Last days

It is hard to believe my time in clinic here is coming to an end. I am really sad about leaving (and not at all looking forward to going back to residency in a few weeks – though I have only 6 weeks to go!). I have made wonderful friends here and feel more so than I ever do at home that work is making a big difference in people’s lives. I will also miss the sunshine, fresh mangoes, and daily swims in the pool! At our staff meeting this morning (attached are pictures of staff singing and dancing to open the meeting...and Sophy filming it), they gave me a beautiful woven bag and a card as a thank you and people have been asking all day if I will come back. Of course I will. It is hard to see such a level of need and suffering – and such wonderful people working to alleviate it - and not want to return.

These last pictures are around town – two of our friends from clinic took Sophy and me out to buy some local music in a tiny shop down an alley where they custom made mixes for us. Tomorrow night we’ll all go out and listen to some of the real thing before I head off. Also included: the view from our apartment of Lake Victoria at sunset.



I will spend the next ten days traveling – on safari in the Masai Mara, climbing Mt Kenya, more safari near Nairobi – then off to London to visit Katherine and Eugene.

Hospital visits

Every week we visit our clients who are hospitalized. The public district hospital, also known as “Russia”, was built in the 1960’s by (you guessed it) the Soviets and is quite similar to the hospitals I saw in Cuba – from the cement block architecture, to the peeling paint on the walls, to the open wards, with 10 – 20 beds per room. However, Kenya’s public hospital is slightly worse. There is visible dirt on the floors and walls, flies everywhere, almost overpowering smells coming from the open toilets just off the wards, and the degree of illness – emaciated, near comatose patients in most beds – is chilling. Not surprisingly we try and do everything possible to keep patients out of the hospital – even if they are sick enough to merit admission in another world. I think as much disease is caught as treated here – a patient with active TB will be sitting next to a patient with advanced AIDS. It is malaria season now – I diagnosed 6 patients with it just yesterday – and it often brings out other diseases in our already debilitated patients. The quality of medicine practiced is, at times, frightening – tests not done for days, treatments not given (sometimes because a family just can’t afford to buy the medication needed), diagnoses missed. The care on the ward is run by clinical officers who are rotating through for three months – with less training than most medical students in the U.S. so in some ways the level of care is no surprise. We visit patients as much as anything to check that they are being evaluated and treated appropriately and to either bring or help their families buy the medications they need. What is really remarkable about all this, is one of the clinical officers from our clinic was telling me how much better it is now – it is rare to see two patients to a bed (except in the pediatrics ward where that is standard), AIDS patients are actually cared for (rather than being left in the corner, denied beds, and not touched by any provider for fear of contracting the disease), food is provided for patients three times a day, and the bathrooms are actually cleaner than they used to be. The picture above is from the outside (looks pretty nice from here!) and two of the clinical officers I have been working with.

The private hospitals are a different story - still definitely not what I am used to, but at least not the public health nightmare that the district hospital is. Not everyone here is suffering the level of poverty I am seeing so often.

Kakamenga Rain Forest

This weekend's travels took me to the last remaining swath of rain forest in Western Kenya, Kakamega, which used to be part of a band that stretched across Africa from the Ivory Coast. As a result of human encroachment and land overuse it has shrunk to only 230 square kilometers, which is now being "protected" by a local organization. As always the travelling was as much an adventure as being there.

The forest is near a mid-size town but essentially quite rural. After an easy matatu ride to the town, I wandered through the bustling Saturday market in search of buses to Shinalayu - a small town that marks the end of the road for public transport. The "bus" was actually just a pickup truck with two rows of facing benches and a roof. As always, the rule in Kenya is there is always room for one more. On the way out, this was fine - a cozy mix of people, chickens, and market purchases bumping over the country roads. On the return trip, in addition to the twelve of us seated on the benches, four chickens, and two small children, we then proceeded to add EIGHT more people to crouch in the (nonexistent) space between our knees and two more hanging off the back. It was like a bad version of that soap commercial ("aren't you glad you use Dial..." though of course most people don't have the luxury of daily baths or deodorant). I thought we might have gone one too far when one of the chickens started to lose it - after a flurry of squawks, feathers in the air, wild pecking, and lots of shouting in Swahili, order was somewhat restored.

