Marion

I've been thinking a lot about Marion lately, but I don't think I've yet blogged about her. She's a little 5 year old girl who was admitted on my very first day in the wards, about 4 weeks ago. She presented with bone pains, fatigue, and weight loss. From her lab work, she had terrible anemia and low platelet counts, and during her stay on Upendo ward we had a horrible time controlling spontaneous bleeding from her gums, nose, etc.

This poor little girl went through hell. Suspecting some sort of leukemia, we attempted 3 bone marrow biopsies on her that were "dry" (no marrow). Not knowing what else to do, we did an excisional biopsy of a huge lymph node she had under her chin. The next day, the pathologist was finally able to get a succesful bone marrow biopsy. Waiting around for the results, she just kept getting worse and worse. Eventually she needed oxygen support, and we were continuously trasfusing either blood or platelets. Her lymph node biopsy came back as lymphoma, but her bone marrow showed no malignant cells -- really it didn't show any cells, so the pathologist called it aplastic anemia. Our consultant suspected that she had a leukemic lymphoma, that is a lymphoma that had infiltrated the bone marrow and caused a leukemia-type picture. Even though we weren't sure of the diagnosis, the team decided it would be best to start on cytotoxics (chemo) anyway, as she was so sick. The last time I saw her was yesterday. Her mother, crying, was holding her, as Marion looked like she was literally on the brink of death. Well, she was. We got to the wards today, and the intern said that she coded right after rounds got over.

I really liked this little girl (who was my patient), and her mom, who was SO nice. So, it is sad. But at the same time, I don't think prolonging her life with chemo and its horrible side effects would have been that great for Marion either. It's always sad when a child dies. But, when a child is no longer suffering, I think that's a blessing. And this little girl suffered more than any other child on the ward, with countless sticks for biopsies, blood draws, and transfusions. It got to the point that she screamed whenever anyone besides her mother touched her. I'm less grieved and more retrospective about this death, due in part to a very encouraging email I got from Emily today, and also due in part to the fact that our team worked very, very hard to figure out what was wrong with Marion. In the end, I really think we did all that we could have. Even in the United States would likely have been a little girl that didn't survive.

Ups and Downs

One more picture! This one is of me at the Crying Stone on the way back from Kakamega.

It's been a relative blogging dry spell (really only 3 days), but I've been unbelievably busy lately. I didn't /really/ want to be as busy in Kenya as I am at home -- I was looking forward to it as a sort of vacation. But, alas. I had 2 presentations to give on Monday, and the pediatric student lectures have really revved up now -- we usually have 3 or 4 on a given afternoon. I don't necessarily make it to /all/ of them, though I do try to make most. If I did go to morning rounds, afternoon lectures, and admit patients at night, I would never have time for laundry, reading, going to the bank, etc. You know, normal life. I don't know HOW the Kenyan medical students do it -- as they are required to be at all lectures and have read on the topic ahead of time. Joy, one of the Kenyan students on my team (who I like a WHOLE lot) told me she hasn't done laundry in 4 weeks. Too many things to do and not enough time -- yet another thing about medicine that I've found is universal.

Dayna left on Monday. It's kinda weird that she's not here. When Priti and I first got here, we thought we would be sharing a room at the hostel, then when Dayna left one of us could move into her room. I may have told this story already, but about a week ago, Shawn the IU house administrator told me that actually two Utah students were coming as soon as Dayna left, and would be moving into the hostel. Two girls. Ok, I guess that's fine. Well, Shawn called us early Monday morning to say that -- whoops -- the 2 students from Utah were actually a male and a female, so they would each be taking one of the hostel rooms and Priti and I would be moving back to IU house. Oh and by the way be ready to move at lunchtime today. Sure, no problem. Let's frantically pack all of our stuff and try to round in the morning. So... we were set to go, when Shawn called us yet again in the afternoon to say, hey, it makes more sense to have Natalie (new Utah student) move into the empty room, Teanu (new Utah student) stay at IU house, and Priti and I just stay put. (That was my EXACT thought when he called us that morning at 7, but I wasn't about to complain about moving back to warm showers, big rooms, and internet access). In the end it's probably for the best, because when we go back to admit at night it's much easier to walk across the street than to take a taxi from IU house to MTRH and back again. It's also nice to live with the other students, especially since we know many of them now and have made friends. Plus, it's weird to try to make yourself part of a team and live as a Kenyan medical student if the place you actually live is much better than where they do.

I spent today in "Module 4" -- ie the pediatric AMPATH clinic on MTRH campus. (Nothing to do with HIV/AIDS is actually called that here, as I've learned. People use a lot of euphemisms like "exposed" "seropositive" "ISS positive" "DCT positive" "been to room 54/Module 4, etc." Which I think is too bad. Because if healthcare professionals can't even say HIV/AIDS, how can they expect their patients to? A good example of the stigma that AMPATH is still fighting to eradicate). The clinic was pretty fun. Most of the kids were healthy little people, who I got to play with while the clinical officer and the mother spoke in Swahili. I was surprised that so many of the children aged 11 to 14 or so came by themselves. Many of them were orphans who lived with their "aunties" (could be a relative or just caretaker) who had to work or take care of their own 5 children. I just cannot fathom children having the presence of mind to keep clinic appointments, get there by themselves, and then communicate in a mature way with the CO. Not to mention have the presence of mind to self-administer something as complex as antiretroviral therapy and the various prophylactic drugs that they're on. Yet, I saw many examples of it today. I suppose that growing up hard makes you grow up fast. And of course, it was nice to get out of the wards today. It can honestly be such a depressing place.

Right now we are taking care of two abandoned little boys -- brothers, ages 3 and 5. The history is a little fuzzy, but apparently the landlord (or possibly a neighbor?) of the house the boys lived in heard them crying off and on for a few days. Eventually he went over to the house, looked in a window, and found them locked inside. He broke in, and no one else was home. Who knows how long they had been in there by themselves? They were taken to a childrens' social services type place, then immediately to MTRH for de-worming, nutrition, not to mention treatment for some sort of TERRIBLE skin rash/infection they have on their hands and feet. The Kenyans keep calling it "chiggers" but I'm thinking it's something else. It looks really bad. A few days ago, we found out their names: Philip and Kevin. So, I immediately took to them even more than I had already. Since coming and getting adequate food and water, Phillip the 5 year old has turned into a real crazy kid. He's constantly climbing out of the crib that he and his brother share and running all over the ward like a maniac, "rounding" with us, stealing things out of our pockets, trying to be goofy to get us to laugh -- which often works. He's actually really funny, and very smart too, and he likes to spend time playing with the other kids in Sally Test. Kevin, the little one, is a different story. He's the saddest little boy I've ever seen. He never gets out of the crib unless someone takes him out. Most of the time he just sits in the crib, staring with the saddest face I've ever seen. No matter how we try, we can't get him to smile. When he's in Sally Test, he just sits there with the same slumped posture and defeated face, watching the other kids play but never joining in. It's the saddest thing. Who knows what kids can remember, especially at such a young age, but being abandoned by your parents clearly has a profound and lasting psychological effect.

We also have Enock, a 5 year old boy with Burkitt's Lymphoma (VERY common here -- a cancer caused by the EBV virus [same virus that causes mono]). He was diagnosed in January, got some chemo but was then lost to follow up like so many of our patients. When he came back he had horrible disease, which this time did not respond to treatment. Now he's just getting palliative care, which includes morphine and low-dose chemo. The chemo is making him so ill, so a bunch of us are pushing to send him home with generous amounts of morphine, but for some reason he's still here. Everyone really likes Enock, because he's always in Sally Test, attempting to play and smile, even though he's the sickest kid there by far.

I've been here for 4 weeks -- halfway done already. It's so hard to believe. Though I will be so excited to get back to my family and friends, I can see already that I'm going to miss Kenya, despite its many problems. For sure I will be back someday.

Baringo and Bogoria

What a weekend. Let's see if I can get this all out.

We left for the Rift Valley at 6:30 Saturday morning (7am KT). The valley stretches north to south along the length of Kenya, and is home to 6 spectacular lakes: Turkana, Baringo, Bogoria, Nakuru, Elmenteita, and Naivasha. Our destination on Saturday was Lake Baringo.

I don't know how many different ways I can try to describe the landscape here, but suffice it to say our drive there was beautiful. We hired Ashley to drive us again this weekend, and he was very good about pointing things out along the way and letting us stop and take pictures. Our drive took us out north of town, where we soon found ourselves driving along the rim of the Kerio Valley -- the Cherangani Hills and Tugen Hills on either side. There were several vista points that we stopped at along the way to take (a bunch of) gorgeous pictures of the sun rising over the hills, the valley sprawled out below. The drive itself was less than ideal -- lots and lots of steep, hairpin turns on a pot-hole filled road. I had to concentrate very hard on not being ill. At one point Ashley took a speed bump at full speed, I flew up and hit my head on the celining of the matatu and completely hyperextended my neck. The only very bad thing about this weekend was that I spent it with a headache and feeling like I'd been in a car accident.

The drive to Baringo was about 3 hours. Just outside the lake entrance, we stopped in a little town and picked up a Kenyan named Douglas, who was apparently educated at IU and Shawn (from the IU house office) had called to be our guide for the weekend. Ok, fine. Never know who you'll meet in Kenya. It's a good thing he was with us, though, as we soon found out. Apparently about 5 years ago the road into Lake Baringo was completely washed out by a huge rainstorm. Sure enough, where the road should have been, was a huge pile of rocks and dirt about the height of the matatu. So, we had to go onto a worn dirt path, and pretty soon we come to a river. Douglas was able to navigate us across the river pretty well, but I was holding my breath and white-knuckle-ing it the whole time. Luckily the river was considered "low" at the time. After the great fording of the river, we get back on the real road and get to the lake entrance; drive down to the jetty, where a boat (basically a canoe with a 30 horsepower motor on it) was to take us to the island we were staying on.

The boat ride out to Ol Kokwe island was spectacular. It actually reminded me a lot of Lake Tahoe. The lake itself is huge, at least 15 km long and 10 km wide, the water is completely brown from the inflow of river silt, and it is rare in that it is a freshwater lake -- most of the other Rift Valley lakes are salt water. It is also completely surrounded by mountains in every direction, so the contrast of the landscape was just gorgeous. There are 7 islands in Lake Baringo -- only 2 of them inhabited, and we were heading for Island Camp Baringo on the southern tip of Ol Kokwe island -- smack dab in the middle of the lake. It was about a 15 minute boat ride out there, and we loved every minute of it.

When we docked at the Camp, we were immediately greeted by porters to carry our bags and the owner/manager with glasses of fresh pineapple juice. (I should mention that we decided to go for the high end place this weekend, in the name of relaxation and in honor of Dayna leaving tomorrow). We were shown to our tents, which really weren't much like tents at all. Well, they were /actually/ large tents, they looked like about 15 person tents in reality, but they were outfitted very nicely for 2 people, with 2 actual beds, 2 tables, and connected to the back was a cement building that was a REAL bathroom with hot running water. Our tents each had an entry way area with chairs to sit in that faced the lake -- the view was spectacular.

