Out of America: An adventure in health care in rural Kenya

Library Project Update

2009-01-28T09:55:00.000-08:00

In spite of Paul and I leaving Kenya rather unexpectedly (OK! We were thrown out!), the library project was a success thanks to all of your generous donations. We hoped to collect $1500 but with your help, we raised more than twice that amount. That means that the Kenyan staff will be able to fill the library with all new, culturally relevant books, maps and other materials. They may even have enough to start a smaller version at the orphanage, the Ongoro Children’s Home.

The Lalmba Matoso Library is the only library in the entire region and an important source of educational materials for the local students. Education doesn’t guarantee a Kenyan a successful future but it does give them a big boost. Perhaps more importantly, the library will open up a whole new world to those children in the surrounding villages whose families are unable to afford school fees. In addition to books written in their mother tongue of Luo and by African authors from across the continent, they’ll be exposed to works that will bring the whole world to their village. In the coming months, the Director of Education, John Chacha will go to Kisumu to order books and when they arrive we’ll ask our successor to take photos of the new and improved library for all to see.

The past year has been an amazing, challenging, frustrating, eye opening and joyful experience. We were privileged to spend 9 months working with our Kenyan colleagues and caring for their Luo patients. We not only learned so much about health care needs in Africa but also saw first hand the interconnectedness of our lives. Looking back at our country from that distance also gave us new appreciation for the freedoms that we enjoy but often take for granted. We appreciate our free and fair election process and our society’s ability to continually evolve to meet the challenges of our world. We appreciate our country’s history of embracing people from diverse cultures who have the freedom to create new lives for themselves and their families.

We thank you all for your interest in our journey and your love and support throughout the year. We are so grateful for all the packages and emails filled with treats and news and love. We give special thanks to my siblings Francesca, Karen and Jim and their families for welcoming us into their homes during the past 7 weeks while we were waiting to move back into our Denver bungalow. The vagabond life of living out of a suitcase could have been unsettling and frustrating but you made it feel like a prolonged vacation. It is indeed good to be home.

Peace and love

Darcie and Paul

Confessions of an illegal alien

2009-01-04T12:48:00.000-08:00

By now, most of our faithful readers know that Paul and I are back in the US but to those who don't and have been worried about us, I apologize. Let me fill you all in on the interesting events of the past 2 months.
In late November, Lalmba founders Hugh and Marty and their new executive director Carrole were preparing to leave Kenya following a productive 3 week visit. They approved our proposal to add a pediatric HIV program to the PSC and we were excited to get started. But, after spending 9 months in the bush, Paul and I decided to take a short vacation and get re-energized for our final 3 months in Kenya.

Our friend Maggie Tidwell is executive director of Bead for Life (www.beadforlife.org), a wonderful organization that works to lift Ugandan women out of poverty. She lives in Kampala, Uganda and had given us an open invitation to visit (her amazing blog can be found at : www.ugandandays.blogspot.com. Maggie was the founder of Colfax Community Network which provides all kinds of needed services to homeless and poor working families who live along the Colfax corridor in the Denver metro area. We had collaborated on a project to provide health care to these families by bringing the Stout Street Clinic's mobile clinic along on outreach with her team every Tuesday for 5+ years. Maggie joined BFL in May 2008 and has already done amazing work for that organization. We were anxious to see her and her projects and this seemed like an ideal time to visit.

On November 20th we rode along to Kisumu with the Hugh, Marty and Carrole. They were flying to Nairobi the same evening on the first leg of their journey back to the US. After running many errands, shopping at an outdoor artist market and having a goodbye lunch, we bid them farewell with plans to see them back in Denver in early March.

On Friday morning, November 21st we took a matatu to the Ugandan border. A matatu is a van with seats for about 12 but carrying 17. The trip to the border town of Busia took about 2 1/2 hours and cost 400 shillings each (about $5.30). We stood in line to get our exit visa from Kenya and entry visa for Uganda. I handed the cards and passports to the immigration agent who inspected them and then waved us out of the line. We were taken into an office and accused being in Kenya illegally. We were told that the one year visa which we applied and paid for in February 2008 needed to be renewed after 6 months. Since we'd been in the bush we hadn't had a need to use our passports until that day. We never looked at the expiration date.

