Obamaland

Elections...

If there is anywhere I'd want to be outside of the US for a presidential election involving Barack Obama, it would definitely be Kenya. Since our arrival, people have been asking us about Obama. Will he win? Will Americans really vote for a black president? What do I think he'll bring to Kenya if he's elected? Will I be voting for him? Etc, etc, etc....

As most of you probably know, Obama's father (who was actually kind of a deadbeat dad, as far as I know--he only met him for one month when he was 10 years old) was a Kenyan. In Kenya, all identifications begin with tribal affliliations (this was the major source of the violence that erupted after one tribe allegedly stole the national elections from another tribe last December). In a way, it's like being at DePauw for undergrad, where someone's description is always [name] and then [greek house], i.e., "You know Matt Jones? That Delta Upsilon we met the other weekend?" It goes the same here, except with tribes. Obama's father was a Luo, a tribe which is based in Kisumu, the third largest city in Kenya, which sits on Lake Victoria. His grandmother raised his father in a small village not far from the city, near where Nadine and I went to a rural clinic last week (more below on that). Anyway, the Luos are the second largest tribe in Kenya, and they're the ones who had the presidential election "stolen" from them last year. So it's my belief that they feel particularly vindicated that one of their brethren has now ascended to the most powerful job in the world. Interestingly, their reputation in Kenya is that they produce intellectuals, leaders, and innovators. (They also party heavily and have the one of the highest HIV rates in the country.)

All of that above is to explain that on election day, the only topic of conversation here in Kenya was the US. In the week preceding the election, we watched various news stations (BBC international, CNN, Al Jazeera) devote 90% of the coverage to the US elections. Being in a foreign country for such an event definitely gives you a deep appreciation of how much the world follows, is invested in, and cares about the doings of American democracy.

So the night of the election (or the day of, in the US) we all gathered at Sonak Pastakia's place. He's the pharmacy director here, and he has a big screen with satellite TV in his place. We watched speeches he'd DVR'd, including the convention speeches, the notorious Palin interviews, and some of the SNL skits making fun of the candidates. Then, we turned to the live coverage of voting across the US. Some of the group members stayed up most of the night watching. I went back to the student hostel and returned at 645 am (1045 pm EST in the US) the next morning to a room packed with med students, pharm students, and a couple of Kenyans, waiting for the West coast polls close. As 7 am rolled around and Wolf Blitzer announced that Obama was the predicted winner, a cheer went up in the largely Obama-leaning crowd. We stayed to watch McCain's withdrawal speech and Obama's acceptance speech, and then we headed off to work. Needless to say, all of the employees at the hospital were elated. There was much cheering, high fives, and handshakes. As Monty Python would say, "And the people rejoiced." Later in the morning, Kenya's president declared the following day a national holiday to celebrate the victory of a Son of Kenya, as they like to call him here. Smart political move, too, as the president is the guy who allegedly stole the election from Obama's tribe.

Last night (the night after the results came out, and the night before the national holiday) we went out to one of the clubs in Eldoret to see what the scene would be like. The bar, called Spree, is typically a quiet place with pool tables, a dance floor, and very tasty snacks (best samosas in Eldoret). The last time we went, we walked in, grabbed one of many open tables, and chatted for several hours. This time, the place was jam-packed full of Kenyans out celebrating. There was nowhere to sit, and we could barely hear each other over the din of shouting and American rap mixed with (of all things) 80s. The Kenyans went out of their way to ask each of us what country we were from, if we had voted for Obama, and if they could shake our hands and congratulate us. Quite a feeling!

There may be a downside to all of this ebullience, though. Don and I have often talked about what we see as a problem with the general enthusiasm for Obama. We have been trying to ask around about what the average Kenyan thinks will happen when Obama takes the presidency. Answers have varied from, "America will be like a brother country," to "it will be much easier for me to go to the US and work," to "other countries in Africa will respect us more because they know we have US backing now." We're a bit worried, obviously, at how exaggerated and unrealistic these expectations are, and whether or not there will be any backlash when they realize that Obama is not, in fact, a Kenyan, but an American whose responsibilities are to America.

We'll see....

Lake Naivasha and Hell's Gate....

This past weekend, we hit the road again. We all piled into a matatu and cruised the 6-7 hour drive to Lake Naivasha, which is a large, freshwater, high altitude lake. On the way, we passed over the equator!

0 degrees, and about a mile up.

Shortly after arriving, we took a boat out on the lake. The edges of the water were ringed by large clumps of vegetation that served has homes for many species of fishing bird. Near these areas, in the shallow waters, hippopotami tend to lounge around, waiting for the sun to go down so they can come ashore and feed. The water was warm, although cloudy and muddy. We cruised along to a peninsula and got out for an afternoon hike.

Our transportation

On the hike, we came very close to a herd of giraffes. We also saw buffalos (scary!) up close, some gazelles, an eland (largest and tastiest of the gazelles), zebras, more giraffes, and lots and lots of birds.

Keith and Nadine, photographing a giraffe from about 30 ft

It was a great walk around, and then on the way back in the boat, we whistled at some fish eagles and threw fish to them in the water. The way they swooped in from the trees ringing the lake, hovered, and dove for the fish reminded me of watching the War Eagle at the Auburn/LSU game with Laura shortly before I left to come here.