So, the 6 of us got settled in and went about the difficult business of lounging about the pool. The southern part of the island is basically one big hill, with the tents/bandas spread out stepwise up it, and the pool and clubhouse being at the very top of the hill. It was an amazing feeling to swim in the pool, at the top of the island, and be able to look out and see the lake below, the mountains beyond. Big surprise, we took a ton of pictures. After a few hours at the pool, it was time for lunch, which was delicious, and SO much food it was unbelievable. Then a few more hours at the pool, before Douglas met us to go on a short walk through the village on the other side of the hill. In theory this sounded like a good idea, but I was wrong.

From the moment we set foot in the village, it was clear that they were expecting us. Not in itself a bad thing, but we were immediately set upon by children and other villagers telling us over and over again about the 700-plus impovereshed villagers on Ol Kokwe island, whose only source of income is from selling things to tourists. Everything just seemed so...played up, dramatized even. They couldn't afford motors for their boats (oh yeah, except that one we saw like 10 minutes later) or walls for their church, etc etc. They were friendly, for sure, but overly so, I thought. It was just so obvious that they wanted, expected something in return for walking through their village, whether it was buying the necklaces, etc that they were selling (and carried along beside us as we walked) or even Abby getting asked by a man to be his sponsor. Their expectations were so apparent, they were tangible - you could feel them in the air. The whole thing just seemed SO contrived -- even the cats and dogs ran up to us begging for food! Not that I thought their poverty was made up; no, that was quite apparent. Shabby one-room huts, dirty little children in tattered clothing or nothing at all, genuine looks of desperation on the womens' faces. No, that was real. So real. They told us it was ok to take pictures, but I really just couldn't. Some things can't be captured on film, and other things shouldn't.

In the end, we hightailed it out of there pretty quickly. I didn't buy anything. Who knows, maybe I'm just too much of a cynic. Maybe buying something from the village /would/ have been the right thing to do. They very clearly needed the money. How is it, though, that I can feel like I was used by people who have universes less than I do? Is that a selfish way to feel? I really struggled with the whole situation after we got back. Was my denying them anything in return for their "hospitality" a basic injustice and a cruelty toward them? Did I, in fact, owe them something after all? We are told not to cling to earthly treasures, but to store up our treasures in Heaven. But then, aren't we also told to "do to the least of these"? I just don't like the feeling taht every encounter or relationship here is heavy laden with expectations and pre-conceptions about me as a Westerner, right from the outset. But show fault is this? Is it the Kenyans' fault for expecting so much from our white skin? Or is it our fault -- the West's -- as we flaunt our wealth everywhere, exporting our culture and modern ways? No doubt these poor people have had ample opportunity to witness the ugly side of rich Westerners.

So what, exactly, is the answer? SHOULD I have given money to the villagers? If yes, does that mean that the answer to 3rd world poverty is tourism? Should we all travel around Africa, etc spending our money? Something tells me no, that the solution to poverty is not just money. It is such a complex problem, I think, so too is the answer. Besides, I believe that all people have some intrinsic amount of pride, and I know I would not like to pander to the wealthy as a way of living. How could I think so ill of these people who wanted my shillings, as I sat atop my Ivory White Tower (literally -- the Camp [full of white people] sat atop the hill overlooking the village) of luxury, with more food than most see in a month, the sound of the generator that gave me electricity and a warm shower drowning out the sounds of the evening? We've set ourselves as gods above them, in a way, so how can I be surprised when they attempt to gain some advantage from that? Who knows, maybe I was just so uncomfortable sitting there in my absolute luxury, pondering these questions, that what I was really upset about was me.

At any rate, after we left the village we swam for just a little bit more, as all of a sudden a HUGE storm rolled in across the lake. The wind was whipping around us, and from the top of the hill we could look out over the lake and see the storm clouds pouring rain into Baringo, coming directly at us. There was even a rainbow. The storm was short lived, then it was time for dinner. At the pool, where there were tents and candle-lit tables set up, and the most amazing barbecue I have ever been to. Sitting with 5 new friends, eating fresh foods from the island, and looking at the moon behind the mountains, shining over Lake Baringo in Kenya. It was a nice moment.

We woke up at 6 this morning to go on a sunrise boat ride around the lake with Douglas. Fantastic, all around. We bought some fish from a local villager, Douglas stuffed them with balsa wood so they would float, then we drove around the islands, searching the cliffs for eagles. When we found one, Douglas would whistle very loudly, launch the fish into the water, and here would come the eagle -- soaring right over our heads, dipping down gracefully into the water to grab the fish, then back up to the perch for breakfast. It was unbelievable. I got 3 great pictures of eagles skimming the water and even one video. After we fed the eagles, we got sort of a general tour of the lake, and we drove around the only other inhabited island -- Parmalok Island. Also called Teddy Bear Island, because it looks like a teddy bear floating on his back in the water. Douglas told us that one man lives there with his 5 wives and 28 children, which started an interesting conversation about polygamy and dowrys in Kenya. Being somewhat pigheaded and being with 6 girls, Douglas almost got tossed in the water several times. Apparently, if a man wants to marry an educated woman, he needs to give her father about 8 cows (cows not being cheap, about 10,000 kSH each). But, if he wants to marry an UNeducated woman, he needs to come up with 24 cows. The logic behind it is that uneducated women are more likely to stay home, raise the children, help on the farm, etc etc. Which makes sense. But, Douglas said it's also because all educated women do is spend their husbands' money on makeup and clothes. Cue time number 1 of Douglas almost being pushed into the water. This led to more interesting conversation, and I decided it might be a good idea to ask Mike how many cows he thinks I'M worth. So... what do you think honey? 8 cows? 24 cows? More? I'll give you awhile to think about it. I expect an answer when I get back.

After the islands, we went in search of hippo. Which we found! We maintained a respectable distance, as hippos are quite dangerous and territorial, but I got some great pictures of their pink little ears and noses poking out above the water. We also saw 3 or so crocodiles, but apparently they are quite "shy" and wary of humans, so they maintained a respectable distance from US, which I appreciated. The other wildlife we saw was amazing -- the birds. The lake was chock-full of them, of all sizes and colors. At the camp they are so acclimated to humans they will come and perch all around your table while you eat, waiting for crumbs to fall. I got some great pictures of various birds as well.

After our lake tour, we got back to camp in time for delicious breakfast, then we put our minds again to the great task of swimming and sunbathing until lunch. After lunch, we packed up and got back on a boat for the mainland. We met Ashley at the Jetty, where he proceeded to take us the 45 minutes or so to Lake Bogoria.

Lake Bogoria is actually a natural reserve run by the government, so it was just teeming with wildlife. We saw ostriches, zebra, dik-diks (the smallest kind of antelope), antelope, gazelles, warthogs, and some monkeys. The most amazing thing about the lake was its flamingo population. We drove the length of the lake, which took about 40 minutes itself, and the shoreline was completely lined with flamingos. They were beautiful! Every now and then a group would take off, all in a single-file line, and wherever the leader went, the rest would follow, up, down, up, down, then landing again elsewhere in the lake. The other main attraction of Bogoria is the hot springs, a row of about 5 or so geysers of hot water. And I mean hot. This is a popular place to picnic, especially on Sunday, and many people were there cooking their lunch in the springs. We had brought along eggs and potatos, which we put in a bag and cooked in the spring. It was fun.

After eggs and potatos, it was time to head back to Eldoret, which was another beautiful yet hair raising ride through the mountains, and we got back about an hour after dark. I am now at IU house, in the process of working on one of two presentations that I have to give tomorrow. Not the best timing, but well worth the price of the fantastic weekend I had.

Kwa Herini!

PICTURES!!

Ok, maybe more like pictURE, as the internet is being finicky owing to the massive rain/hail storm we're currently experiencing. I loaded all of my pictures up to now (all 250 of them) onto a computer at IU house, and I really wanted to post them all onto my kodak site, but... the connection here is so slow that it took over an hour to upload 20 of them... so I'll have to wait to do a full picture expose when I get home. For now I'll just put this one up -- it's me at the top of the mountain in Kakamega. Notice how dirty my pants are!

Plans are set for the weekend -- We'll be staying at a nice resort/hotel on an island in the middle of Lake Baringo, spending the day Saturday at Baringo and Sunday at Lake Bogoria. We decided to save money and only stay for one night, so we're leaving tomorrow morning and coming back Sunday. This way we can stay at the really nice hotel that has a swimming pool, etc. I'm excited. I'm sure there will be fun stories (and 100s more pictures) after the weekend is over.

Perspective in Mosoriot

Perspective in Mosoriot

Today I went to the AMPATH clinic in Mosoriot with Dr. Mamlin. This came none too soon, as the wards have really been starting to wear on me, and with Patel and 2 other kids dying, I really needed a break. It was great to get out of the city and drive through the countryside. The scenery here is completely beautiful. I could take thousands of pictures and never quite capture it, I think. Every time I look at it, I can’t help but think “I wish the people I loved could see this.”

So, the Mosoriot clinic. It was great. I’m so glad that I went. When we first got there this morning, I got a little tour of the place. It’s a government rural health clinic, so there’s a lot of different services there every day – OB/GYN, General practice, peds, etc. There’s even a very small 6 bed “hospital” (3 beds on the male side, 3 beds on the female side) as well as a mess hall and a dormitory. Mosoriot was the very first place that Dr. Mamlin started an AMPATH clinic. First, maybe I should back up and explain a little more about AMPATH. It stands for “Academic Model for the Prevention and Treatment of HIV/AIDS.” Back in 1982, IU School of Medicine was looking for a foreign medical school to have an exchange with. It took several years of looking, but eventually Moi Teaching and Referral Hospital (MTRH) in Eldoret was chosen. The program continued as just a simple US/Kenya faculty, resident, and student exchange for a few years. But, this was about the time that HIV/AIDS was becoming a true and recognized epidemic in Sub-Saharan Africa. The IU faculty and residents on the wards felt powerless as literally dozens of people died every day from HIV/AIDS. As the story goes, Dr. Mamlin was rounding with his team one day, when one of the Kenyan medical students kept leaving rounds and reappearing. Eventually Dr. Mamlin asked him where he kept going, and the student replied that his friend and fellow medical student was very sick in a bed in the other ward, and he had just recently been diagnosed with AIDS. Dr. Mamlin and the rest of the faculty realized that an exchange was worthless if they were not addressing the epidemic disease right in front of them – a disease that they saw could affect anyone. So, AMPATH was born.
At its minimum, the program is two-fold – addressing the prevention of HIV/AIDS transmission, as well as treating those who have the disease. But it’s really so much more than that. AMPATH, over the years, has attempted to address the AIDS epidemic as a whole. One major component is through education, attempting to reduce disease stigma and therefore compelling more people to get tested. Another huge part of the program is food security through various AMPATH farms and the Family Preservation Initiative (FPI). If a patient cannot afford food for his/her family, or spends all of their energy in the acquisition of that food, there is no hope of them being compliant with their antiretroviral therapy. So, AMPATH has attempted to address this major facet of noncompliance. The other major issue with treatment compliance is transportation. 150 kSH for a round-trip matutu trip to Eldoret is out of the reach of so many Kenyans. So, AMPATH went to where the patients were. First, by putting an AMPATH clinic in the pre-existing clinic building at Mosoriot. As that took off, various other clinics sprung up, and there are now 25 or so spread out through western Kenya. The distance from clinic issue has also been taken one step farther, as I saw today. Just before we got to the clinic, Dr. Mamlin pointed out to me a shelter that had been built about 2 years ago using funds from North United Methodist Church (the church that Mike and I are members of, as well as the Mamlins, when they lived in the US). The people who stay in this shelter are the sickest of patients, those who need to be seen every week or two times a week, and who otherwise would never be able to come to clinic. I met one such patient today. Her name is Jane.