A very angry and aggressive immigration agent questioned what we had been doing in Kenya for 9 months. I answered honestly about our volunteer work for Lalmba and he said "if you say that to me again I'll have to arrest you for working without a work visa". We stressed the volunteer nature of our work which he said didn't matter. It was still work and we should know their laws if we were going to be in their country. He then confiscated our passports and told us we were being taken into custody, transported back to Kisumu to meet with Immigration.

In Kisumu we had charges brought against us for being in the country illegally and for working without a work visa. We went before a magistrate, found guilty of the first charge, fined 20,000 shillings each and ordered deported. Nothing we said made a difference. We were given the choice of paying the 40,000 sh immediately or being jailed for 30 days. We only had enough money on us to pay one fine but luckily the Lalmba Project Director, Marico, arrived in time to pay the second fine. The police threatened to jail us until we could be deported but Marico was able to get us released on a personal 400,000 sh bond with a bribe of 3000 sh. What a long, crazy and at times frightening day.

We drove back to Matoso the following day, arriving in the late afternoon. We had one evening to pack, tie up some loose ends, write notes to various staff regarding projects and try to say goodbye to as many people as possible. As staff learned of our situation they began to come by to see us. They were all saddened by the way we had been treated and by our impending departure. At that point Paul and I still hoped to be able to delay our deportation for 3 months or to get help from the US embassy that might reverse our situation. The worse case scenario we thought was to have to fly to the US, get another visa and then turn around and fly back. We never really thought we wouldn't be back.

We packed our most important belongings but left a lot behind including clothes, personal supplies, and Paul's Ovation guitar. Our departure from the compound was a very sad one. We didn't know what the coming days would hold or how soon we could return. We were disappointed to have missed the opportunity to visit Maggie and to get started on the pediatric HIV program. As it turned out, it would be our last look at Matoso for a very long time.

On Sunday we drove back to Kisumu with Marico (a 5 hour drive over rutted, bumpy roads) and were turned over to Immigration at 8 AM Monday morning. We were driven to Nairobi in a government vehicle, accompanied by a guard and 3 other immigration officials (or ride-alongs... we were never really sure). We asked where we would stay in Nairobi and were assured that there was a place for us to stay while they made our travel arrangements. Arriving at 9 PM, after business offices were closed we were turned over to the Immigration office at the airport.

We were questioned about our travel arrangements and when we said we had been told they were making arrangements, they became angry and threatened to throw us in jail for 2 or more weeks until their government got around to it. In fact, they said, we were going to jail anyway, and it was up to us how long we stayed there.

Paul was taken to the men's cell where 9 African men were already being held. I was put in the adjacent women's cell. Paul was on the phone trying to make flights plans with Carrole but as soon as they got us onto a morning flight to Cairo, the immigration officers told us we weren't authorized to leave yet. This was a pattern throughout our interaction with Kenyan immigration. We were given erroneous information and kept in the dark for much of the time.
The concrete cells had metal doors with small peep holes in them. No sleep, no food, just bright lights and lots of noise. In the middle of the night 15 men from Ethiopia were added to Paul's cell. There were 6 men on one bunk, sleeping like spoons and rotating in tandem. Paul found that if he crawled onto the upper bunk he could look into my cell and give me updates on how many men were in his cell, where they were from and how long they were there. One man had been in their custody for 2 months. If we had waited for them to make arrangements we would most likely still be there.

The following day we finally got approval to book our flights. Paul got us on a midnight flight to London and after a 7 hour layover we got onto a direct flight to Denver. Due to the 10 hour time difference, we arrived there on Wednesday, the night before Thanksgiving.

We had been in contact with my sister Francesca who notified our families. As we made our way through customs we were welcomed home by Francesca, Ed and daughter Katie, Karen and Todd, and the entire Roseto family- Jim, Julie and their 4 kids Sophie, Chloe, Isabelle and Phil. It was an emotional welcome for us and just what our hearts and souls needed the most. It was the night before Thanksgiving and we were home with our family again. What an unexpected gift and blessing it was.

After a hot shower, a slice of pizza, and a good night's sleep we were almost feeling normal again. After the holiday Carrole at Lalmba worked with someone in Washington DC to hand deliver our request for a new visa. In the end, we weren't able to get another visa in time to return. We wish more than anything we had been able to finish our year there so we could help the Kenyans initiate the Peds HIV program, complete some of our other projects and say a proper goodbye to our friends and colleagues.