Fish eagle, swooping up our bait

After the fun day, we went back to the campsite and had a big tasty dinner. I ate some fresh lake tilapia with fries. Then we went back to the bandas, had a Tusker, and got ready for sleep. Unfortunately, for some reason, this place had no mosquito nets, and the mosquitos were out in force. I tucked myself in so only my mouth was exposed, but I could still hear them buzzing around and occasionally trying to land on my mouth. Sooooooo terrible. Andy and I both lied there in our room for hours tossing and turning and trying to find a way to breathe without suffocating or sweating to death (the comforter was really hot). I finally got to sleep around 2 am (after going to bed at 10) and Andy didn't sleep at all. To add insult to injury, I was sharing a bed with Kelvin, who both snores and has untreated allergies. Didn't help. I had a line of mosquito bites on my arm the next morning when I awoke. Hooray for malaria prophylaxis.

Giraffe!

Anyway, we got up again a couple of hours later, around 545, to get ready for the big day. We had a huge breakfast down at the main camp (English-style, as the place we stayed at is run by Brits), then rented cross bikes to head into the gorge. This was one of the best parts of Africa so far. With my Camelbak strapped up and filled with water, I mounted the bike and headed out with the rest of the crew.

Crystal, Don, and Emily, biking through the canyons

We biked about 5K over to the entrance to the park, called Hell's Gate. Once inside, we were biking down a dirt road next to giraffes, zebras, warthogs, baboons, marshall birds, ostriches, and all kinds of other wildlife. SOOOO much fun. Then, when we finally got to the gorge, we got off our bikes and walked down through the canyon ringed by hot springs.

Melissa, climbing down next to a near-scalding hot spring spilling into the gorge. Kelvin points the way.

Needless to say, it was a great day. Fresh air, wild African animals, exercise, and camaraderie.

The group, at the top of the climb back out of the gorge

Rural AMPATH clinics....

I should also comment briefly on the experience Nadine and I had last week. We had the opportunity to travel out to one of the rural AMPATH clinics. We traveled to Kisumu (the area of the country where Barack Obama's grandmother still resides) to work for two days at one of the rural clinics outside of town. It's these extension clinics that do all of the patient recruitment and on-the-ground treatment. It was refreshing to see a clinic dealing mostly with healthy patients. (Our patients on the wards at MTRH, given its cachement in the millions, are typically the sickest of the sick, having already been treated at and then referred from the outlying clinics.) We observed the breadth of the AMPATH approach to treatment by spending time with the nutritionist, the food delivery servicemen, the social workers, the registration officers, the pharmacists, the clinical officers (like physician assistants or nurse practitioners in the US), and then finally the MD we traveled with. We got to see lots of first-time HIV+ enrollees, as well as patients who had been on antiretrovirals for months and years. It was encouraging to see the progress that these clinics are making. There is currently a door-to-door testing initiative that is trying to test everyone within the domain of each of the rural clinic sites for HIV. Part of this initiative is to provide counseling and encouragement against the stigma that HIV used to carry. Slowly but surely, these efforts are taking hold, as people are allowed to stay in their villages, rather than be cast out and left for dead.

In sum, it was a fantastic look into how the AMPATH machine operates here.

Pediatrics....

So I started this week on pediatrics. I'll write more about it next week, but it promises to be a much happier experience than working in the adult side. Kids' resilience is a universal, even in places with few resources and with all of the odds stacked against them.

Hope all's well with you, and regardless of your party, I hope you enjoyed seeing democracy at work last week. Being here makes you appreciate an election without physical violence associated with it!

Week 3

The Goat (Sheep) Game....

Occasionally, the IU med students play a basketball game against the Kenyan med students. I'm not quite sure how the tradition started, but for the past few games, there have been two prizes at stake: 1) bragging rights; and 2) a goat.

This year, Phil went to town with Benson, one of the guys who works/lives at the IU house. They were supposed to buy a goat, but for some reason they ended up coming home with a fat sheep. I'll leave it to you to read more about it on Phil's blog (uvmster.blogspot.com), but we all heard it was a great time.

The game was played on a Friday night before we left for Kakamega rainforest. Our team looked very strong at first; we clearly had a skill advantage, and we were able to move the ball around easily and get some good outside shots. Unfortunately, the altitude and the athletic prowess of the Kenyans caught up with our team in the second half. The game ended up going into overtime, wherein the conditioned Kenyan athletes blew our team away. Thankfully for us, they agreed to share the sheep with us on Monday night after we got back from the weekend trip.

Don and one of the Kenyan med students, grilling up some sheep meat.

I'll spare you the gruesome details of the skinning and slaughtering in the lawn in front of one of the houses at the IU House compound (we have photos if you really want to see them). Don's dad is a vet, so he has lots of experience with animals and some with slaughtering. He helped the very skilled Kenyan med students with the slaughtering, skinning, and preparing of the meat. In the end, it turned out to be quite a party, with lawn games going on during the meat preparation. Everyone was happy with the result. The meat was a bit sinewy, but it tasted great!

Keith, one of our basketball players, enjoying his freshly-cooked dinner.

Medicine wards....

Last week was the third and last week on the medicine wards. Although some of the same frustrations I wrote about last week carried through, I did have some very interesting patients and even a couple who improved and by now (I hope) ought to be out of the hospital. For you meddies, I had a case of toxic epidermal necrolysis (TEN), the first I'd ever seen. Very, very sad. I had one patient in particular, with cryptococcal meningitis, who showed significant improvement over the course of the week. I was also able to spend a fair amount of time doing procedures, which is always enjoyable. My meningitis patient required what we call "therapeutic taps," which means doing a lumbar puncture (insertion of a needle through the back to drain fluid away from around the spinal cord and brain) every 2-3 days to relieve the increased pressure around the brain that results from the infection. We call it therapeutic because most lumbar punctures are done for diagnostic purposes (to detect what type of infection may be present, or to look for evidence of bleeding), but this tap is done to ameliorate the headache that arises when the pressure of fluid around the brain gets to be too high. It's a pretty great procedure, as it provides virtually instant relief of symptoms that are not really controllable by standard pain medications. I had done 5-6 lumbar punctures before coming over here, and I easily doubled that number over the last two weeks.