From Shinalayu, I then took off on an hour's walk down the road towards the rain forest. It is beautiful country, quite lush, the red road lined on either side with farms - and of course, many small children, yelling "Mzungu" and running out to shake my hand. It is also a bustling thoroughfare for commerce - the bicycles (as pictured on the right) or people's heads (above) are piled high going to or from the market. Two popular items of transport are the long grasses used to thatch roofs or as cattle feed and long branches for firewood. I later learned the reason these were all being transported rather inefficiently. As part of the environmental protection of the rain forest, goods that are illegal to remove from the forest (grass, wood, bark), are okay to take as long as they are carried out by hand and not by a vehicle that would pollute the area. Though, of course, other diesel-powered vehicles are allowed through - and no-one is trying to really stop the removal of products from the supposedly protected forest.

The forest itself is beautiful, filled with butterflies (home to 45% of the country's species), birds, and monkeys. I stayed in a little cabin on stilts - looking out into a sea of green. It was great meeting the other travellers and sharing stories - including two other women, Spanish and Swedish, who had done quite a bit of traveling on their own. We went on an afternoon hike in the dripping forest (it rains 200 cm per year and this is the rainy season), stood inside trees hollowed out due to "strangler" vines, watched the monkeys play at dusk in the trees outside our rooms, and did an early morning walk to listen to the birds and watch the sunrise. We did see one viper - but it was very small and our guide assured us it would only bite if we tried to harass it - so there is no picture of said snake and I am here to tell you about it. Very relaxing just sitting on the porch listening to the sounds of the forest.

The matatu ride back was great. There are no scheduled departures, your bus just leaves when it is full. The one I climbed into was blasting reggae in Swahili - the cashier (fare collector/general recruiter of passengers) was urging passersby to check out his very nice car and join the trip to Kisumu (and all points in between). We then took off around the neighborhoods of Kakamega recruiting additional passengers - remember, no vehicle is EVER full. Then took off down the mountain, barely slowing to let off passengers and pick more up - literally, they often come at a run. Despite all the unscheduled "stops" we made the trip back down in far less than it had taken to get there.

I spent a very American afternoon - sitting by the pool with Sophy, another medicine resident who has just arrived from San Francisco and the pediatrics resident, Lisa, who is about to head home.

Food

My lunch everyday costs about 50 cents. The Kenyan diet staple is ungali - a big pile of starch which can be made from corn, yucca, millet, or any other grain which is boiled in a big pot and served in a lump next to your beans/meat/greens. (see photo to right). You then break off a little chunk, make a scoop out of it and use that as a spoon to eat your food. (see left). Lunch is usually beans, sukuma wiki (greens), and ungali, rice, or chapatis (there is a sizeable Indian influence here). The common thing to have on the side is nyama choma - which is roast meat (not planning on trying that...i'm sure its great.)

As Kisumu is right on the lake, fish is a huge part of the diet. It is sold directly out of the market - which always smells great on a hot afternoon. And in restaurants (open air shacks that are everywhere called hotelis) is served whole - eyeballs and all. The better part of the market is the fruits and vegetables - mangoes, pineapples, passion fruit, avocadoes - all very in season and very yummy.

BUGS!

The other night was like a scene from an Alfred Hitchock movie. It was pouring rain and every creepy crawly thing that lives outside was attempting to get in and many of them succeeding. Within minutes of the onset of the rain, moths were pouring in through cracks around the screens. I looked up to see hundreds of flying bugs outside. Before I could plug up all the holes in the screens 2 lizards and probably 50+ bugs found their way in. After trying to beat them off for a few minutes, I finally retreated to the safety of my mosquito net covered bed. Once the power went out the lack of light calmed things down. I came out the next morning to a ground covered in bug carcasses (apparently these particular flying things only last a few hours).... not one of the prettier sides of life here.