Jane is 45, she was diagnosed with HIV not too long ago. At the time, she was severely malnourished, weighing only 26 kg (about 57 lbs) and days away from death. She was immediately put in the shelter right by the clinic, where she was initially visited by a CO (clinical officer) every day. Her weight is up to 32 kg, and she is now coming to the clinic once per week with the help of her daughter. I met Jane today, and she is still so emaciated you think a gust of wind would knock her over. The main thing Dr. Mamlin discussed with her and her daughter today was food. Making sure they had enough, where were they getting it, what were they eating, etc etc. He gave them money out of his own wallet so they could buy food. He took a picture of me with Jane, so I could “show (my) church what they’ve done.” Afterwards, I saw her daughter in the hallway, she had tears in her eyes as she gave me a huge hug, just saying “asante, asante asante” over and over again. It was amazing.

The rest of the clinic was great too. I saw some interesting things – like a woman with an 8 year history of “leg sore” that was the biggest, ugliest sore I’ve ever seen. The skin on her foot and leg was completely necrosed away, and you could see her bone underneath. We referred her immediately to orthopedics, but it’s likely she will need an amputation. Mostly, though, it was good to see healthy people. Sure, they all carried the diagnosis of HIV, but for the most part they were completely med compliant and living healthy lives. Our last patient of the day was great – it was an HIV positive mom who had been bringing her little girl to the clinic for monthly checkups. Because of maternal antibodies, you have to wait until a child is 18 months old to determine if they are truly HIV positive. Well, this little girl had her 18 month check-up, and she was negative. The mother was so happy she cried. (And then I mad the little girl cry by trying to give her a sticker, but she just screamed and jerked her hand away. Ah, I’m going to be a great pediatritican).

The other thing I enjoyed about the day was just chatting with Dr. Mamlin. I find him to be such an inspirational figure with what he has created in AMPATH. And it’s absolutely proof that one person can change the world. He told me that when he first went to Mosoriot, he had only one room at the clinic, so he put a wall down the middle of it so one side could be for check in/check out and the other side for examinations. He went into the local village and said “I have enough money to treat 15 people” and he was immediately told his presence was unnecessary, as no one in Mosoriot had HIV/AIDS. So, Dr. Mamlin sort of scratched his head and said, ok, send me the people with diabetes and hypertension, then. They came, were tested, and what do you know, Mosoriot had HIV after all. Eventually the clinic grew far larger than 15 people, and a generous but anonymous donor from Indianapolis gave funds for AMPATH to have their own independent building at the Mosoriot clinic. The building houses rooms for counseling after diagnosis, adherence counseling (a HUGE part of AMPATH. Antiretrovirals and clinic visits are completely free through AMPATH, but patients have to show compliance by showing up to 3 visits straight before they are even given the initial treatment. If they fail visits, they have to start the process all over again), nutritional counseling, and a fully functional pharmacy (Dr. Mamlin said that when he first started at Mosoriot, he could carry all of AMPATH’s meds in one small backpack). Plans for a psychiatric counseling component of the clinic are currently underway. Mosoriot AMPATH clinic was the first free-standing rural clinic for HIV/AIDS treatment built in Eastern Africa. And until a few years ago, it was the only one.

And so the program continues to grow. But of course things are not free, so funding is always an issue. AMPATH is currently run fully out of a grant from PEPFAR, but someday even this money will be gone. Last week’s fireside chat was about the ethics of treating “third world” diseases, who pays, and where do we get the money after the grants are gone. It was very interesting and uncomfortably thought-provoking. If, for example, you had the choice between treating 100 people with 1st line antiretrovirals or 50 people with 2nd line antiretrovirals (which are fore more expensive), which would you choose? The obvious answer seems the 100, but say 25 of those 100 people are going to end up needing 2nd line drugs eventually because of resistance mutations in the virus and noncompliance issues? And, how do you or should you even reward compliant patients? How do you measure true compliance, when so many of the reasons our patients don’t take their drugs or show up to clinic are valid? And, what motivation can we give to US pharmaceutical companies to allow developing nations to produce necessary medications for free? It was a great discussion. So many questions that I want to help the world answer.

Overall, it was a great day. I certainly feel a little more inspired about what I’m doing, and today reminded me of all the reasons I wanted to come here in the first place.

Patients

The bright side to all of the sad cases on the wards is that I’m seeing a lot of pathology that I will never get to see in the states. A few of the little kiddos currently on Ward 3:

--Harriet. A previously normal, healthy 11 year old girl with a 9 month history of worsening headaches. About 6 weeks ago, she woke up one morning and was blind. Since then, she’s had increasing paresis of her limbs, as well as decreased overall level of consciousness. By the time she got to our ward, she was essentially in a coma. It took awhile for her family to get the money, but she eventually had a head CT, and it showed that she had a massive craniopharyngeoma (brain tumor) that was pushing on her optic nerves (hence, the blindness) as well as jamming up the normal flow of CSF, so she also has hydrocephalus. The neurosurgeon took her immediately to the theater (OR) to put in a CSF shunt. If she improves, they will consider attempting to remove the tumor, though she presented so late that her prognosis is not good.

--Patel. Again, previously healthy, 7 year old boy. He’s had a 6 month history of yellowing eyes and increasing abdominal girth. This boy’s liver is massive – by far the largest liver I’ve ever felt on an adult or a child. He had an ultrasound that showed a large mass in his liver – what the radiologist thought was hepatocellular carcinoma (liver cancer), but this would be extremely rare in a kid this young. So, we’re thinking he has either a lymphoma of some kind or some kind of parasitic liver infection. But, we haven’t yet been able to biopsy, as you first have to be sure his blood clotting ability is normal (the liver synthesizes most of the blood clotting factors), and the lab has been out of reagent to run the test for the past week. Supposedly they got some today and hopefully we’ll soon know exactly what he has.
*Edit: Though I am posting this on Tuesday, I actually typed it up on Monday night. I got into work this morning and found out that Patel died overnight. Sigh... I don't know how much more of this I can take*

--Mary. 13 year old girl with a history of rheumatic heart disease, now in florid congestive heart failure. She had an echo that showed terrible heart function, and that she really needs 2 of her valves replaced. Of course, in a resource-poor setting this is extremely difficult. If the family can get the money (a very big if), she would have to go to Nairobi to have the surgery done. And, as pediatric cardiothoracic surgeons are few and far between, she would have to be placed on a 6 month to 1 year waiting list. Sadly, I don’t think she has 6 months to 1 year to wait. The family is still discussing the options and working with our social worker, but things are not looking great.

--Robert, 8 years old. I may have mentioned Robert before. He was a favorite of mine. He had AML, and presented SO late that his eyes were essentially completely out of his head. He had frequent nosebleeds and gum bleeds, as well as bleeding from his eye sockets. He was getting massive chemo, and was actually improving somewhat for awhile. We got to rounds on Friday, and the entire right side of his face was swollen. I mean, hugely swollen. He was almost unrecognizable. The consultant thought it was probably a dental infection/abscess that just progressed at lightening speed since Robert had no immune system left (and dental care here is quite bad). The plan was to drain the infection, start on heavy-hitting antibiotics and wait till he recovered to start chemo again. None of that ended up happening, as Robert died over the weekend. It may have been sepsis from his infection, or just his leukemia finally taking over, or maybe both. Either way it just makes me so sad. And of course, his dad is such a sweet, nice guy. He is one of the few parents we have here who speaks English, so I always liked going in to say hi to him and Robert. He was very calm about his son’s illness, saying that if it was God’s will for Robert to live, then he would live. And if not, he would try very hard to accept that.

How about something a little more uplifting. Today I got conscripted to lead a parent discussion group. These happen every Monday and Friday, where a physician (usually Dr. Tran) will sit in the Sally Test Pediatric Center with any of the parents of our patients and discuss a certain topic and answer questions. Well, Dr. Tran’s nanny has malaria, so she was trying to find someone else to watch their kids, and asked me would I mind going? So of course, I don’t mind. Oh and by the way the topic is potty training. Yeah, don’t really know much about that one. So I go in, and the translator is there, and he says, ok, let’s get started. Go ahead. So I’m like, ok… um…does anyone have any questions to start off with? Well, of course no one does. So, I ramble on about everything I remember learning about potty training (the expanse of my knowledge filling all of 5 minutes), and then we still have 55 minutes left. Enter awkward silence. Luckily the translator had done this particular topic before, so he was able to engage the moms (and one dad) a lot more. By the end of the hour, the parents were swapping stories and tips back and forth. Which really is more helpful than a white coat yakking at them for an hour anyway. The other interesting thing about the conference was that one of the moms there had a baby with Down’s Syndrome. Definitely the first African baby I’ve seen with it, but unmistakable nonetheless. The baby’s almost 2 years old, and her mother was expressing frustration that she hadn’t even started potty training yet (kids start quite young here compared to the US – as early as 5 months!). It was uncomfortable for me to try and explain to her that her child would be delayed in all areas – including this one. Not that I couldn’t do it in a tactful way, but it was awkward with 15 other parents listening intently. Ah well, at least there’s no HIPAA here to worry about.

After work I walked into town by myself for the first time. I went to the bank (exchange rate was up one whole shilling today, wahoo!) and the grocery store and I didn’t even get lost! Afterwards, I met up with Priti and Dayna and we shopped around town for a bit, then walked up north of town to the Imani workshop. Imani – meaning “faith” in Kiswahili – is a part of the AMPATH program. It is a workshop that employs only HIV positive Kenyans, and they make and sell a wide variety of very nice things such as bags, jewelry, shirts, skirts, etc. The dressmaker was out today, but we’re going back Wednesday, at which time she will measure us, we’ll get to pick out our fabric, and she’ll custom make African skirts for us. We got to look at the fabrics today – there were SO many and they are all absolutely gorgeous. I’m very excited about my skirt.

Lorein got her hair braided. Actually, it was a 2 day process, totaling about 18 hours. It looks SO good. I’m totally sold now, I figure if a pale, blond-haired, blue-eyed Dutch girl can have braids and have it look so great, I should be able to pull it off ok. I’ll probably get mine done in a month or so, just before I go home.

