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.