Last night I was much smarter and all doors were tightly shut at the first rumble of thunder and I could watch the idiot bugs swarm my porch from the protection of my bug free living room.

Outreach

Today I travelled with one of the outreach team to the slums. The outreach teams consist of a group of young adults who are trained at the center and get paid a small salary to go out every day of the week to different sites around the city and offer HIV testing and counselling. There are also two professional counsellors who do the testing and the training. The group I was with was composed of kids (the oldest was 21) who were in recovery - mostly from alcohol abuse. All had graduated or nearly completed high school (a relativelly rare feat) and then had found themselves with nothing to do and fell into drinking and smoking weed (there are few harder drugs, like cocaine or heroin in Kisumu). The unemployment rate in Kenya is estimated to be THIRTY FIVE to FORTY percent!! The youth center also offers a drug treatment center which all these kids had been through and were now employed there.

The most fascinating part of the day was talking to the kids between their recruitment efforts about their experiences. Although they joked about it frequently, they were clearly frustrated by the poverty and lack of opportunities in their country. They were fed up with the government corruption and lack of government action to create jobs. Barak Obama, whose father is from Kisumu, had recently visited the region and there was frequent talk about how great they would have it if someone like him was in charge. They thought their own government was old and inbred (which it is a bit). They also thought Obama being the president of the U.S. would make their lives better as well. Emigration was universally seen as the best option - but not really a feasible one for most of them, both because of the cost and the lack of visas. Their life goals basically centered around staying sober and keeping a job. One or two of them mentioned wanting to go to college but not being able to because of funds. The same acceptance and depression I saw in the patients newly diagnosed with HIV was visible here. And I can see why. We were in the middle of the horrible poverty of the slums and these kids were faced with few options.

The point was illustrated later in one of the patients I saw with one of the counsellors. Her husband had died in 2000 (of an accident - not AIDS for once) and had left her with four children to raise and no income. She is now 28 years old and has gotten by the past seven years by essentially working as a prostitute (though she described it as having multiple boyfriends). She had never yet been tested for HIV but was engaged and wanted to check before she settled down. Not suprisingly, her test was positive. This is the fourth time in two weeks, I have seen a positive test done - and that is aside from all those newly diagnosed and referred to our clinic. She came back later with her fiancee who was negative. They walked off together, looking oddly happy. She had seemed visibly reassured by the promise of treatment.

I don't know that the kids I was working with would feel the same way. Their disbelief extended to their own work. Though each of one of them swore they would never die of AIDS (the prevalence rate is 30% among their age group), they also felt like their country had no chance of recovering from the disease, that they are being ignored by much of the world because they were young and African. We had some interesting discussions about putting HIV + patients in concentration camps (which is actually what was done in Cuba - though they weren't exterminated - just exlcuded from the rest of society) and whether condoms and ARVs really worked!

I am reading "And the Band Played On", a book about the early AIDS crisis in the U.S. and the parallells between the attitudes of these kids and that of the gay community in the U.S. at that time is eery. Prevlance rates of HIV in the Castro in the mid-80's were similarly estimated to be 30%. The difference, of course, is there were "only" a few tens of thousands of people affected in the U.S. then - and mostly people who had access to information and education and ultimately medication. In Kenya, a recent survey showed that condoms were used only 23% of the time and it is estimated that only 5% of people who should be on ARVs are. Scary numbers.

(I took the pictures above while one of the kids took me on a tour of the slum area. There's also a picture of two members of the outreach team.)