Planning for a new adventure this weekend is underway. In honor of Dayna’s last weekend (she leaves on Monday), we’re planning a nice, relaxing weekend in the Rift Valley, at Lake Bogoria or Lake Boringo. If we hire a private driver – which we probably will – we’ll spend one day at each lake. Lake Boringo has hot springs. It will probably be the 5 girls who went to Kakamega, plus Abby, a social work student from IUPUI who just arrived this week. I’m excited!

In other not so exciting news, I found a cockroach in my bed tonight. Actually, a mamma cockroach and a bunch of baby cockroaches. Eww eww eww eww EWWW! I’m normally not a complete girly girl when it comes to bugs and such, but really, IN MY BED??? Come ON!!?!?! So, I immediately stripped everything off, put clean sheets on, and hung my blankets outside for while. Still though, really really gross. Priti immediately checked her bed over as well.

Here’s hoping I’ll remain bug-free for the remaining 5 ½ weeks. Lala salama!

AIC

This morning a group of us from IU house went to church at the African Inland Church. It was pretty fun. (Despite the fact that we were up until about 3am this morning at Spree. I just can't do that anymore. Those days have flown).

The church itself was very big, and as the service went on, more and more people kept showing up. By the time the service was over, people were packed into every pew and aisle. There were even quite a few people standing outside. One of our Kenyan friends told us that churches here tend to be like that anyway, as over 80% of the population is Christian. But today it was a little worse, as we had 3 special guest speakers at the end of the service. These were 3 men who are currently running for Kenyan president, so they were there basically drumming up support for their campaigns. One of the men was the clear favorite, and our Kenyan friend told us that he is the most powerful member of Parliament right now. He's who most people hope will win, I guess, because he stands the greatest chance of ending government corruption.

I'm usually one that tends to shy away from such blatant mixing of politics and religion, but at least there were multiple candidates there instead of just presenting one viewpoint. More importantly, in a place like Kenya where many people don't own TVs or buy newspapers, campaigning at churches is the easiest way to reach the most amount of people. The sermon was appropriate too -- it was about the wisdom of Solomon and how political leaders need to emulate him.

The service iteself was in English, though they did sing a few songs in Swahili. They do 2 English services and 1 Swahili service every Sunday -- I think it would be fun to go to a Swahili service at some point. It "started" at 9:00, though the doors the church didn't open until about 9:15 or so. And, it "ended" at 10:30, which really means 11:15 in KT (or, Kenyan Time, as we like to call it). The choir was very good, and overal we had a good time.

Then it was time to cook Sunday Brunch with the crew at IU house -- we made omlettes and chai. Very tasty! And now, now it is time to nap. Then Swahili lesson and gearing up for another weak on the Nyayo Wards.

Kwa Herini!

Med Student Article

I know it's an anomaly for me to post twice in one day, but I read this article by a first year med student about the struggles of going into medical practice, and I thought it was pretty good. It broadly covers what most med students go through when trying to pick a specialty that they like versus a specialty that is more well-paid.

And also, pedatrics is primary care.

And one more thing -- I got the results of my Step 2 CS today -- and I passed! I wasn't really worried about failing, but it's still good to know that one more thing is out of the way...

Chill Weekend

Unfortunately I'm not at the street children's fair, as I got quite ill last night and I'm taking it easy at IU house. (Yeah, going up 2 flights for the bathroom is NOT fun when one is sick).

So here I am, doing some laundry, trying to hammer out my personal statement and work on other residency application things (Scary!), another swahili lesson and generally relaxing on this absolutely gorgeous day.

Yesterday afternoon the girls went to the Matumba market on the far west side of town. This is a market that's mostly clothes, and it only happens on Fridays. Unfortunately it rained (poured, really) for a few hours yesterday afternoon, so we didn't get to go right after lunch like we'd wanted. I wish we had, because this market is absolutely MASSIVE, with piles and piles of clothes just laying on the ground. It's sort of Eldoret's version of Goodwill, I suppose. (Ironically enough, many of the clothes still had Goodwill tags on them!) So, we spent a lot of time digging, but I found a few good buys. As my only pair of non-work pants got totally ruined at Kakamega, I bought 2 pairs of running-around-town/weekend adventure pants. I'm sure I payed too much for them, but I wasn't in the mood to argue with the vendors and they were both less than $5 American. I also found an ADORABLE bright yellow skirt for only 100kSH (a little over $1). I might not wear it here -- I don't want it to get all muddy!

The clothes they had there were just crazy -- Priti got a really nice Banana Republic skirt for like 200kSH, and there were all of these random American t-shirts that were obviously not current. I want to find some really funny American t-shirts for Mike and Brant, just to say I bought random American clothing in Kenya. But, I didn't really see anything that grabbed my eye (and I didn't really think Mike or Brant would /wear/ an Eminem or Snoop Dog t-shirt anyway, no matter how cheap it was).

So, after the market was when I really started to feel unwell, so I didn't join the rest of the girls for dinner/dancing. I'm kinda glad I didn't, as Priti got robbed at Places, the club they went to. She had a backpack on, and it all of a sudden felt lighter. When she took it off to look at it, there was a giant gash in the bottom, like from a knife, and the only thing left were her tic-tacs! Her wallet was gone, thankfully with not too much cash in it, but it also had credit cards and ID and social security card in it. How terrible. Her parents were able to immediately cancel her cards, which is good. Her phone got stolen too, so we want to text the number and tell whoever stole her stuff what a not nice person they are! I guess it just goes to show you really can't be TOO careful. (And only wear your backpacks on the front of you, I suppose).

The plan is to go out to a different club tonight, and I suppose I'll tag along. I'm pretty much past the point in my life were "going out" is a regular part of my schedule (I'm an old, boring married person after all!), but it should be fun to go with my friends. I'm just not at all interested in being harassed by random men (which is VERY common here, regardless of marital status). Even if I was single -- you know, didn't really come to Kenya to find someone to date. Alas, I guess that's why we go in big groups, with our guy friends. And one of our Kenyan friends told us not to be afraid to tell the guys to "piss off." Not very nice, but maybe I just will.

Kwa heri!

An overly frustrating day

The inefficiencies of the hospital really got to me today. Well, it's really the inefficiencies of the healthcare system as a whole, reflected at MTRH.

Yesterday, we had an M&M (morbidity and mortality) conference for the pediatrics department. In America, these once- or twice- monthly meetings are used for different departments to present cases that had bad/avoidable outcomes (such as infection, prolonged stay, disability, or death), in order for the department as whole to discuss them and see what improvements can be made to avoid such outcomes in the future. So I thought it would be here, but I was wrong. For example, newborn unit presented a few-day-old infant who came in overnight basically in septic shock. The intern overnight was not able to get an IV in this baby (IVs in children tend to be very difficult), and it was not clear as to whether this intern had called for backup from the registrar or consultant. Long story short, this baby was delayed getting fluids for about 12 hours, and the infant ended up dying in about 48 hours. The lack of immediate IV fluid resuscitation was pinpointed as the critical moment in this case. Which, it probably was. But instead of discussing with everyone how this can be avoided in the future, it turned into a slam-fest, with the consultants completely lambasting the team for their "terrible" doctoring, "In my opinion, it's like this patient was never seen at all." Yes, it's all well and good to blame the intern. The ONE intern, who I might add, is in charge of both pediatric wards at night, which means seeing ALL of the patients that get admitted that day (which can be anywhere from 20-50), as well as deal with all of the patients who are crashing. And in a ward where 60% of the kids would be in the ICU in America, that's a tall order. Yes, the intern should have taken steps to get an IV in the infant, there's no question. But can we not arrive at that point without completely beating everyone down? Apparently not. The most frustrating thing about the conference was that the consultants want to get all up in arms when things go wrong, but they take absolutely NO responsiblity for anything. For example, on my particular team we're supposed to have 3 different consultants. Dr. Tran (the IU doc) rounds with us on Mondays and Wednesdays, Doc 2 on Tuesdays, and Doc 3 on Thursdays. Dr. Tran rounds with us faithfully, I've seen Doc 2 all of ONE time (She showed up for 10 minutes of rounds 2 days ago), and Doc 3 has NEVER once been to rounds. She was on the ward today, but blatantly looked at our team then turned around and walked away. So.... basically the interns and registrars end up making all of the decisions all by themselves, and you know, I really think they do the best they can. It's not like they blatantly neglect or harm patients on purpose. But without the guidance of the more experienced, how can you not expect things to go wrong??? A system that gives the most responsibility to those with the least amount of knowlege and experience is patently wrong. Yes, the interns and registrars need to LEARN, but how can they if no one is ever there to TEACH???

In America, it works as a pyramid. The Attending is in charge of all of the patients on the team, they take ultimate responsibility for what does or not get done for or to the patient. Then the upper level residents, they are in charge of about half the patients on the team, then the interns, about a third, and the medical students one or two patients each. This way, when the medical student misses 10 things that needed done for the patient, the intern will catch five of them, the upper level resident the next 3, and the attending will catch the last two. This greatly reduces patient harm, and in the process everyone LEARNS, and the next time the medical student only misses 9 things, and so on. But here, it's totally backwards. The INTERN is actually in charge of all of the patients, and the consultants apparently, put no responsibility on themselves. I'm going on and on about this, but if the healthcare system here is ever going to change, it's the CONSULTANTS who have to place it on themselves to start that change; by taking responsibility for patient outcomes and training those under them to do the same. At least that's my opinion.

Overally it is just so frustrating. Patients wait for hours before getting fluids, tests are not ordered, or are ordered but not sent, or are sent and then lost...and all the while patients are dying around us, and the consultants just seem to scratch their heads and say "how can this be?" We have one little girl who is SO sick. She came in with severe pneumonia but then got septic, and we've been treating her with antibiotics but she just keeps getting worse. So we switched to 2nd line antibiotics, and she just keeps getting worse. Well, it turns these past 7 days we've been ordering antibiotics she's not actually been GETTING them. Any of them. At all. Not even one dose. How can this happen?!?! In America the staff responsible would be immediately fired and then probably sued. (Robert says what the Kenyan medical system really needs is a bunch of US lawyers.) And this kind of thing happens every day, on every ward, to multiple patients.

I just have to realize that I'm not here to make systemic changes. If I tried I would be this unbelievably frustrated every day, and I'd burn out very quickly. All I can do is try to make a difference one patient at a time. And if I can get my patient IV fluids in 3 hours instead of 6, well then I will have to count that as a major victory.

Eldoret Street Kids

Well, I’ve been here for 2 weeks now, and things are finally starting to settle into a sort of routine. I’m definitely feeling more like part of the Ward 3 team now, and definitely starting to be friends with the Kenyan medical students, instead of just acquaintances. The other exciting thing is that I admitted my first patient on Monday night! The mother spoke English, so I was able to do it all by myself, too. The patient was a 3 ½ year old little girl with earache, fevers, and vomiting. Her blood smear was positive for malaria, so we’re treating her for malaria, BUT I also looked in her ears and diagnosed her with an ear infection. Go me. Usually they just get an ENT consult for ear infections here, because looking in kids’ ears is not bread and butter pediatrics here as it is in America.