AMPATH....

Yesterday I transitioned off of the medical wards and started a week of AMPATH experiences. As I wrote about below, AMPATH is the institution associated with IU and Moi that is responsible for the treatment of HIV+ patients here in Western Kenya. We've been hearing more and more about the progress that the program has made since its inception. It's great to finally spend a week looking at how it functions. Yesterday several of us traveled out to one of the farms associated with AMPATH, where food is grown to provide to HIV+ patients and their families who are starting their treatment regimens. They grow a wide variety of crops, including leafy greens, onions, carrots, watermelons, etc.

I met a White Sox fan at the farm. Boo!

All of the food is given away until the newly diagnosed HIV+ patients regain enough health to participate in the workforce again. The goal is to eventually build up the farming with some cash crops (like sweet peppers) such that it will be a self-sustaining entity without any dependence on foreign aid. (The farming initiative is almost entirely paid for by USAID, the United States Agency for International Development, which gave AMPATH a $20 million grant recently to do this type of infrastructure building.) Obviously, the goal is to eventually make all of the services provided completely independent of donors, and the farm is a big step in that direction.

Crystal, myself, and Nadine, along with the farm workers we spent the morning with. They taught us how they fertilize beds for planting. We helped hoe and fertilize soil, and we planted some watermelon and tomato plants.

Today, Nadine and I will be headed up the road to the Imani Workshop. This is a place that employs HIV+ individuals and gives them an opportunity to re-enter into the workforce. Gaining employment after receiving a status of HIV+ is not easy here. 10 years ago, patients would have been thrown out of their villages and left for dead after receiving the diagnosis. But since that time, and largely due to the education efforts made through AMPATH/IU/Moi, which depend on community leaders and patients speaking to tribal councils and local villages, attitudes have begun to shift tremendously. When Dr. Mamlin first proposed the idea of setting up an AMPATH clinic/hospital that would be labeled as such, many critics laughed in his face and said that under no circumstances would any Kenyan willingly go to such a place and identify themselves so publicly with HIV. Now this clinic serves 13,000 patients who come on a daily basis for checkups and medications. The credit for this change should be given mostly to the patients themselves, who do almost all of the talking when AMPATH leaders go to visit outlying villages to try to educate and change the stigma surround the disease. There's still lots of work to be done, and the stigma is still more severe here than in the US, but progress is certainly being made.

I digress. The Imani Workshop is one of the institutions that provides labor for HIV+ patients. They fashion souvenirs, purses, bags, and many other products to be sold at market. The funds from this endeavor then go to pay the laborers so that they can become independent. The excess profit on top goes back to AMPATH to help pay for anti-HIV medications. Again, another part of creating sustainable development.

Tomorrow, Nadine and I will have the chance to travel with one of the Kenyan doctors to some of the outlying clinics. It will be a two day trip, as we'll stay overnight Wednesday night in a hotel in one of the rural centers. It should be a great experience!

Rafting the Nile....

So this weekend, we took another fairly long trip. 14 of us loaded up into two vans and headed west to the border with Uganda. For various reasons, including a strike by the Kenyan truck drivers, computer malfunction at Ugandan immigration control, and bad weather, the drive took almost 8 hours, but we did finally make it across and to a campsite near the source of the Nile. The campsite was fairly spartan, but we each had our own bunk beds in rooms that held six people, and there was a large bar/cook-to-order restaurant area. We were welcomed by the on-site directors, a young Scotsman and a young Australian (I love it that adventure travel around the world always, somehow, involves Ozzies), who gave us the intro for the weekend. Afterwards, we pretty much proceeded directly to bed in anticipation of the next day.

On Saturday, we awoke to perfect weather. The sun was already shining, and you could see the Nile bending through the lush, green land just below where the restaurant overlooked a steep embankment of about 50 feet. We all loaded up into trucks and headed up the road, where we ate breakfast and received our instructions, gathered up helmets and lifevests and oars, and got back into the truck to head to the water. Once there, we divided up with the other rafters (there were maybe 50 people total). Our boat consisted of me, Keith, Andy, Kim and Pearlie (two medicine residents from Lehigh Valley), Melissa (one of the pharmacy students), and Sarah (an OB/Gyn resident from University of Toronto). Our guide was a very chill guy named Elias, from Tasmania, who had only recently come to Africa after leading tours for some time in Australia.

So I've been rafting several times before. I spent a week with my family rafting lazily down the Green river in Colorado and Utah. I've rafted in West Virginia. And two summers ago I rafted on the Indus high up in the Himalayas. None of these experiences compared with rafting Class 5s on the Nile. The volume of water is simply incredible, and it's difficult to describe the force with which it rocks your boat.

To begin the day, we practiced flipping the boat, what to do when you're sucked down in an eddy, and how to avoid hurting your fellow rafters with your oar. All good tips.

I don't know if I can do justice to the rafting itself, but we have a video that I'll try to post if I can rip it off of the DVD. It gives you a much better idea of what it was like, and you get to see us being flipped out of the raft and sometimes, inexplicably, holding on when we should've flipped! This was the first time I've really been pulled underwater by a current, which is totally disorienting. You can't tell which way is up or down, and all you can do is hold on to your life jacket, hold your breath, and try not to panic. By the time you rise up you feel like gasping for air, even though you've really only been down for maybe 10 seconds. Such a rush!