Music

No wonder Kenyans are such happy people - their music rocks! I went out over the weekend with some Kenyans and a UCSF med student who is in town for a few weeks. After finally getting going at 9:30 (despite our 7:45 meeting time...all expected, we chose to meet at a place where we could have a few beers while waiting!), we first went to the local dive. This was a cement walled room, bare lightbulbs and frequently patched walls, a mix of plastic chairs and what appeared to be old church pews squeezed in next to the pool table (more than one person was hit or nearly hit by swinging cue sticks - their concept of right of way or personal space is a bit different from ours), and warm Tuskers only - don't even think of asking for cold. The band was led by the percussion - a collection of six or so huge bongos, a few gord like things that rattled, and various other noise making instruments that combined to create some incredible rhythms - impossible to sit still while you are listening. Everyone was dancing - actually initially it was mainly just men. In Kenya, it is very rare to see a couple showing affection or even holding hands - however, totally normal for two men to walk along holding hands (and, in case you were wondering, I was told today there are no gay people in Kenya). So apparently its also totally normal for two men to dance together, normal for a Masai warrior in full dress, including a machete at his side, to be on the dance floor - but very odd to see a mzungu out there! The music was a take on traditional Luo folk music - ohangala.

Next we went on to a more traditional club with fake rock walls, black lights, and cold Tusker, where one of the local popular groups the Malo Malo Kings was playing sort of a mix of reggae, rock, and folk music. Definitely going to bring some of this back!

Pictures

Pictures from clinic:
The reception desk


Rosie in pharmacy









My house and garden

and living room

Teen Clinic

Today I worked in the young adult clinic where patients range from 11 to 26 years old. I saw three patients who were newly diagnosed with HIV. When talking about their reaction to the news, each of them was apparently unmoved, almost dismissive. One woman even said to me, "Its what you expect living here." I asked the clinician I was working with about it, not sure if their guarded reactions were simply because they were talking to me, an outsider. Sadly, though, that is the reality and part of why prevention efforts are so difficult. Too many young people have grown up with AIDS being an ever-present (and untreatable) part of life and can't really see a way to avoid it - there is almost a collective depression around the topic, which is why clinics like this one are so important. Most of their community outreach workers are recruited from among their clients - volunteer kids who are unable to afford going to school (school is only paid for by government through sixth grade) and go out every day to set up VCT (voluntary counseling and testing sites) tents in their neighborhoods. They are very effective at convincing their friends to get tested - this one little clinic runs over 1000 rapid HIV tests per month. What's amazing, though, is how little education on prevention there is - very few clinics are allowed into schools (for legal reasons, I am told... the parents wouldn't approve) and though there is some education in school it is apparently quite minimal.

The saddest of all though are the young children - 11 through 15 who have been living with AIDS for their whole life. So many of the kids have been through so much - stigma, multiple illnesses, loss of their parents - that by the time they are in their early teens they just seem stunned. Most of them are very small for their age, don't do well in school, and many are orphans. There are definitely lots of services out there to help them but seeing them and talking to them is a sad testament to how much damage has been done to a whole generation of kids by this disease.

Rain

Wow. Yesterday the rains officially started - I don't think I've ever seen so much water dumped from the sky in such a short period of time. I watched the storm with a large crowd of people after ducking into a store - you could barely see five feet through the wall of water. After an hour or so it let up and we headed out. This was the most fun of all - the streets were now rivers with water at times over two feet high and flowing fast. All the traffic that had stopped for an hour (pedestrian, vehicle, and bike) was now filling the mud and rain drenched sidewalks in a vibrant mass of humanity and hilarity. The market that lines the sidewalks was still going on as people literally slipped and slided into the piles of fruit and fish (wet banana peels and mud do not make a good combination). I think there was a competition between matatu drivers to see who could create the biggest waves - a large splash, particularly if it hit a bunch of pedestrians, would get a cheer from the audience on the sidewalk. It was one of my more amusing walks home - and for the first time I didn't arrive home hot and dusty... I was soaked and muddy, and very entertained.