Every Thursday night after dinner at IU house we all gather in the lounge and have a “Fireside Chat” about an important non-medical topic. Last Thursday’s was on Eldoret Street Kids. Let me start by saying that I was somewhat unprepared for the street children here. There are quite a few of them, and every time we go into town, they target us (being the wealthy Americans) to ask for money. They’re what you might imagine – dirty, malnourished, desperate. Not to mention persistent. Once they find you they’ll follow you up and down the streets, waiting outside stores for you, saying “muzungu (white person), money for bread” or “muzungu, 20 bob” and when you tell them “Hapana (No)”, they ALWAYS ask “Why?” It’s so heartbreaking. But, we are advised not to give them money, because unfortunately and shockingly these gangs of small children are drug addicts. The main thing the street children do is sniff glue (it’s a cheap, easy high), or they will smoke marijuana or drink alcohol if they can get it. It’s just awful. The alternative is obviously to give them food, which we do whenever we have any with us. The majority of the kids are boys, as girls are more readily taken in by friends or family – they can help care for the house and the children, and there’s a relative assurance that girls will eventually leave the house to get married, in addition to bringing in a dowry payment when they do get married.

So, at our fireside chat last Thursday we had 3 men speak: Frances, Mwenge, and Benson – all of them former street kids. Their stories and experiences were things I could not even fathom. Either one of many, many kids in a house with too many mouths to feed; or abandoned by parents; or attracted to the street life for any reason, these 3 found themselves living on the streets of Eldoret. They told stories of the drug/glue/alcohol addiction, the purpose of the high being strictly to distract them from their hunger or cold or loneliness. Mwenge and Benson are brothers who lived with their grandparents as young boys. In 1992 there was a lot of tribal unrest in Kenya, and one night they boys were forced to flee their home with their grandparents as a rival tribe attacked their village. “With only your feet and your God to protect you” as Mwenge said. Benson was 6 at the time, and he remembers cowering under a bush, being discovered, and having semi-automatic weapons pointed at him as the attackers shouted, demanding to know where the grown-ups where. All he could do was cry. Can anyone imagine ever going through anything like that? I know I cannot. All 3 boys were rescued from the streets by a German missionary who came to Kenya to start a school/home for street kids. Frances is now married with 2 kids, Mwegne is a university student in Nairobi, and Benson wants to go to pharmacy school once he catches up on his primary schooling. Their stories were harrowing, and I couldn’t help but feel incredibly grateful for all that I have; even in Kenya. Yes, I may complain about our small hostel room and our cold showers in sketchy bathrooms, but the fact of the matter is that I have so much more than most of the people in this country. It’s a very humbling thought.

Unfortunately, we see abandoned children not only in the streets, but also in the hospital. Many times kids will be brought in and parents disappear, or a baby will be born and the mother won’t take it with her when she leaves. Unimaginable I know, but a fact of life here in Kenya. Nine times out of 10 the abandoned child is HIV positive, or again is one more in a long line of too many mouths to feed, or both. And what can MTRH do but treat the child and wait for placement in one of the few already overcrowded orphanages? We have one little boy now, Benhein, he’s about 3. He’s so cute and playful, and he especially likes to grab the “torches” (penlights) out of our pockets. We’re not sure what the story is with his father, but his mother has recently married and had another baby. The new husband does not want to care for the child of another man, especially now that he has a son of his own, and especially since the Benhein is HIV-positive. So, Benhein was left at MTRH by his mother. It’s so easy to be outraged at the mother, but she probably has limited options available to care for herself and her new baby, so she had to agree to her husband’s terms. The whole situation is just incredibly sad. When I was at the hospital admitting Monday night, it was about 9:30 or 10, and Benhein was just up running around, acting like a total nutcase (normal toddler, if you will). My immediate thought was “why isn’t he in bed?” And then it hit me, he has no mother (or father) to put him to bed. He has no structure whatsoever, no one to teach him how to eat, sleep, or survive. He eats if he goes up to the foodcart when it comes around, otherwise… who knows? There is no one person assigned to his care. Horribly tragic.

And of course the worst part is that children almost never get adopted in Kenya, especially not HIV-positive children. The real injustice is that international adoption out of Kenya is impossible for various political and social reasons that I need to learn more about. HIV is becoming such a chronic, treatable condition now, especially in the West, so I really feel like international adoption may be the only hope for kids like Benhein.

Again, I don’t want to sound like I’m criticizing Kenya or the way things are here. There are changes that need to be made for sure, and I think eventually circumstances will be much better for Kenya and Africa, if the West can assume its critical role in the process. The happy part about the Eldoret Street Kids story is that, this Saturday, there is going to be a fair of sorts for all of the street kids at a local school. It’s a project organized by the Swedish medical students who are currently here. They’ll get fed, get some general health check-ups, and will even have some basic antibiotics and other meds available for them. Most importantly, Benson will be speaking to them, telling his story, and letting them know of the resources available to them to get them off of the streets. The organizers have asked the other med students to come and help out with physicals, etc, so I’m pretty excited about it.

Sorry this was such a depressing post. I just think I have to share the realities of life in Kenya, because if we can’t understand something, how can we ever change it?

Since things have settled down here, I’ve had quite a bit more time for quiet time/devotions, and I just wanted to share a few quick things. I’m currently working my way through Acts, which is one of my favorite books – I think the stories told about the original Church are just great. Acts chapter 2 tells the story of Peter and the apostles converting the 3,000 at Pentacost. “And all who believed were together and had all things in common, and they sold their goods and possessions and distributed them to all as any had need.” Chapter 4, verse 32 goes on to say “Now the company of those who believed were of one heart and soul, and no one said that any of the things which he possessed was his own, but they had everything in common…There was not a needy person among them, for as many as were possessors of lands or houses sold them, and brought the proceeds of what was sold and laid it at the apostles’ feet; and distribution was made to each as any had need.”

A very convicting few passages for me, especially as I am re-reading them while actually living amongst the poorest of the poor. Before I came to Kenya, I really resented the fact that I would immediately be identified as the “rich westerner.” Me? RICH?! I’m a STUDENT for crying out loud. Six figures in debt by graduation!!! But the reality is, compared to so many of these Kenyans, I am wealthy. What’s 10 shillings when bartering at the market? Next to nothing to me, but it could mean all the difference to the person I’m paying. These are just the things I try to keep in mind.

Keep the emails and prayers coming my way. I appreciate them more than words can say.

Adventures in Kakamega

Before anything, let me first say:

HAPPY BIRTHDAY MICHAEL!!!!!!

If you're reading this, you should DEFINITELY call or email Mr. Mike to wish him a Happy 26th, especially since his stinky wife is not in the US to celebrate his birthday.

Ok. Now. About this weekend. It was amazing. In so many ways.

On Friday night, some of the 6th year Kenyan medical students took out the Americans as a sort of welcome to Eldoret type thing. These guys had just recently returned from spending 2 months at IU as part of the exchange between our universities. First we went for dinner at The Klique (the same bar/restaurant where we watched the soccer game last week), which was really fun. It was nice to chat and get to know them better, and hear about their experiences in American and what they thought of our med school. It turns out that they stayed in the same apartments that Mike and I first lived in when we moved to Indy -- the ones that were constantly being set on fire and flooded and whatnot. They've been rennovated recently, and apparently are much nicer now. It was also nice to laugh and joke with them, about how some things in medicine are universal -- such as attendings with egos so big it's amazing they fit through the hospital doors.

Dayna had mentioned that she wanted to hear some live music, so after The Klique, we took some cabs over to a bar called the Wagon Wheel, where there was a live Kenyan band playing. The music was quite good, though I had no idea what they were singing. Most of the other patrons there were in their 30s and 40s, and also quite drunk. There was one guy there (who was two-fisting it the whole night) who became our best friend once he learned that we were from Indiana. Apparently he graduated from IUPUI, but that's all I could understand, as he was slurring his words quite badly. He even decided to buy me a Tusker (local beer) and call me "Miss Indiana! Miss Indiana!" for the rest of the night. He also introduced me to his wife, who apparently is a clinical officer at the hospital, and kept wanting me to come over for dinner to meet his son. Yeah, no thanks. Once I told him I was already quite happily married, he asked who the single girls were and started harrassing them to come over for dinner and matchmaking. He provided quite a few laughs though, and now everyone likes to call me Miss Indiana.

After staying up late on Friday night, Saturday morning came very early. We were supposed to leave for Kakamega from IU house at 7. Well, it was raining in the morning, and we didn't feel like carrying all our bags, bedding etc down the wet and muddy road in the rain. So Priti and I walked to IU house, helped Venus pack up our matatu with food & supplies from IU house, drove to the guesthouse to pick up Lorein, then back to the hostel to pick up Dayna and all of our stuff. So, we didn't really leave until about 7:45.

The ride to Kakamega itself was not to long, but we had to turn off of the main road and drive along a very primitive, bumpy, and muddy road to get to where we were staying. The Rondo, which is a fairly nice & expensive hotel where the IU people usually stay, was full for this weekend, so we had made reservations and booked a tent at a place called the Forest Rest House (or so we thought). We finally find the Forest Rest House, which was quite a bit farther down the road than the Rondo, and they have no idea who we are or why we're there. Great. Apparently they don't rent tents, and have no idea who would have told us that we had a tent reservation. Luckily, one of their bandas was opening at 11am, so we could get that for the weekend. Otherwise it would have been back into the matatu for another hour drive over bad roads to the next closest hotel/camp site. It worked out fine, actually, as the banda house site was beautiful -- smack dab in the middle of the rainforest.

Because of the time it took to figure out our housing fiasco, we got started on our first hike much later than we had wanted. We left about 11:15 for our short hike. This one was just in the forest around the campsite. Our guide, Smith, spent a lot of time telling us about Kakamega rainforest, its various plant and animal species, and the efforts that began in the 1960s to conserve the area and stop deforestation. The rainforest now is massive -- it covers about 24,000 hectares. Before Western colonialization, it used to cover over 350,000 hectares. Yikes. So this was a fun hike. The forest itself was BEAUTIFUL beyond description. So many interesting and massive trees. I probably took 50 pictures just of various trees. Smith was also very good about pointing out various plants that locals use for medicinal purposes. At one point we stepped into a beautiful clearing that contained a massive tea leaf farm. The purpose of the farm is to prevent local villagers from living directly next to the forest, in addition it actually employs most of the local villagers. This was a fun hike too in that we saw quite a lot of monkeys -- Colobo monkeys, blue monkeys, and red tail monkeys. It was so cool to watch them feeding high in the trees and hopping from branch to branch.

We got back from our first hike about 1:30, grabbed a quick lunch, then left with Smith at about 2:30 for our "long" hike. Yeah, marathon was more like it. He told us that if we left at 2:30 and picked up the pace a bit, we would make it back by 5:30 or so -- plenty of time before dark. This hike took us past some local farms before we went into the forest, where we saw some more monkeys, and a lot more interesting plants and birds. We spent some time on the main road that runs through the forest, which was the main area for seeing butterflies, flowers, and a lot more very beautiful birds. I took SO many pictures. We went up through a guava orchard, where Smith picked us a bunch of guavas to eat -- they were very good. The orchard also had some fantastic views of the surrounding mountains. We even saw a baboon in the orchard!