Anyway, it was a fanastic weekend. Unfortunately, I don't have any photos to share, but the video is, I hope, pending.

Thanks for reading, and thanks for your comments! Hope all's well wherever you may be.

There goes another week

Frustrations….

Working in medical settings in the third world inevitably necessitates a change in expectations. In the West, we generally do anything and everything that is necessary for the patient to live, with regard to cost and resources only after the fact. In places like rural Costa Rica, remote northern India, or most parts of sub-Saharan Africa, thought must be given to these considerations beforehand. When someone is dying on the ward and has begun to lose cardiac and respiratory function, we often call a “code “ in the US. This involves a team of nurses, physicians, and technicians who immediately attend to the patient. This often involves intubation (place a breathing tube, typically attached to a ventilator). Code situations or pre-emptive intubation (for the patient who is going downhill and has foreseeable respiratory failure) frequently result in stabilization and the patient may be moved to the intensive care unit (ICU) for more specialized care with continuous drips of various medicines and aggressive ventilator management. At the Moi Teaching and Referral Hospital, one of the largest institutions in Kenya, there are five ICU beds with ventilators. These are generally reserved for post-operative patients who need monitoring until anesthesia wears off. Only very rarely may they be used for patients on the wards, and only in cases with immediately resolvable issues (such as acute poisoning, where after a brief ICU stay with dialysis a patient might be expected to make a full, or close to full, recovery). With any other patients who are “coding” or close to coding because of an underlying process with a more dismal prognosis, the standard of care is not to code.

All of the above is to say simply that patients here often die much sooner than you would expect coming from the West. There was a morning last week when Serena, the Purdue pharmacy student on the same team with me, and I arrived for rounds only to discover that three of our patients on our census of 15 or so had passed away during the previous night. We were shocked. The most upsetting part of it was that no one seemed to know how or when they had passed away. All the team knew was that the beds were now stripped and sanitized, ready for new blankets to be put down, which meant either they had been discharge or had died. Since we hadn't discharged them, we knew they must have died, which the nurses confirmed. We couldn't believe how little gravity and attention was placed on the departure of three people from this Earth.

Sadly, they all died from conditions that should be easily managed and treated in the US. The anger and frustration that arises from these situations is tough to describe. In contrast, the Kenyan medical students and physicians take it all in stride. This blase attitude is not due to lack of compassion, but rather that you simply become accustomed to the facts of the system over time. If the rate of death on the inpatient service is always that high, you simply know that you cannot save everyone, that you are not God, and that you can only do what you can within the limits of the system. Death becomes part of life. It would be impossible to base your emotional and psychological well-being on the health of and survival of each and every patient; you would end up destroying your own mental health and your ability to take care of the next patient. So, you care as much as you can , you do as much as you can, and you work to improve the system. The rest you accept begrudgingly as things you cannot change, at least not immediately. After all, we are not the final arbiters.

However, even here, some of the deaths ought to be preventable. The nurses are completely overwhelmed, taking care of 10-15 patients each. (In the US, the average would be more in the 4-6 range, or fewer in the ICU). That being said, one of our patients who died last week had been on service for four days with hypertensive urgency (uncontrolled blood pressure). He was only intermittently receiving his medications even in the hospital. We complained to the nurse, tried to emphasize how important BP control was with him since he was having symptoms from it. When we came in the day after he died, we saw that he had not received his BP meds again the previous day. Whether he stroked and died because of that failure, or whether it was some other cause, we'll never know, but the disappointment and anger over such a preventable passing lasted all day...until the next admission of a sick patient needing our help. And it starts all over again. Do what you can. Change what you can change. Accept what is beyond your control. Trust in God.

(One of the reassuring considerations when events like this happen is to think that a mere 20 years ago, there was no hospital in existence here at all. The progress that has been made has been exception. Obviously there is a long way still to go. It's for that reason that people like the Mamlins and their Kenyan counterparts work on a daily basis to make those infrastructural changes that will be necessary to improve outcomes in a sustainable way. Imagine what further change might occur in the next 20 years!)


Natural history….

Partly because of the lack of preventative care and the lack of resources here, we as medical learners have the opportunity to see and to learn what is called the “natural history” of disease processes. This term refers to the way in which a disease progresses, from onset to endpoint, without any intervention or treatment. The endpoint can be resolution of illness without sequelae (long-lasting repercussions); it can be some sort of permanent impairment; it can be temporary resolution with later recurrence; or it can be death.

We don’t often see the full natural history of most diseases in the US, because we intervene and treat and alter the course of history for that particular illness. Here, however, we’ve had many opportunities to see much more of the natural history of diseases like HIV, Tb, meningitis, rheumatic fever, heart failure, cancer, etc, than you would see at home. While it is sad and sometimes horrific to see this natural history before your eyes, it also serves as a strong education by sharpening our mental images of how diseases typically progress. Having now heard the unmistakable murmur of profound mitral valve stenosis (the valve controlling blood flow between the left atrium and left ventricle in the heart) caused by rheumatic fever in several patients, I know that I won’t miss this finding back in the US, rare though it may be. Having now seen several patients with disseminated Kaposi’s sarcoma (and AIDS-defining malignancy), I know I won’t miss those lesions in a previously undiagnosed ER patient in the US. The same goes for the natural history of malaria, Tb, meningitis, etc. Seeing and understanding the full scope of the disease process here should mean (I hope) that I will be able to more easily recognize the early stages of these diseases back home.