Meetings

Every meeting starts with a group song, a prayer, and a "clap" (a "clap" means someone gets up and leads us in some form of chanting and clapping that lasts anywhere from 5 seconds to a few minutes). Today we had an all day retreat/planning meeting to talk about goals for the clinic for the next year. The clinic is still pretty new and growing quickly (they hired ten new staff in the past month) and the staff is all quite young (the clinic directors are probably mid-30's) so its fun to be part of something so new and dynamic - and actually feel like I have something to contribute. We took breaks in the middle of the meeting to play games (that's what's happening on the right - "Simon Says"). One of the guys in clinic borrowed my camera so they could put pictures on the web site (their IT department = one person) so sorry some of these are blurry but its fun having his view of the meeting and his fellow staff members. We were at a little retreat place about 15 minutes outside of town - which we got to by (surprise!) squishing all 52 staff into 3 vans - its very fuel efficient. They have a LOT of meetings (which are generally not the most efficient things) but the monotony is relieved by lots of joking and clapping.

my 'hood

April is the beginnning of the long rains - they haven't yet started in earnest - just a sprinkle here and there, the occasional thunder, and loss of electricity that presages what sounds like some impressive showers. It has gotten a bit cooler though - my first week it was in the 80's during the day and HOT (not humid though - we are up over 1100 meters so its pretty dry). This week it rarely gets out of the 70's - and they all think its so cold! One of the women in clinic couldn't believe I had on short sleeves and no jacket the other day. Even when it was in the 80's, people were wearing thick jackets in the middle of the day - and didn't seem bothered at all. The picture to the right is a road near my apartment, running by Lake Victoria - it shows the red dirt that sticks to everything!

The lake is about five minutes down the road from where I live - I run past it in the mornings. Most of the water in close is overgrown by plants which apparently have done a lot of damage to the ecology of the area - but there are still hippos - and fishermen eager to take the mzungu (me) out to see them.

clinic

The past few days in clinic have been ridiculously busy. We are seeing a steady stream of patients - over 300 the other day and still at meetings there is talk about how we aren't seeing enough, especially kids. One of the problems is many parents are reluctant to have their children tested or, if they are, to disclose their positive status to them. Access to medications for HIV is still a relatively new phenomenon here and as a result there is a lot of denial. Ten years ago, people didn't want to know their status because there was nothing they could do about it. Its changing but slowly. I imagine this is what it was like in the US in the late 80's and early 90's before there were drugs for AIDS.

Kenyans work an incredible amount - that is, if they are lucky enough to have a job - the rates of unemployment here are quite high. The stalls are opening on my way into work at 7 or 7:30 and many still open when I leave after 6 pm. The bicycle taxis are out all day - my "driver" today was telling me he often works 14 hour days (some of my most interesting conversations are on my commute - amazing how quickly one becomes accustomed to carrying on a complete conversation while swerving amid motorcycles and cars in the semi-darkness while perched on a little plastic seat on the back of a bike). Most of the clinic staff works 10-12 hour days. But no one ever moves very quickly or seems rushed despite the fact that the clinic is literally packed with patients waitng to be seen. One of the favorite expressions here is "pole, pole" - slowly, slowly. Its used often in place of "excuse me" or "watch out" (or maybe I just get it more often because my baseline walking and talking speed is 8 x as fast as the next person's). I saw nearly 30 patients today and felt far less rushed than I ever have in a day where I see half that many at home. Most of the clinicians are in their early 20's and it is hard to imagine how they will not all be totally burnt out in another ten years - they talk about it fairly frequently... and then joke that they are too busy to be burnt out and try to figure out ways to see more patients in clinic.

Lake Nakuru and Lake Naivasha

Serendipitously, we had a four day weekend (because of Easter) so I got an early and unexpected chance to travel - and go on my first safari!
The sign above says "Danger - wild animals crossing at night - slowly, slowly"... more on that later.

The traveling itself was a huge adventure. Roads in Kenya are not like those in the US. Though we were on "paved" roads, for large stretches the roads are not exactly maintained - there are potholes the size of a Civic. Also there will be intermittent road construction (marked not by bright orange signs but by a large pile of dirt in the middle of the highway) at which point the bus takes off onto an often smoother but incredibly dusty dirt road on the side. Though the norm is to drive on the left hand side of the road, that is apparently just a guideline - we passed people on both sides, often driving for long stretches on the shoulder or on the right. On the way out I rode in a real bus - which was a bit alarming at times when we were driving half off the road and tilting at a 45 degree angle! I learned on the return trip however that the advantage of the bus is that there is no danger of smashing your head against the roof when you go over potholes and you don't lose all sensation in your legs. On the way back I rode a matatu - 15 people packed into something slightly larger than a minivan - for four hours over very bumpy roads. To the right is a picture from the inside back row. I was glad to discover I could still walk at the end.