It's January28, 2009 and we've been back now for 8+ weeks. We're slowly moving back into our "normal" lives while trying to hang onto the wonderful lessons of Africa. People have asked us if we'd ever go back and my answer is an unqualified yes. (the first time I said we would, Paul looked at me and asked jokingly "who's this we you're talking about?)

The 9 months we spent in Africa were some of the best times of our lives. We worked as a cohesive team, accomplishing a lot and keeping each other good company. We learned so much about tropical diseases, the Luo culture, local customs and foods, living in the bush, being an ex-pat in Africa and so much more. When I look back at our photos I feel nostalgic for those beautiful people and their land and hopeful that we'll meet again.

I'll continue the blog for a while longer to upload many more photos now that we had a high speed internet connection again. I will also update the news about the library project in the next few days. To all of our faithful readers, erakomona and asanti sana- thank you for sharing this journey with us.

Albinism in Africa

2008-11-16T04:09:00.000-08:00

Two weeks ago I walked to the village of Got Kachola with some visitors from the US. As often happens, we attracted a large crowd of curious children around us who yelled at us “goa picture” (take our picture). As we set up to take a photo we heard the familiar voice of our co-worker Geoffrey Ochieng calling out to us. Ochieng, as he is known, insisted on taking us on a walking tour of his village including his own store front pharmacy.

Kenya

allows anyone to be a “chemist” and buy and sell pharmaceuticals including medications for malaria, antibiotics and even Valium over the counter. Although we have strong feelings about the safety of this practice, it is legal here so we can only use education to try to guide consumers’ usage. Ochieng had 3 people in his community on whom he wanted to consult so he brought them to me for a brief consult.

The first man had advanced HIV disease, a severe oral infection and other complications. I did a brief exam and advised him to come into the clinic to see me ASAP. The second patient was an infant with severe wasting disease. She was a 2 year old who was the size of a 6 month old. She had the classic symptoms of malnutrition with sunken eyes, bony arms and legs, a big belly, and sparse reddish hair. Although her mother was trying to feed her some porridge she was too weak to eat. Ochieng told me the child’s father had recently died so it was very likely that she was also infected with HIV. She would need hospitalization in order to save her life but as we later learned, she died before getting care.

The last child was a school aged boy with albinism. Albinism is a rare genetically inherited disorder which results in a lack of pigmentation in the hair, skin and eyes. In North America and Europe it is estimated that 1 in 20,000 people have some form of albinism. I was not able to find the statistics or Kenya but in Tanzania it’s much more common, affecting approximately 1 in 4,000 people.

As a child with albinism living in equatorial Africa he is exposed to high daily doses of sunshine that burns and blisters his skin. This little boy had burnt and blistered skin on all exposed areas of his head, neck, face, arms and feet. He was squinting in an effort to see us because his eyes are also affected. We offered to obtain a hat and sunscreen for him and give it to Ochieng the following week.

On Monday, Paul was talking about him with one of our co-workers and he learned some vital information about how the African cultures view albinism. First, we learned that any hat we gave the boy would be stolen within a day by other children or even adults in his community. It was suggested that we do some community education about albinism at his school first. So this past Tuesday we went to his school to talk to his teacher, classmates and grandmother.

Paul explained why we have pigment in our skin and how it protects us from the harmful effects of the sun. He showed the children the difference between the skin color on his forearm and his upper arm. He stressed that the boy was a normal child who just happened to be born without pigment. We gave the boy the hat (donated by our US visitor, Jack) and applied sunscreen to all his sun exposed skin. All the children made a pledge to help their classmate keep possession of his hat. Our translator Daniel offered to talk to the community at a funeral the following Saturday.

(this next section may not be appropriate for children to read)

We also learned about how albinism is viewed by some people in parts of Africa. When we researched this on the Internet we read shocking stories of murders of albinos living in Tanzania in recent years. An albino spokesman said there was a belief that the condition was the result of a curse put on the family. Some people in Tanzania think albinos are a kind of ghost-like creature.

We also read that there is a rapidly growing industry in the sale of albino body parts. Some people in Tanzania believe that the body parts of people with albinism have magical powers capable of bringing riches if used in potions produced by local witchdoctors. In the last year official reports indicate that 26 persons with albinism have been brutally murdered and their body parts hacked off and sold to witchdoctors. Though the official count is 28, leaders in the albino community believe the number to be over 60.