Unwinding....

I get the feeling we'll be traveling and trying to explore other parts of Kenya almost every weekend here. To this end, we took two SUVs and drove down a couple of thousand feet in elevation to the rainforest on Saturday morning. The area we camped at is called Kakamega Rainforest. It's a protected reserve of what used to be a forest that was continuous all the way from Kenya through the Congo. This huge swath of rainforest has been hacked up and carved up over the past century by British colonialists and local communities such that only a few small pockets remain. Kakamega is one of those pockets.

Keith's photo, experimenting with his camera settings. Kakamega is full of flowering plants.

After two hours on the bouncy, pothole-ridden Kenyan "highways," we made a turn off onto a dirt road that led into the forest. After another 20 minutes or so of jostling along the road through the increasingly dense foliage, with large broad-leaved trees stretching above the road and Kenyan men riding by on bicycles and women carrying cut logs for firewood on their heads, we finally arrived at a small clearing near some traditional thatched-roof houses.

A view from inside the banda. Phil, the side of Benson's head, and Keith.

We stayed in similar, but much larger, thatched huts called "bandas" at the edge of the forest. Each banda had a couple of beds with mosquito netting overhead. All of the cracks and openings between the walls and the roof were covered with wire mesh to keep out mosquitos. The floors were cement covered over by dirt. No electricity or water, but quite comfortable.

Keith, sitting atop a lookout tower for the biologists who work in the forest. You can see forest to your left and a large clearing in the center.

There were 13 of us in attendance (me, Keith, Nadine, Andy, Don and his wife Crystal, the five pharmacy students, Phil the resident from Brown, and Benson, one of the Kenyans who lives/works at the IU house). So, quite a crowd. We had four bandas, and they each surrounded a central meeting/eating area. We did two hikes, one when we first arrived and another at 5 AM to climb up to a hill top that overlooks the whole forest where we could see the sunrise (although it was a bit cloudy, and thus we didn't see much of the sunrise...but it was still an amazing view and it was nice to be up and out before dawn!). The forest was thick and dense. It reminded me of the rainforest in Costa Rica, although it was less humid here, as we were still at roughly 5000 ft.

One of the many monkeys near our camp.

We saw all kinds of varieties of plants and trees. Additionally, the rainforest is host to 200 of the 400 butterfly species in Kenya, so we saw a number of them, many brightly colored, others darker and closer in nature to the black swallowtail that's common in Indiana. One of the best parts was the monkeys! They were everywhere. There were three different species we saw, each of which were pretty different (four if you count the baboons we saw during the morning walk).

Walking through the forest. Much greener than Eldoret!

On Day 2 we had an episode with some of the blue monkeys, who descended from the trees to steal a loaf of bread from us.

Andy, Nadine, me, and Keith, all standing within a tree that's been strangled by another tree

We also went briefly into a bat cave in the side of the hilltop that we climbed on a walk at sunrise. I was expecting dormant small bats attached to the ceiling of a large cavernous cave, as you tend to find in southern Indiana. I was wrong. These bats were huge, the cave was small and narrow, and there were anything but dormant. Given my distaste for bats flying close to one's head, I didn't last long before I had to leave, but it was definitely an experience.

Phil, cooking up his masterpiece over the fire. Veggies on the left, chicken on the right.

For dinner, Phil cooked an amazing meal of carrots, potatoes, onions, and chicken, wrapped up in tin foil, seasoned well, with some white wine added to the veggies and some Tusker (the Kenyan national beer) added to the chicken. It made for a delicious meal. After the meal, we sat around by the fire and listened to Benson tell us about how to avoid being eaten by predators in Kenya. I wish I could approximate his high-pitched, colorful voice with his Kenyan accent, but I really can't describe it except to say that his stories were enthralling, especially after he'd had a couple of Tuskers.

Tasty meal, eaten with a leatherman, complimented by a Tusker

In the afternoon on Day 2, it poured on us (I guess there's a reason it's called a rainforest), so we just sat around and waited to be picked up.

Looking down on the rainforest from atop a hill (the highest in the area) after our sunrise hike on Day 2

That's it for now. I'm off to go enjoy some fresh sheep meat (the result of a basketball tournament, I'll write more about it later this week) and move my things down to the hostel, as Nadine and I are swapping locales today.

One of a hundred bats in the small, narrow cave.

Cheers!

Maasai Mara

Old male lion, as seen from a safari van.

Weekends....

Since Friday was a holiday (Moi Day), we had our first extended weekend to travel outside of Eldoret and explore more of Kenya. To this end, a group of us signed up for a trip to the Maasai Mara. Mara is the name of the river that runs through this part of the Serengeti, and the Maasai are the native people who live in the southernmost portions of Kenya. They are a tribe of semi-nomadic character with very distinctive, brightly-colored dress. Their males carry large spears. They are a monotheistic, patriarchal people who subsist mostly on the food and trade provided by their herds of cattle, sheep, and goats. Interestingly, one of their religious beliefs is that God provided cattle for them to live; they therefore believe that all cattle on Earth belong to them. Needless to say, this can be awkward when they try to claim ownership over their non-Maasai neighbors' cows! They share many similarities with American Indians, as they had their land reduced in a piecemeal fashion by Westerners (the British colonial government) in the early part of the 1900s, and they now live mostly on reserve lands in southern Kenya and northern Tanzania.

Our trip involved hiring a driver (Hassan, who often drives for the IU House) to take us into the park to a lodge. The drive took about eight hours over variable roads, with the final hour or two consisting of mixed dirt and paved road with jarring bumps throughout. We also descended quite a bit in altitude from the 7000 ft elevation of Eldoret. As we went down, the temperature rose and the vegetation changed, from the lush greens around Eldoret to the more open expanses of browns and golds that is stereotypical of African plain regions.