On the plus side traveling by bus is a great way to see the country and how it changes. We started in the hotter but lusher fields in Kisumu, moved up into the cooler mountains of the tea country, Kericho, where the vivid green tea bushes stood out against the red dirt roads, then back down into the drier plains of the Rift valley. Throughout we passed through tiny towns most of which are grindingly poor but enlivened by brightly painted walls (all advertising of course) and roadside markets (see right). Everytime the matatu stops, crowds of people come to the windows selling food ("sosej"'s (aka sausages) and yogurt in a carton are particularly popular) and anything else you can think of from men's underwear to purses to cell phone covers



In Nakuru, I met up with one of the pediatrics residents from UCSF who is working in a different town. It was nice not to be the only Mzungu for a bit. Lake Nakuru is a small but densely populated game park which is best known for its "flock" (?) of half a million flamingos (a small portion shown at right - or the pink splotches all around the edge of the lake behind me on the left). Not only an impressive sight but also an amazing sound - its a kind of humming, whirring, rustling noise that at first you hardly notice and then you can't believe you didn't because it is so loud. But the flamingos were just one part of it. The following is a list of what we saw: impala, zebra, cape buffalo, redbeest (type of antelope), hornbill stork, waterbuck, eland antelope, dikdik (apparently very hard to spot - a tiny little antelope), hyrax, giraffe, lizards, baboons, white rino, ostrich, warthogs (my favorite), egrets, mantal eagles, velvet monkeys, fish eagle, golden pippit , lots of other little birds, and a LION - just hanging out in a tree by the side of the road. All in all a pretty amazing experience - esepcially because we were only about half an hour outside the town - it was kind of like the "Disneyland" of game parks.

Next I headed over to Lake Naviasha. I rented a mountain bike to go riding around the lake which is dotted intermittently with private game reserves, including the estate of Joy Adamson (hence the sign at the beginning about animals crossing the road). It turns out the animals don't only cross at night - I started a small zebra stampede when I went through ( I was only fast enough to catch the last one running across the road to the left), also saw some antelope, giraffe, and my friend the warthog. Shortly after scaring the zebra, my cell phone started ringing - and it was my sister Katherine and mom! Very weird experience to talk to your family from the side of the road in Africa with zebra running by - but great :)

That evening I went out on boat safari to visit the hippos. They are big and ugly and luckily didn't do much when we saw them. Apparently, though, they sometimes stir up a lot of trouble in the campsites and there is electrified "hippo wire" at the base of the hotel/camp area where I was staying. I ended the evening sharing some Tusker beer (Kenya's national beer - it tastes like Coors and they think its the best thing ever?!?) with some Kenyans at the poolside bar at my hotel.

all in all not a bad weekend!

Pictures

Two of my first views of Kisumu. It captures it well - simple and friendly. Things are very high tech here.

okay, so i'm really not roughing it at all. This is the view from my front porch, where I can sit and eat my dinner, listen to the birds (or the trucks on the road outside), or fight off the swarms off mosquitos.

Home Visit

Today I went out on home visits. The first place we went to involved a boda boda ride over dirt paths for over half an hour (and believe me these are not bikes equipped with shock absorbers!) - I was just glad I managed to stay on. As we passed from the inner city slums to the more open areas, I was greeted by cries of "Mzungu!" (the term for a white person) by the many children who went into fits of giggles when I waved back. Outside of my apartment complex, I have seen one other white person since being here so I guess my appearance in the back roads of Kisumu is a bit of an event.