Soon after the orchard, we turned off of the beaten path into the part of the forest that is completely untouched except for the few trained guides in the area who take hikers in there. It was completely astounding. EXACTLY what I have always pictured a rainforest to be like. The trees were much taller and closer together, and the canopy above allowed very little light to shine through. It was just unbelievaby beautiful. We walked through as quietly as we could, just absorbing the scenery and listening to the many, many sounds of the forest. We stayed in this part of the forest for about 90 minutes, then Smith took us down to the river rapids, 'rapid' being a severe understatement of the fact. This was the most violent and powerful display of water I have ever seen. Smith said that anyone who has ever gone in that water has never made it out. It was fantastic. Again, I took a ton of pictures. Because there has been so much rain recently, we had to find a different path away from the river, as the one normally taken was flooded over. By this time it was about 5:30, but Smith tells us we still have a little way to go. This was when the fun really started. We really picked up the pace. Now, I should mention that these trails are incredibly muddy, so we were just slogging through ankle deep mud as fast as we could. Up hills down hills, over trees and branches, across bridges and rivers, all at a rather punishing pace. Despite the fact that I was WORN OUT, it was absoultey FANTASTIC. After about an hour of this, we rest a bit at the top of the hill, and Smith proceeds to tell us that we still have another HOUR left and we need to pick up the pace even MORE. Holy goodness. So, we're pretty much running through the rainforest at this point. And it's raining now. Which I actually didn't mind, as it was getting quite warm, and what's the point of being in a rainforest if there isn't any rain.

So, we're running and running (and slipping and falling quite often, due to the mud and the rain), and we turn off of the path. Smith tells us that as it's now past 6, the park gates are closed, so we can't take the main road back in, but have to take a "shortcut" through the forest. The shortcut actually took us through the roosting grounds of the black and white crested hornbills we had been seeing at a distance all day, so that was quite amazing. We startled them of course, so they would take off from the trees en masse. It was quite the site to see. They are also called helicopter birds, because of the sound their wings make when they're flying. It was just amazing. By the time we made it onto the main forest road, it was definitively dark. I was inexplicably the only one in our party to bring a flashlight, so 6 people were sharing one small flashlight on a pitch black muddy, hole filled road. Not so fun. Smith kept telling us it wasn't much farther, but we must have walked on the road for at least another 30-45 minutes. By the time we FINALLY made it back to the campground, it was almost 8pm, and we were very sore, extremely dirty, tired and hungry. Thankfully, we had ordered dinner from the Forest Rest House canteen before we left on the hike, so we had a lovely meal of chapata and greens waiting for us. Between that and the chips and cookies that we brought, as Dayna said "it was the best random meal I've ever had." After dinner we sat around a fire and had an interesting conversation with 2 people who were there -- a civil engineer who has lived in Kenya most of his life, though his family and culture is Indian and his citizenship and education are from England. The woman he was with was born in Holland, had lived in Kakamega for 2 years some years ago, and now resides in Canada. You never know who you might meet in the middle of a rainforest, eh?

Being exhausted, I slept very soundly that night. We woke up at 5am this morning to go on our sunrise hike. We were kinda bummed when we woke up, as it was raining steadily and had been raining all night. Smith assured us that we would still be able to see a lot from our viewpoint, if not the actual sunrise. We had arranged with our matatu driver Ashley to drive us all to the trail starting point, so we wouldn't have to get up quite so early. So, the 5 girls and Smith pile into the matatu, and we're on our way. Well, as it had been raining all night, the roads are an utter mess at this point. The matatu is basically a big minivan, so of course we get stuck. So the 5 girls and Smith pile OUT of the matatu and push it up the hill. In the dark. In the rain. With mud getting spattered everywhere. We finally made it to the trail starting point, and we being a 30 minute steep uphill climb. We ended up about 250,000 meters above sea level, starting from about 75,000. It was tough, especially as I was quite sore from yesterday. Before we got to the summit of the mountain we were climbing (Smith says it is just a "big hill", but I say it was a mountain), Smith took us into a bat cave. Not my favorite thing. The ceiling was very low and there were bats flying in and out right over our heads. I know that they're harmless, but there's something about shining your flashlight down a deep cave and seeing hundreds of pairs of beady little eyes looking back at you that just gives me the willies. Being 5 girls, we hightailed it out of their pretty quickly.

After the cave came the last 10 minutes of our hike to the top, and they were the hardest. We were going pretty much vertical for this part. It was very strenuous, but more than worth it. What we saw at the top defies description. We were standing on the highest poing of Kakamega rainforest, looking out over miles and MILES of canopy in the early morning light. We could hear thousands of sounds of the forest as well as flocks of birds soaring over the trees, landing, then taking off again. It was AMAZING. We were actually standing above the cloud cover, and we could watch the low-lying clouds move over the canopy, and hear the rain being dumped into the forest. We didn't get to see the sun acually rise, as it was a little too cloudy, but it was the most beautiful thing I've ever seen anyway. As I told Mike, if he had been there, it would have been by far the best moment of my life. I took a bunch of pictures, and even a couple videos, but I know this was one of those things that can never be fully justified on film.

After having breakfast at the top of the rainforest (what really felt like the top of the world), we headed back down. Ashley drove us back to the campsite, where we packed up and cleaned up as best we could (all of us being completely caked in mud and soaked through by this time) and packed up. We had a little bit of time to hang out before Ashley came back to pick us up, so we sat out in the sun (which was out by this time) and read. I'm so glad we did, because the group of blue monkeys that lives nearest the Rest House came through. Smith told us they probably would. They were on their morning feed, and the sound they made as they lept from tree to tree overhead was unbelievable. We just sat outside and looked straight up at the monkeys eating. Unbelievable. At one point, the male (he was by far the biggest of any of them) came down and sat on the ground no more than 10 feet away from us. According to the camp staff, they are very acclimated to humans, and will raid banda houses and kitchen if they are not closed securely enough. The male monkey just sat there in front of us for about 30 minutes, not really bothering much with us (of course we were taking pictures like maniacs), surveying all of the females feeding in the trees, eyeing our snacks, before he finally climbed a tree again. It was fantastic!

So, Ashley comes, we pack the matatu, and he says, I'll take you on the other road around Kakamega and show you the crying stone. We say sure, why not, and we're off. Well, this 'other road' was the least road-like of ANY of the roads I've yet been on in Kenya. It was one giant mud pit. It was honestly like driving in the winter in Indiana when there's a thick layer of snow on top of the road with a sheet of ice underneath. The matatu was fishtailing and sliding all over the road. We kept saying "pole pole!" (slower!), but of course the back end fishtailed into a ditch and got soundly stuck in the mud. Us 5 girls jump out -- all wearing flip-flops -- and immidiately sink into ankle-deep mud. Despite our awesome buffness, our pushing of the matatu was if anything, getting it stuck more. So, about 20 of the local villagers come out and help us push, we eventually get unstuck and are on our way again. We drive for a little bit more, swerve around uncontrollably for a bit more, and of course, get stuck again. The back end of the matatu, in a muddy ditch. We were NOT amused. Ashley told us not to get out this time, and again a bunch of local villagers manage to get us pushed out of the ditch. This was not nearly the most fun I've ever had. Soon after the 2nd time of getting stuck, the road improved a great deal (though I can't imagine it getting much worse), and we drove through Kakamega town. It was quite pretty. The sun was very bright, and there were even more people out on the roads than usual, as it was a Sunday and everyone was going to or coming back from church.

Just outside Kakamega town, we stopped at the Crying Stone. It was beautiful. It's a gigantic (and I mean huge -- as wide as 2 skyscrapers and as tall as one) rock formation that looks like a person -- a big broad rock for a body and smaller round rock for the head. It was quite a ways back from the road, so we had to walk through a little village to get to the actualy formation. By the time we climbed up it, we were trailing quite a few of the villagers, most of whom were children helping us up the rock (again, all of us wearing flip flops that recently got a mud bath). The view from the rock was very nice -- we could see the surrounding countryside and villages quite nicely. Ashley told us the story of the Crying Rock: Many years ago, there was a great Kenyan warrior who was the leader of a great tribe. All of the other tribes envied their greatness, and he was constantly being attacked by other tribes. During battle, he was indestructable, as his skin could not be pierced by a spear. The leaders of his rival tribes came up with a plan to have this great warrier fall in love with and marry one of the rival warrior's daughters. This happened. Some years later, the great warrier fell sick, and in order to be healed needed to be pierced on his skin and have medicine injected. He told his wife that the only way to pierce his skin was to pierce his shadow, which she did, and he was healed. His wife went back to her father and told him of the great warrior's weakness. The rival tribes attacked the great warrior, stabbed his shadow, and he died. It is said that when he died, he became a great stone statue that weeps because of his betrayal. Sure enough, there was a steady stream of water flowing from the top of the rock to the bottom. Sort of Africa's version of Samson and Delilah, I think. It was very cool. Again, I took a ton of pictures.

After the Crying Rock, we enjoyed a blessedly uneventful drive back to Eldoret and IU house, where I took quite possibly the most refreshing shower of my life, scrubbing VERY hard to get all of the mud off. Now it's about 20 minutes until my 2nd swahili lesson. (Most of us are taking some basic swahili lessons from Wycliffe, a local tutor. I had my first lesson on Friday, it was fun and went quite well! I won't become fluent by any means, especially not on this visit to Kenya, but I do hope to be able to at least communicate in some way with my patients).

It was a perfectly fantastic weekend. It was only my first real weekend away trip here, but I think that it's going to be hard to beat. We'll see what other adventures Kenya holds.

Been here a week

Well, I've spent a week in Kenya. In many ways it seems longer than that, as so much has happened. In other ways it seems like it flew by, and I think that the next 7 will as well.

I'm slowly getting more used to the wards, and getting more integrated into the team. The Registrar even asked me a few questions today! I went back to the hospital yesterday afternoon to help the team give our heme/onc patients chemo. That was an interesting experience. We got a big box of meds from the pharmacy, and we took them into the procedure room, where the interns proceeded to mix, measure, and dose the meds themselves. Now, understand that in America, chemo drugs (being highly toxic) are strictly regulated, mixed by trained pharmacists under strict body protection by suits, masks, and eye shields, and the doses are calculated and measured very precisely. None of us being oncologists, yesterday we read many of the package inserts to figure out the dosing, then calculated the actual doses on a phone calculator. Moreover, it was a very crowded room with needles everywhere, and our only protective equipment was latex gloves. Again, I don't want to sound like I'm criticizing the Kenyan way of doing things, as they really do the best with what they have. I just find the differences between here and the US very striking.