Left to right in the van: Phil, me, Crystal and Don Zimmer, Nadine, Andy

On arrival at the park gates, our jeep/van was stormed by Maasai women selling various wares, including hand bracelets, painted wooden masks, and small spear tips. We all successfully avoided purchasing anything, except for Keith who bought a mask.

After proceeding through the gates, we started to really see some of the wildlife in the park, including tommies (small gazelle-like animals), zebras, and a few wildebeests. We proceeded immediately to the lodge where we were staying, as our first true "safari" wouldn't occur until later in the afternoon.

Andy, Keith, Phil, me, and Don outside one of the "tents"

The lodge itself is basically a 5-star hotel. We had requested the next step down in accommodations, but given that it was holiday weekend, they were all booked. This was a plus for us, because we got bumped up without any increase in price. Our rooms were semi-permanent "tents," complete with hardwood floors, marble bathrooms, hot water, and electricity. The lodge itself has a large restaurant area with an all-you-can-eat buffet for every meal (we definitely took advantage...I think most of us gained five pounds over the weekend!). Additionally, there was a meeting area/bar with a huge fireplace, an outdoor pool, a lawn for yard games, and a pond with a walkway overtop.

Nadine loves giraffes

Without being too long-winded, it was basically a Western-style paradise in the middle of the African plains.

As seen from the van

On safari, we had the chance to see basically every animal you'd want. We got up close to lions on several occasions, both male and female. We saw gazelles, tommies, topis (smaller deer-like animals with small straight horns), wildebeests, zebras, hyenas, warthogs, jackals, and plenty of birds, hawks, and vultures. We went to an area where hippos wade to see a pack of them cooling off. We saw a cheetah on the prowl. And on the last morning, best of all, we saw a leopard lounging out by a bush, with a half-eaten topi hanging from a tree next to it. Straight from a Discovery channel documentary.

Don, on the lookout

I'm sure I'll have this feeling on future weekend trips as well, but we all couldn't help but notice and be somewhat bothered by the stark contrast of our weekend life compared to the weekday life we see for our patients in Eldoret. The extravagance of wealthy Western vacationing stood in stark relief next to the abject poverty and poor health of our patients. We all felt somewhat guilty while out on safari, knowing that we were living a kind of life that only the richest people in the world can enjoy, while there were patients dying back in our hospital for lack of those same resources. Obviously, there is no real way to palliate this feeling except to do your best to fight against those disparities as you are able. I would like to think that our work here would count as part of that fight, and that we will take those sentiments of guilt and anger back to the States with us, where the same kind of disparities exist, if only in somewhat smaller magnitudes. And if there is a lesson to be learned from observing doctors like Joe Mamlin, it is that the best way to address disparities is help build and strengthen sustainable institutions that can address problems in a systemic fashion. Such is the lesson of AMPATH.

Hyenas, finishing off a wildebeest (we thought) carcass

Despite these misgivings, we did enjoy ourselves thoroughly. The wildlife we saw was incredible, and I felt privileged to have seen these animals in a truly wild setting.

Excited to see a lion, about 15 ft away

Give credit where credit's due....

I neglected to mention last week that we've been compiling photos on my computer, so some of the pictures you see may be mine, but many of them were actually taken by Keith, Andy, or Nadine.

Back to rounds....

I think we're all starting to settle in to our roles here. The last couple of days of rounding last week felt less foreign, and this morning I've begun to interact more with my Kenyan colleagues (up until now, I've basically stood and watched during rounds, trying to understand the way the system here functions). Each day is a new learning experience, not only with regard to general medical fund of knowledge (manifestations of tuberculosis...complications of HIV...typical reactions to antiretroviral/anti-HIV drugs...treatment of organophosphate poisoning...treatment of prostate cancer...diagnosis and treatment of UTIs), but also with respect to procedures (IV placement, lumbar punctures, chest tube placement and removal, abscess drainage) and health care system function (what antibiotics are available here...what is the cost of text X or treatment Y...do you start empiric treatment without an absolute diagnosis because more testing would financially ruin a patient...who follows up on lab tests...who hangs IV bags...etc, etc, etc). The differences are sometimes rather nuanced. I'm sure by the end of two months I'll have only begun to appreciate some of the more obvious ones. One of my US attendings who helped establish the program here, Dr. Einterz, once told me that it took him almost a year before he felt comfortable enough with the system here to take total charge of his patients' care.

That's it for now. I'm headed back up to "clerk" (admit) patients this afternoon, so we'll see how the week goes!

Kwa Heri....

Swahili for "good-bye" or "go with blessings."

Week One

Wow! It’s only been a few days, but quite a bit has happened since my last post. Let me fill you in.

Andy, me and Nadine walking from the IU House over to the hospital.

Rounds

I admitted my first patient on Tuesday afternoon. He was a young guy from an outlying area who ingested this substance here called “dip,” which is basically the pesticide of choice in Kenya. Unfortunately, its mechanism of action against insects (it’s an organophosphate with similar properties to the more concentrated and lethal Sarin or VX gas, most famously used on the Japanese subways a few years ago, and also featured prominently in The Rock with Nicholas Cage) also works against humans. It also happens to be a preferred method of committing suicide here, and this gentleman was the second person on our service suffering from “dip” poisoning. Unfortunately, there really isn’t much of a treatment aside from supportive care with atropine (part of the cocktail that Nicholas Cage injects into his heart at the end of The Rock). On the upside, we don’t generally inject into people’s hearts; peripheral IVs work just as well.