We arrived in the mud-walled hut (dung, too I'm guessing by the smell!) to visit one of the clinic patients who was unable to walk. Just sorting out what is going on is an incredible challenge - there are so few tests they can run compared to what we are used to. Much of diagnosis is based on probability and "treat and see". For example this woman had undergone treatment for toxoplasmosis and TB meningitis both with no response so now we were left pondering what else it could be. What about CMV (a viral infection that can cause blindness - which this woman also had)? An opthalmology exam a month ago hadn't shown anything and, regardless, there is no way the woman's family would be able to pay for the expensive treatment of IV antivirals. A lumbar puncture (or spinal tap) was done but it can only be sent for a limited number of tests (total protein and cell count and CrAg for all you medical types). It could be lymphoma of the brain or PML (another virus that causes weakness in advanced AIDS), but without a CT scan (which the family would have to pay for), how could we be sure?

Just one month prior, I had a similar patient who was brought into the ED by his family. Between MRI's, PCR of his cerebrospinal fluid, special cultures for various viruses, we had no trouble arriving at a diagnosis - and paying for three weeks of expensive anti-viral therapy.

This woman would have no such luck. In the end, we hoped it was something we could cure - or at least help - by putting her on anti-retrovirals and building up her immune system. There are programs to be sure she has food - if the family can make the long trip in to pick it up. The clinic will be sure she gets her medicine - and hopefully there will be someone who can stay home from work to give it to her.

But somehow, in the midst of being confronted over and over again with what we could not do, the fact that we were there at all and able to offer the patient and her family something to combat her inevitable decline was actually reassuring and fulfilling. Because how many patients like her die alone and far from any care at all?

First Days

The past week has been a series of contrasts. I am living at a gorgeous flat in a wealthier section of town with amazing gardens (the owners of the complex are professional landscapers), a pool (which I swim in every day), and more space than I've ever had to myself. In the mornings, I get on a bicycle taxi (boda boda) for a ride into our clinic. We slowly progress from the well paved streets and quiet, gated communities of this side of town for the vibrant, people-filled, colorful streets of downtown Kisumu and the clinic.

This is an amazing place. In contrast, the US seems sterile and slightly boring. In the mornings, I pass the stalls just opening for the day's business, throngs of people walking, biking, or packed into the crowded matatus (buses) following traffic patterns that are a bit difficult to discern. (Don't worry, Tom, I showed some judgement and opted not to bike myself into work - I wouldn't last a day!)

The clinic is run by a rapidly growing number of staff (now up to 45), all of whom know a surprising number of the 4300+ patients - from receptionists to nurses to pharmacists, social workers, pastors, clinical officers (about the equivalent of our physician assistants) and two overseeing physicians. The patients start lining up before 6 am, many after walking for hours to reach the clinic because they can't afford the bus or taxi fare to come in. On average over 200 patients are seen a day - in a space about half the size of our clnic in San Francisco - which always seems packed and overcrowded! It is incredible how much they achieve and how many people are treated and given hope with so few resources and such minimally trained staff.

I can't help but compare the experience of being a patient here to what I see in San Francisco, where a diagnosis of HIV makes you eligble for all sorts of insurance and support services. The striking difference is how many patients in SF take what they have for granted - or even complain about the lack of resources, long waits, limits on tests, etc. In comparison, the patients I have met so far, think nothing of waiting for hours to be seen by a nurse only and are excited about whatever care they get. Sadly, the clinic is having to turn away many patients because the providers are already stretched too thin.

Travelling

After months of anticipation (and a slightly crazed last week in San Francisco), Tom dropped me off at the airport - to be picked up at the other end by Katherine, Eugene, and my mom, who was serendipitously out visiting London at the same time. After a quick visit and a welcome night's sleep for my jet lagged self, I was on the plane to Nairobi.

Early the next morning I took a very bumpy plane ride over the Kenyan Rift Valley (unfortunately, too far away to see anything more than a colorful landscape!) and part of Lake Victoria to land in Kisumu - finally after 2 1/2 days of travelling!