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.