Trying to see the consultant (attending) during rounds. Always a challenge.

One of the major differences between hospital-based healthcare here and in the US the limitation of resources in Kenya. This not only means that many drugs aren’t available (although their formulary is pretty extensive, actually), but also the lack of ICU capacity. There are only five ICU beds here with ventilators, and they’re mostly reserved for post-operative patients who are expected to make a full recovery. For your typical patient on the wards who “codes,” or goes into cardiopulmonary arrest, there is simply nothing that you can do. There is no code team. There is no intubation. The resources simply don’t exist. Even if you could intubate and get the patient through the initial phase, the rehab facilities necessary to bring them back to quasi-normal functioning also are scarce, and the cost associated with such treatment would totally devastate any family here.

With respect to cost, it’s also interesting here that some families pull their loved ones from the hospital prematurely due to cost constraints. We had another patient on the wards for the last two days with a brain infection caused by toxoplasmosis, which is an opportunistic organism that targets patients with weak immune systems, such as those with AIDS. This patient was not doing very well. He had a very severe infection in his brain with swelling and inflammation that had resulted in complete quadriplegia. In cases like this where the outcome is looking dim and the prognosis is poor, many families do as his did: they paid their bill, removed him from the hospital, and took him home to care for him. Most of these patients are never seen again.

Even given these limitations, the physicians and nurses here are doing great work. When I think about the fact that this hospital did not even exist 20 years ago, I’m amazed at how much progress has been made. The AMPATH program, with its cost-effective mechanisms for distribution and monitoring of anti-HIV and anti-Tb drugs, is making a tremendous difference. We see patients every day here who would have died long ago without these institutions in place. It’s definitely an honor to participate and learn from the doctors here, who have so much experience to share.

Outside the hospital

Outside the hospital, life has been good. Just like moving to any new place, it's involved a series of adjustments. Brushing teeth with bottled water. Walking 15 minutes on a dirt road to the hospital. Not being able to call home whenever I want. Having to walk another 20 minutes from the hospital down to town for any purchases I might want to make. Etc, etc.

But overall, the transition has been pretty smooth. I miss you all quite a bit, but luckily, we've got a great group here. The residents and faculty are all very welcoming, as are the Kenyan medical students. In fact, we had a chance to head over to meet some of the med students with Sarah Ellen Mamlin. The occasion? Hep B vaccines!

Andy giving a Kenyan med student a vaccine. (Not the best way to make new friends.)

The IU House also gets together on Wednesday nights for dinner out on the town. Last night we went to a Sikh restaurant on the far side of town. There were in excess of twenty of us for the feast.

Nadine, Andy, Keith and me during IU House dinner on the town

Tomorrow morning at 5 AM we leave for a long weekend trip (tomorrow is Moi Day, a national holiday named after the second Kenyan president, just like Moi University where we're working). Our destination for the three-day weekend? Maasai Mara! This trip is what you think of as a typical African, non-hunting safari. We'll be traveling through a portion of Kenya's national park, which is essentially a contiguous with the serengeti. Supposedly, we'll be seeing lions, hippos, giraffes, etc. Pics to be posted next week!

That's it for now...time to pack for the weekend.

Cheers!

PS: If you're interested, here is Keith's blog, with plenty of extra photos:

http://keithmd.blogspot.com

I'll add Andy's next week. I don't know the address offhand.

The first few days....

Hi all,

If you're on this website, you know I decided to do a fourth-year med school elective in Eldoret, Kenya, which is in the western Rift Valley area of the country. The elective is two months in duration, so I'll be over here from October 1 until the end of November (sadly, just after Thanksgiving!). The Internet has been good to us so far, so I've elected to communicate with you all mostly by blog. If it goes down...well...my posts will become more intermittent, but I'll do the best I can.

My primary traveling partners are Keith Earley, Nadine Wakim, and Andy Shriner. We're all fourth-year medical students. We're all, for the most part, pretty laid back people who are interested in the world outside of what we know. So far we've traveled well together, and I'm excited to spend the next couple of months with them.

First, some background

Indiana University started sending physicians to Kenya about 20 years ago. Dr./Prof/Godfather Joe Mamlin is the director of all things IU here. In about 1990, shortly after he arrived, the Kenyan government decided to open its second teaching hospital (the other is in Nairobi). This hospital would be named after Kenya's second president, and would be called the Moi Teaching and Referral Hospital. Since its inception, the school has been tangled up with IU, as faculty and residents have gone between the two. Later, students started the exchange as well.

Shortly after the inception of the new medical school here and its partnership with IU, the physicians here were faced with a rising epidemic: HIV/AIDS. It became a primary goal of the school here to treat and prevent this terrible infection, especially in this part of the world where access to the latest antiretrovirals and other medications may be limited. Out of these efforts, Dr. Mamlin and his Kenyan colleagues developed what is now known as AMPATH: The Academic Model for Prevention and Treatment of HIV. This program serves roughly 60,000 HIV-infected individuals in the area. It has also garnered significant international attention due to its focus on sustainable development of local resources and infrastructure. This attention resulted in Dr. Mamlin being nominated twice in recent years for the Nobel Prize.

Those are the basics of the setup here. Now, I'll put up some excerpts of emails I sent to my family on the way here.