So after mixing our chemo drugs, it was time to administer. One little boy, who's not as sick as the others, came to the procedure room to get his intrathecal (in the spine) chemo. No pain meds or anything, just a big needle in his back. He didn't even flinch. (One thing I've certainly noticed -- the patients here are extremely tough, especially the kids). The other 3 kids who got chemo yesterday we did at the bedside. Two of the boys IVs' were blocked, so they needed another stick before they got their drugs. The process of actually giving was a little hocus-pocus as well -- you can't generally give these drugs in one big bolus, in fact the US they're usually given via a pump for a constant small infusion of drugs over a certain amount of time. But here, there are no pumps obviously, so the interns just injected slowly, guessing at the rate by trying to keep the rate of IV fluids going in about the same. The worst part about the whole thing was that these drugs burn going in, and after about the 2nd or 3rd syringe, the kids started getting really sick and vomiting. It was awful. It was the first time I've almost cried in the hospital. In a way, it's great that we can offer chemo to these kids for a chance at palliation or even a cure, but in a way it made me feel like we were just torturing these children.

Last night was the big IU house dinner, we went to an Indian restaurant, which was quite good. They brought us out plates and plates of food, and when they took away my plate I was full. But then they brought out BIGGER plates and new utensils. I asked Sonak if there was more, and he informed me that the first "course" was just the appetizers! Good Heavens. The IU people go out as a group every Wednesday, and they cook dinner for the students at IU house on Thursdays, so I won't be eating beans, rice, and ugali for /every/ meal.

This weekend 5 of us are planning a trip to Kakamega -- a rainforest reserve about 2 hours from Eldoret. We'll be camping for one night, and going on 3 guided tours of the forest while we're there. I'm pretty excited about it. I'm sure I'll have a lot to say about it when we get back.

Keep sending your emails (or start, if you haven't sent any! ;)), I like to hear from home.

First Days at Work

The first few days at the hospital have been somewhat overwhelming. It's difficult to learn a new system in a new country with patients having diseases I've only read about in books. Despite this, I'm trying to stay positive. The first few days of any rotation are hard, because everything is new, and I expect this is magnified greatly by the fact that I'm in a different country.

The medical teams are organized differently than in the US. There are the Consultants (basically the equivalent of our Attendings), the Registrars (upper level residents), Interns (Interns), Medical Officers (like Nurse Practitioners or Physicians Assistants), and Medical Officer Interns. Add to that 5-10 medical students of various nationalities and stages of traning, and you've got one big team huddled around small beds.

I've started on peds wards, where the patients (and their mothers) are always 2 to a bed, usually 3 or 4 if the hospital is busy. The wards are pretty much what you might expect in a developing nation -- crowded, hot, and not subject to the strict standards of sterility, etc that US hospitals are.

In my 2 brief days, I've seen quite a few interesting things. Lots of malaria, of course, quite a few cases of HIV (often newly diagnosed in both patient and mother), and a few kids with TB. We have one little boy who I think is very interesting -- he's 13, and has had intermittent facial and leg swelling for almost a year. In the past 6 weeks he's been hospitalized 6 times for the same thing (at an outside hospital) and has been diagnosed with heart failure every time. Well, this time his mom reported a big decrease in urine output and change to "coca cola" colored urine -- basically this little boy has kidney failure for unknown reasons. Because of it he's having a lot of problems with hypertension and all-over body swelling, as well as needing a special diet very low in salt and protein (not as easy to do as it sounds). He really needs a renal ultrasound, healthcare here is all pre-pay before you get the service, so tests usually take a few days to get, so the family has time to get the money. Sometimes the registrar or consultant can choose to waive the fee if the patient really needs someting, which I think we might do for this little guy.

The other really difficult thing about the past 2 days is that our team covers the peds heme/onc ward as well. These little guys are so sick. And most of them present so late in their illness that most care is palliative. We have some AML and ALL patients, as well as a few Hodgkin's disease patients. One little boy came in with a midline cranial tumor that has basically taken over his face. It's very sad. They all get chemo and pain control, but unlike in the US, there are a very limited number of chemo drugs available, and what is used may not neccesarily be what is the very best for treating a particular kind of cancer.

Not to make this a depressing post. I'm very happy to be here doing what I'm doing, and learning about things I will rarely see in the US.

Yesterday Priti and I moved into the hostel. This was an amusing experience. Being girls, we both have a lot of stuff, naturally. Well, this is pretty much the smallest room imaginable, and we have to cram 2 people and their stuff in it. If anyone remembers my freshman dorm room at Anderson (mom? dad?), this room is actually about half that size. But, it forces us to be social, as we're only in the room to sleep basically. Once Dayna goes back to Indiana at the end of this month, one of us can move into her room, so that will give us a little more space. The hostel itself is -- functional -- but definitely the roughest type of place I've ever lived. The 2 rooms that IU rents from the hostel are on the 1st floor, which is the male floor, so we actually have to treck up to the 3rd floor for the bathroom & shower. I say "shower" very lightly, as it's really nothing like in the US or even at IU house. It's all cold water, and most of the time there's not enough pressure to have water coming out of the shower head. Most people take bucket-type showers, which I did last night -- that was an experience. Luckily, IU students sort of leave stuff behind in the IU hostel rooms, and someone left a plug-in water warmer contraption, so at least our bucket showers will be warm!

I bought what I thought was a converter yesterday, so could charge my camera batteries. Well, I plugged in the charger and it didn't turn on, so I thought either the converter was bad or I had ruined the charger by trying to use the Kenyan outlets (which is likely). So, I decide to plug in my hair dryer to see if it was the converter. As soon as the prongs touched the converter, there was a loud bang, a ball of fire and smoke leaping from the outlet. So of course I screamed, and quickly moved the curtains and the mosquito net out of the way, so as to not set the hostel on fire on my first day there. Apparently what I bought was just an /adapter/ and not a /converter/ so much. Doesn't really matter now, as I've already ruined the only 2 electrical appliances I brought with me. It's ok though, I can just buy batteries in town and I don't need my hair dryer anyway.

We had the afternoon off today, so Priti, Larien and I braved town for the first time on our own without Dayna and Erin (who know where everything is), and we actually did quite well. I found the bank where I can change my Ameican money (which I did), though apparently you need to bring your passport with you every time. The teller let me use my student ID this time though. Then we went to the Eldo-Chem (pharmacy) where I bought the rest of my malaria prophylaxis -- it's much cheaper here than in the US. Drugs and such are much less regulated here than in the US -- you can buy pretty much anything over the counter, but of course the selection of available drugs is much less.

I really don't mean this to be a negative or complaining post. I'm pretty satisfied with how things are going thus far, though I do look forward to more familiarity in terms of the living conditions, wards, and the town. Although I am already much more used to being stared at everywhere I go.

I read this in the Lonely Planet guide to Kenya recently, and wanted to post it:
"AIDS IN KENYA. Like most of its neighbors, Kenya is in the grip of a devastating AIDS epidemic. There are 2.5 million Kenyans with full blown AIDS and nearly 700 people die from the disease every day. AIDS is predominantly a heterosexual disease in Kenya and now strikes all classes of people. At least 890,000 children have been orphaned and many others are infected while in the womb. Teachers have been badly affected - at least 18 die daily - because they are predominantly in the 20 to 29 age group that's most affected by HIV/AIDS, and Kenya is facing an education crisis as a result, leaving even fewer people to spread the AIDS-awareness message. Around 85% of prostitutes are affected, and young girls are especially vulnerable, due to the widespread belief that AIDS can be cured by sleeping with virgins. Drug treatments that are available in the West to increase the lifespan of AIDS sufferers and reduce the risk of infection passing to the fetus in HIV-infected women remain well beyond the financial reach of most Kenyans, few of whom have access to even basic health care. The problem is unlikely to improve as long as Western drug companies refuse to allow developing countries to produce much cheaper generic versions of their products. Currently the cost of treating a single AIDS vicitm for a year is US $34,000, while the annual wage of most people in Kenya is under US $500."

Those statistics make me cringe. Though I do think things are getting better -- albeit slowly. At least in Eldoret, AMPATH has gone a long way to reduce the stigma of HIV/AIDS, and more importantly educate people about transmission and prevention; as well as giving treatment access to those who need it. I read that and I'm reminded of a large reason I decided to come here.

Now it's time for dinner and a shower at IU house!

A quick update

So yesterday was pretty chill. I slept in a bit, got up and had a leisurely breakfast with Priti, and Dr. Mamlin was back from his weekend away, so we talked to him for awhile. He was telling us a bit about what he did over the weekend -- took a long ride into Uganda, then out on a boat to an island in Lake Victoria, where they did an HIV/AIDS educational program, then to an orphanage, and another long ride back to Eldoret. I wish that I had half of his energy.

We were feeling brave, so we made our own lunch in the kitchen -- pasta with a sauce that we kind of invented on the spot. Venus, Priti, and I ate with Sonak (an PharmD/MPH who will be living here for 5 or more years getting a pharmacy exchange program off the ground), and we met 2 of the Kenyans who live in IU house -- Benson and Simon.

After lunch the 6 of us walked into town and met up with Dayna and Erin. We went to the market, where I found a fleece almost exactly like the one that got left in the Subaru, for 300kSH -- not bad! I also bought some more phone cards. I can see spending a significant amount of money on those things. We went to a cafe and had some chai & coffee, then Sonak took Priti and I to Nakkumat -- basically Eldoret's version of Wal-Mart. There's actually quite a lot of stuff there, and a fairly wide selection of electronics and home goods as well.

After Nakkumat, we met back up with Benson, Simon, Erin, Dayna, Venus, and Laurien, and we all wen to a bar called The Klique to watch Man U vs. Chelsea. Futbol! It was quite fun, as everyone in the bar was very into the game. I even learned more about soccer (which wasn't difficult, as I knew next to nothing to begin with). As someone in the group said, it was a lot like America's Monday Night Football experience, and it was a lot of fun. I could definitely get into soccer more if America cared more about it, but as I told Mike, we'll have to see if there's a Beckham effect.

After the game we walked back to IU house (not my favorite thing -- as it had just gotten dark, but still too early to call a taxi, and we were a large group and had 2 Kenyans with us), where we met Robert and Hao, our medical directors, who had just gotten back from a weekend away as well. We talked a little about the next 2 months -- I'll be starting on Peds wards for 4 weeks, then moving to medicine wards for 3 to 3 1/2 weeks. We also met our 2 American residens -- Hank and Linda, who had also been away for the weekend. So there are now quite a few people at IU house.

We're meeting Hao this morning at the hospital for more orientation and tour, and we'll do a more thorough orientation after rounds. Then this afternoon, we re-pack and move to the hostel. It will be nice to get a little settled and stop living out of a suitcase.

Lala Salama!

A long overdue post...

so... I made it to Eldoret. The ride was... interesting. But let's start from the beginning...

