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!