politely turn on their right hand signal to notify those behind them of oncoming traffic, lest they try to pass. Such is never the case in the Motherland.
Leave it to us, however, to find the one Indian uncle who could help us find the appropriate adapter for our laptop. After having shorted three other ones, one of which nearly caused an electrical fire, Electronics Uncle came to the rescue.
And then Bao showed up. Good old Bao, who graciously introduced us to Ugali and Stewed Fish at Railway Beach. Though it was his first time at that particular location, after a month Bao was an expert on the Lake Victoria fisherman’s diet. The large Tilapia we were about to eat stared vacantly at me, and I half-joked to Bao that he looked well-nourished enough for me to have the courage to consume. After all, fish tapeworm was more common in the little old Jewish lady eating Gefeltefish than the Luo fisherman eating his catch of the day, right?
“My parents used to tell me to eat the eye so that my eyesight would improve. It didn’t do the trick,” he cracked. “Lasik did wonders though.”
And thus Bao, my dear Vietnamese friend from California, became our cultural guide, showing us the way of all things African. It was sad to see him go, though we had only spent a day with him. He was gracious enough to buy us a box of wine to share the night before he left.
“Just so you know, the only women that frequent the bars in this country are prostitutes.”
Our first two days were spent stocking up for our trip to the bush, buying all the necessities- bread, peanut butter, chappatis and garbanzo beans. We did manage to go to the Kisumu Museum, where among the snake pits and bird sanctuaries was a harrowing photographic exhibit of the post-election violence in January of 2008. Kisumu, hard hit, has some remnants of this unusual period of destruction for a country that hails itself as a safe haven of peace in turbulent East Africa. One notable large burnt down supermarket still barely stands on the corner of Odinga Odinga and Nairobi Roads.
As with any country developed and underdeveloped (the US not excluded), tribalism still runs deep in Kenya. The election violence was split cleanly along those lines, and newspaper headlines still remark that intertribal families were torn apart during those times. The major players involved the tribes of the two running candidates, the incumbent Kikuyu Kibaki, and his opponent, the head of the Orange Democratic Movement and Luo Raila Odinga. Ocampo, head of the International Criminal Court, is currently in Kenya to consider bringing major officials to trial for participating in the violence. It is unclear who these officials are.
The Luo are the predominant tribe in the Nyanza Province, and notably, the tribe of Barack Obama Senior. President Obama visited Kisumu in 2006 and apparently publically took and HIV test with his wife, to demonstrate the importance in this area with an estimated prevalence of 30%.
We soon found ourselves far away from everything outside of Luo. The former estate of the principle secretary, a rustic little bungalow 5 miles outside of the main town of Rongo, replete with 70s style mauve and taupe carpeting and secondhand furniture was to be our new home for the month. Our first night was spent attempting to “bug proof” our humble little abode, screeching our way through cold baths and listening to the mice scamper about the walls.
Dave was just as terrified, if not more, of the variety of six to eight legged critters that paid us a visit that night. If only he had
seen the enormous spiders I had befriended in Achappan’s (my grandfather's) bathroom. “I am bigger than you are,” became my mantra every time I went in, though it would often fail when I would see the creature voraciously grab an ant with its enormous pincers and chuck it down its gullet.
So Dave spent the better part of the evening trying his best to make sure nothing got past our stifling mosquito net.
I burst into tears the moment we walked in after our three hour ride from Kisumu, not because of the sparse living arrangements, but because we were so far away from everything. I had never felt so physically isolated in my life.
The next day we took matatus to our respective clinics. The Rongo clinic was unlike any healthcare facility I had ever seen before, even in India. Our clinic “offices” were canvas tents with three walls, an examining table and a long folding table. It was under these tents that on my first day I tapped a joint and placed the needle in a cardboard sharps container, advised Ceftriaxone, Doxy, podophyllin cream and a derm/urology referral for a man with a fungating penile lesion and a purulent discharge, diagnosed complicated malaria and Kaposi’s Sarcoma in one tachypneic woman who should have been hospitalized but “didn’t qualify” and helped one of the clinical officers place an IV in an woman with respiratory failure (who did qualify, only to die 1 hour after she was placed in the female ward).
The woman with Kaposi’s and malaria was brought in by her father the next day with the chest xray we had ordered to be done in Migori, a good 20km away. It showed bilateral diffuse infiltrates. Her breathing was agonal and she soon passed away.
I couldn’t help but wonder if I should have just started her on therapeutic (oral) Pneumocystis (PCP) treatment with steroids….though it could have been just about anything. Acute Respiratory Distress Syndrome from malaria or any number of infections. Pulmonary Kaposi’s Sarcoma. I also wondered if having a pulse oximeter available would have helped justify an admission.
Was any of this preventable? There is an MSF (Medicins Sans Frontier) center in Homa Bay that provides chemo for Kaposi’s, though antiretrovirals (ARVs) must be instituted before even considering it.
She was noncompliant with her ARVs.
Our tent was open to dozens of waiting patients as we watched her die. Her father and an aide carried her body on a stretcher to the female ward while they made arrangements.
The patients watched without emotion and carried on.
I have no idea what a Luo death ceremony involves, or if it involves anything.
But there were dozens of others doing reasonably well, on and off ARVs. The system was remarkably well run, largely protocol driven by “clinical officers” who probably are the equivalent of nurse practioners in the States. And the protocols, because they are evidence based, work.
One example is the use of Cotrimoxazole (TMP-SMX) in everyone diagnosed with HIV, along with a multivitamin. Though in the States it is only reserved for PCP/Toxo prophylaxis, in the developing world it is used to ward off all possible threats to the HIV infected, including malaria.
After a busy morning, the clinical officer I was with asked me if I knew what chapattis were. And so we had a lovely little break with chapattis and sugary tea (which I had to toss out half way through). All the loneliness that I had felt the previous night melted away with each savory bite of buttered parathas.
The FACES clinics have an elaborate system of monitoring and evaluation, data collection and entry. One small 500 sq foot building houses several laptop computers in the Rongo clinic for this alone. Other similar sized buildings house a “minor theater” (mostly for male circumcisions which have been shown to reduce HIV infection in men), an area for VCT (voluntary counseling and testing), and a laboratory. This laboratory amazes me in its capacity to run hepatitis serologies more rapidly than a lactate. I can’t help but be a little bit suspicious, but perhaps I too have a long way to go before I can put away my notions of the superiority of “my” (western) training in medicine.
Interestingly enough, I am the one of two physicians (medical officers) at the clinic, and so many of the clinical officers ask for my “advice.” The other medical officer essentially finished internship and was spending two or more years in an administrative position before starting postgraduate work (residency). It is a bit unsettling to be asked about diseases I have rarely seen, though I can occasionally speak with some authority.
Dave met me in Rongo after our first day and we walked the 4 miles back to our little bungalow. We both had similar stories to share.
“Fine, Mzungu!” the schoolchildren would automatically exclaim the Kiswahili word for “white person” even before Dave would have a chance to ask “How are you?” Alternatively they would excitedly chant “how are you” over and over again without waiting a for a response.
And I, in amazement, realize that it is only the beginning of my trip with my Mzungu.
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