After quite despondantly leaving Mike at the airport (or, he left me there, rather), I had an uneventful flight to Boston. But then the fun started. Of course the plane from Indy to Boston was a little puddle jumper, and we didn't get a real ramp thingy to get out of the plane. We walked down the stairs and into a back door of some sort that led to a maintenance area of some sort that led to a baggage claim area of some sort. Except it was actually the baggage claim area. So.... I had to go BACK through security, which is Boston is a huge deal, and I ended up waiting in line for about an hour. Luckily I had plenty of time. But, of course my bag with medical supplies got scanned twice and then searched (due, I think, to my reflex hammer, which has a sharp metal, dagger-like handle) as it did in Indy, so by the time I got to the gate at Boston, I was quite perturbed. As I left my American cell phone at home, I tried to call Mike on a pay phone, but the first one ate my quarters and then the second one kept telling me I was dialing an out of order number. But by the third phone, I got through.

Flight from Boston to Amsterdam was about 7 hours. I was planning on trying to sleep most of the way, which didn't work out so well. I was in a row of 2, in the window seat, and of COURSE my seat was broken and didn't lean back. But, the seat next to me was never claimed, so I could lay down of sorts. Which really wasn't all that comfortable, with my head jammed uncomfortably against the arm rest, and my feet hanging out into the aisle and getting rammed into by passengers or drink carts or whatever every other minute. The hour or so that I did manage to get some sleep was when they brought dinner around. Of course. After that I couldn't get comfortable so I just ended up watching movies -- Shrek 3 & Spiderman 3. On this plane we had our own individual screens, so that was nice.

So I arrive in Amsterdam, dirty, tired, and schlepping about 100 lbs of stuff behind me. This airport is HUGE -- it really was like being a shopping mall that just happened to have airplanes parked outside the windows. I wandered for a bit, got some breakfast, bought a phone card and checked in with Mike again. Then I met up with Priti, and it was time to -- you guessed it -- go back through ANOTHER security line! Apparently at Amsterdam, security checks happen at each individual gate. After getting my bag searched (again), we get on the plane. And I mean, this was a PLANE. One of those double decker things. They even had 2 separate rams depending on which rows you were sitting in. So I go up my ramp, and one of the flight attendants directing traffic looks at my ticket and tells me to go left. Well, left was the wrong way. I consider myself a fairly intelligent person, but I got totally lost on this plane. The numbers made no sense (plus I was sleep deprived), and the aisles were super narrow, so my suitcase kept getting stuck, plus I was going against the flow of traffic most of the time. I eventually just threw my suitcase in a random bin, and finally found my seat. It was in a little secluded section of the plane, right by a bathroom and a water fountain (fancy!), I was on an aisle seat with no one behind me, and the seat leaned back, so I was thinking this was pretty sweet. I had been sitting there no more than 2 minutes when a flight attendant asked if I would be willing to switch with a man who was traveling with the 2 women next to me (they were African) who didn't speak English, and he wanted to be near them to translate. So I think, ok, I guess, I'm a nice person I will do that. I pick up my bag, fight back through the streams of people entering (seriously, I have never seen a boarding process so chaotic), and we find the guy. Well, he's not even in his right seat anyway, so we were confused about where I was supposed to sit -- but of course it ended up being one of the middle seats in a row of 4. It also turns out that I was once again sitting next to 2 (different) African women who were traveling with this man, and they didn't speak any English either. Now I'm wondering why I gave up my great seat? Luckily, once again, the aisle seat next to me was never claimed, so I moved over to the aisle seat. But apparently, that's what the woman next to me thought she should to too, so she moved over to sit directly next to me again. But atleast I was on the aisle again. All in all, it was a long and uncomfortable flight (there's definitely something to be said about shelling out the extra money for business class when flying halfway around the world), especially since the African women communicated mostly by hitting, nudging, and shoving whenever they wanted something or wanted out.

But, we FINALLY made it to Nairobi after a little over 9 hours. The scene at the airport was total chaos. We stood in line to exchange money, stood in line (for over an hour) to get our visas. Luckily ours were pretty much the only bags left by the time we got through immigration. And everything made it intact! Then we stood in line to go through customs, and then we had to try to find our driver. If I thought the airport was chaos, then the transportation area was an absolute zoo. Or a circus. Or a zocus. We were told to expect it, but people just start randomly grabbing your things, telling you that they are your driver, or they will take you to the hotel, or whatever. So that wasn't fun. But we did find our driver eventually (who by this time was wondering if we had made the plane or not), and he was very friendly and took us to our hotel.

The hotel in Nairobi was quite nice. It had a nice little work out room and a fabulous breakfast in the morning. We felt quite safe, as our driver had to pass through 2 security checkpoints, and the locked front door was guarded by a locked gate. We sort of crashed when we got there, ordered pizza and watched some American TV (J.Lo is present even in Africa). After breakfast the next morning, we checked out and our driver met us to take us to Eldoret.

Our driver's name was Netta, and she is a "white Kenyan" as she said -- having been born and raised in this country, now working mostly as a safari guide. She knew a ton about the city and the country, and answered all of our random questions. The ride out of the city was awesome, as it was the first time we had seen Africa by day, and there were people everywhere. We passed most of the downtown buildings, and an enormous market with thousands of people selling millions of things. A little farther out of the city, we passed an area that wasn't a game preserve, but near it, so we got our first look at some African wildlife. We saw several herds of anetelope and some impala, as well as many random herds of zebra grazing along side of the road. The coolest thing was the baboons, though. They sat on the side of the road eating whatever was thrown. We got to see them running, too, and they are quite quick!

The scenery along the drive was phenomenal -- we drove up to the peak of a mountain that overlooked the Rift Valley, drove down into the valley to Nakuru, then climbed back up into the hills where Eldoret sits. Overall, the trip took about 6 hours. The first 2 hours were awesome, as the road is brand new and there was so much to look at. About halfway to Nakuru, it started to not be fun. This is where the new road ends and the old "road" begins. I say road in only the very broadest and most generic sense. Certainly, it was paved, at some point in the past, but that was it. There is no repair whatsoever and the potholes are unbelievable. To get around this, people drive pretty much wherever they want (though technically driving is on the left here), and you just avoid other cars and people (both of which there are many) as best as you can. The best part is when you're clearly on the wrong side of the road either avoiding potholes or passing another car(s) and the plumes of dust are rising so high that you can't tell if what's coming directly at you is a bus or a bike. The other not so fun thing is the random police stops every few miles or so. Netta said they really like to pull over matatus (taxis) because they tend to break the most laws regarding safety belts, speed limit, number of passengers, etc. If they get stopped, they usually have to pay a ticket (ie bribe) in order to keep going. So that's frustrating on a personal and institutional level. At any rate, we only had to actually stop once, and as soon as Netta started speaking in Swahili, they knew we got to leave again pretty quickly. We stopped in Nakuru quickly, then we climbed the mountain to Eldoret. Again, the scenery was just amazing.

The best part of the drive was stopping at the Equator and taking pictures (of course), and a local guy there showed us the water trick, which I'd never seen before. The water trick involves a pitcher of water and a bowl with a hole in the bottom. When standing north of the equator, the water, when poured into the bowl, will come out the hole in a counter-clockwise fashion. This was demonstrated by putting a piece of straw in the bottom of the bowl, which did in fact turn counter-clockwise. Then, while standing south of the equator, the straw turned clockwise. And when we stood directly on the equator, the straw lay perfectly still in the bottom of the bowl while the water poured out. It was the neatest thing!

Once in Eldoret, we came to IU house, where we're staying for the weekend before going to the student hostel on Monday. IU house is actually a compound of houses owned by IU and used for the staff, residents, and visitors that come here. IU house is where computer access is, as well as laundry and some meals of the week. It's about a 10 minute walk from the hostel (and the hospital, which is across the road from the hostel). After getting settled in, we went out for Indian food (which is apparently quite popular here) with a ton of people. I was so tired at this point, I barely remember the meal.

This is long.... but... on to today.
Today I went to Kisumu with 5 other girls. Kisumu is the 3rd largest city in Kenya (Eldoret is actually 5th -- it has a population of 1 million), and it sits on Lake Victoria. We took a matatu for 300kSH (about 5 US dollars), and it was a 2 1/2 hour ride (once again, on not so great roads). Again there was chaos when we got there, because the matatu stand is right in the middle of the market. Of course it was Saturday, and of course we all stand out as blatantly tourists, so we were getting sales pitches left and right. We made it to the edge of the market, where we each hired a bota bota (basically an elongated bicycle -- there's an extra seat on the back and the drivers make money by peddling people around) to take us to Hippo Point. The lake was absolutely beautiful, and I got some great pictures. We spent about an hour at the lake, and we did actually see some hippos. They were about 50 yards away from the shore, and they were feeding and sunning. It was pretty cool. We had lunch by the lake, then hired bota-botas back to town. This was more of an adventure, as the chain broke on Dayna's bota bota, so she got left behind (the other drivers did not stop), and my driver was last in the pack and had no idea where he was going. We were speeding down a hill and I saw the rest of the group, I shouted STOP and the driver stopped to fast I thought we would both flip over the handlebars. Eventually Dayna made it back into town, and we walked around for awhile. Erin really wanted some fried Tilapia, which we found, and it is actually a whole, entire fish, pulled from the lake and fried. Needless to say, I declined. We meandered back to the market and did some shopping, then got back on a matatu and headed for Eldoret.

Once back in Eldoret, we got some dinner, then wandered over to the video store (bootlegged DVDs, apparently most of them are obviously filmed in a theater). By this time I was exhausted and getting nervous, in that the #1 thing they tell you NOT to do in Eldoret is be out at night. I was apparently the only one concerned. By the time we left the video store it was definitely dark (it gets dark about 7 here), and there are no lights. So, we are searching for a cab, can't find one, dashed in and out of traffic (again, the driving is just crazy here) to get a a corner where the cabs and matatus leave, and no cab will take all 6 of us. We didn't want to split up, so Dayna called a cab driver who knows the med students, but he took forever to show up (turns out he didn't actually know where we were), and the whole time we're standing there (again, standing out like sore thumbs) getting harassed by drunk guys and matatu drivers -- "where you go, where you go? You go to Nairobi tonight?" Yeah, no thanks). Luckily there were 6 of us, but it's still not a situation I want to be in again. I was actually really mad about it, as it was a stupid situation for us to get in, especially as it's only my 2nd day in Eldoret. Eventually our cab showed up though and we made it back to IU house fine.

The group I was with today was actually pretty diverse in terms of culture & experience. There's me, there's Priti (who's Indian though born in the US), then we met Erin, a 1st year Candian medical student who's been here for 10 weeks (she leaves Wednesday), Dayna, an African-American 4th year IU student who's here for July/August. We also met Venus, a business major doing a project here. She's also from Canada, but her parents are Chinese; the last girl is Laurien, a 6th year med student from Holland. So overall, we really REALLY stood out today.

I know this has been very long, but I feel like so much has happened already. I'm sure it will all start to seem more common and less amazing as I get more used to being in the country. Tomorrow is kind of a relax day, and Priti and I will meet with our medical directors to figure out which services we'll be on while we're here. Then we'll move to the hostel either tomorrow or Monday, and start work at the hospital on Monday. I'm very excited.

Asante sana for all of your thoughts and prayers.