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.