Traveling...with a stop-over in London

So we made it safely to London. Things have been well here. We got in early yesterday, took a nap, got some fish and chips, walked around quite a bit and saw some of the city, including the London Eye, Big Ben, the Houses of Parliament, Westminster from the outside, and the Millennium Bridge (kinda the usual, touristy-type stuff that most people see). Today we slept in a bit, then took the tube down to the Globe where we caught a 2 pm showing of 'The Merry Wives of Windsor'. Although it was freezing cold and we had the worst seats there, it was hilarious and definitely worth doing. Afterwards, we walked over to the Tower Bridge, then we tubed it up to Oxford Street to do some window shopping (except for Nadine, who did some real shopping). Then we walked around aimlessly until we found a nice little bistro-type restaurant to eat at. I got some DELICIOUS mussels in a cream sauce followed by some vegetarian lasagna with a glass of white wine. Finally, we worked our way back to the hostel to get some internet time and some sleep.

Side note: we're staying at a hostel called Generator near King's Cross. Apparently it's capacity is about 800 raucous twenty-something travelers. Ever try to sleep to the sound of drunk Germans doing karaoke to 80s Madonna? Well, it's an experience, let me tell you.

Tomorrow, we're going to take a trip to the British Museum (one of my favs--the Elgin marbles and all) and Buckingham Palace before heading to the airport. We have a red-eye tomorrow evening down to Nairobi, followed by a flight Sunday afternoon into Eldoret, where we'll be picked up by the team leaders from the IU House. Then the trip really starts.

So, all in all, things go well. I may or may not start blogging next week, it depends on the internet situation in the hostels and how busy we are on the wards.

After arriving in Africa....

We made it to Kenya!

Things are good so far. We had a good but brief day in london yesterday, then took a red-eye down here from london. Great flight, virgin atlantic, so we each had our own LCD with tons of TV/movies. I watched Don't Mess with the Zohan, which was only marginally funny, then slept for about 5 hours and watched some Entourage. Good flight overall.

Getting into Nairobi was pretty awesome. The earth is all dark tan and clay, looks very stereotypical of Africa, with sparsely located trees. Nice breeze though today, in the mid 60s, very comfortable. Ate at a nice restaurant outside at the airport (had fried tilapia with chipatli, which is basically like nan, or Indian flat bread, and a Coke classic). Then waited around for the flight to Eldoret. Eldoret is MUCH greener, and more elevated (7000 ft or so). The temp was high 50s or so here, maybe low 60s. You'd be really interested to see it.... Dirt roads, with dirt paths worn next to the roads where people walk so they don't get run over. Already saw a cart pulled by goats. Sweet.

The IU house is VERY nice. Like a little piece of America. Hot water, Internet, clean rooms, tasty food. Everything you could want. Great people. One of the pharm directors is this young dude who has a flat screen with satellite in his room and he invites the med students over on sundays to watch football games. Crazy!

After the first day on the wards....

On waking today, we headed down to the cafeteria for some toast, coffee, and juice. Afterwards, we all gathered up, left the IU compound, and walked the 15 minutes or so down the road to the MTRH complex. Here we got a quick tour of the hospital grounds, followed by assignment to a team. Everyone does three weeks of adult medicine, three weeks of pediatrics, one week of work with the AMPATH clinics, and one week off at the end to travel. I started today on adult medicine.

The team is composed of about 10-14 people, depending on the day. Here's the hierarchy:

Consultant: This is the person we'd call either an attending or staff in the US. They have the final call on any decision. They only round with us about 2 days a week, and the days they are there are considered "formal" rounds. Haven't experienced this yet, as our consultant wasn't in today.

Registrar: This is the Kenyan version of resident, although they're a bit more advanced than US residents (they've already done an internship and practiced general medicine for three years before pursuing "registrar" training). Our registrar is in her third year, which basically makes her a PGY6 or so in the US (like most graduating fellows or a senior neurosurgery resident).

Clinical officers: Basically a nurse practitioner or physician assistant in the US. Haven't met one of these yet, they run the clinics mostly.

Intern: Recently graduated medical students. They run the show for each team. The make everything happen. (For those of you in medicine, they have Q2 call for basically a year. That's how hard they work.)

Medical student: Can be anywhere from 4th to 6th year, because they start right out of high school and complete med school in 6 years, where as we do college and then med school for a total of eight years. They basically cut out the goofing off and the random British literature classes that we take to be "well-rounded" in the US, and instead focus immediately on their primary career.

In addition to these folks, we have a Purdue Doctor of Pharmacy student on each team, along with a Kenyan pharmacist. My team also has a US resident, Phil, who's here for a month from Brown. Today, Phil and our Kenyan registrar ran the service. Lots of great teaching, lots of great cases. The HIV infection rate among the inpatients is ~50%, so we deal with lots of AIDS-related illness. As a corollary to the high HIV rate, there is also an extremely high rate of tuberculosis infection. By the end of the two months, I'm sure I'll have seen as much TB as I will in the rest of my career in the US.

In general, the wards are clean and efficiently run, at least more so than I had imagined. The beds are spaced about four feet apart in bays with open windows. Some beds are shared with two patients to a bed. Today was cool and there was a nice breeze blowing in the windows, so the heat and smells weren't too bad, but I've heard they can simply be suffocating at times (many med students have passed out during rounds, apparently). Today was a great introduction to the system, with plenty of challenges to come, I'm sure.

Tomorrow, my team admits patients (each team admits every other day). So, that'll be when I really start to dig in and learn about the sources, manifestations, treatments, and consequences of disease here. Should be good!

That's all for now....

Thanks for reading this ridiculously long initial post. I can pretty much guarantee they'll be quite a bit shorter from now on. After all, brevity is the soul of wit.

Cheers.