Some recent reports indicate that body parts are also being exported outside Tanzania. In one instance a Tanzanian trader was caught with the head of an albino baby on his way to the Democratic Republic of Congo. He told police a businessman was going to pay him for the head by its weight.

On September 4, 2008 the European Parliament passed a resolution condemning the killings and called for killers to be prosecuted. . A crackdown on the witch doctors who encourage the killing of people with albinism was also announced in TZ and as part of this, a 48-year-old woman with albinism, Al-Shymaa Kway-Geer was appointed an MP. Ms Kway-Geer was herself victimized when young. "When I was at primary school, people used to laugh at me, tease me - some didn't even like to touch me, saying that if they touched me they would get this colour," she said. "People used to abuse me on the road when I took the buses to school. They would run after me - crowds of kids following me - shouting 'zeru, zeru'." "Zeru" is a Swahili word for albino. Tanzania's albino society says that traditionally, this is a word for ghost-like creatures and is derogatory. Since the beginning of 2000, the word has been banned.

While there have not yet been any prosecutions regarding the recent spate of murders, 172 were arrested in connection to the cases - 71 of whom said they had been told by witch doctors to bring them albino body parts. They remain in custody.

Kenya Celebrates!

2008-11-16T03:54:00.000-08:00

November 5, 2008 is a day that will long be remembered by the good people of Africa. It’s a day when their hopes and dreams, tied to the ambitions of a certain American politician, came true.

It started early for me. I awoke before first light, threw on some clothes and made my way to the cook house to check the election results. After putting the kettle on to boil for coffee I tried to connect with the Internet and when that was unsuccessful, tuned in to the radio. The BBC was off the air and the VOA had a weak signal so I went back to the Internet. Finally, around at 5 AM (9PM EDT) I was able to connect. The polls weren’t yet closed on the west coast but early results from the rest of the country showed Obama to have a commanding lead. As our US visitors straggled in one by one we each took turns watching the results. Before we walked down to the morning greeting with our colleagues, we knew Obama had won.

The staff was in high spirits and anxious to share their excitement with those of us from the US. The Luo don’t usually hug but on that morning we got hugs along with high fives and back slaps. After our morning song and prayer many of us walked to the village center where we heard they were showing Obama’s victory speech live via satellite. We arrived at the tin structure to find it was already crowded with locals. We joined them inside and watched the last 30-45 minutes of his speech and celebration. People who couldn’t afford the 50 shilling admission were peering in through the small cracks in the building. It was exhilarating to watch in their midst and to share their joy and sense of hope.

That night we joined many of our co-workers at the Sea Lodge, a modest hotel owned by our co-worker Nancy. There was music, sodas, beers and dancing. The Africans were exuberant and continued to celebrate long after we left. The Kenyan President Kibaki announced a national holiday for November 6^th so they stayed until long into the night.

We heard first person accounts of celebrations in the nearby town of Migori where Tanzanians came across the border by the hundreds to join them. Newspaper stories that followed Obama’s win made speculations about what it meant to the people of Africa, particularly to the people of Kenya and wildly unrealistic expectations. Our friend Maggie said the headline of the Kampala (Uganda) newspaper stated “Now that Obama is president, Uganda will be lifted out of poverty”. He has the hopes and dreams of millions of people on his shoulders but for now, there is only joy.

A letter to Sophie

2008-10-29T06:02:00.000-07:00

Our 13 year old niece Sophie often emails us and has been very curious about the African children. She wonders what they look like, what they do for fun, where they go to school and what their lives are like. It's a question we've been pondering since we got here too. We see them in the clinic and when we're out walking but not having a shared language keeps us from fully understanding their lived experience. We have talked to older children and made some observations over the past 8 months and we'll share a few with you today to try answer some of Sophie's questions.

In the Luo culture children are seen as a gift from God and also an investment in the future. Children are born with the expectation that they'll contribute to the wellbeing of their family. They're trained to help with family chores almost from the time they can walk. Girls learn to carry water on their heads and to wash dishes and laundry at the lake. Boys often manage the
farm animals and learn to fish to help supplement the family's food. Kids of both sexes take care of their younger siblings. They carry children on their backs that often are almost as big as they are. In fact, there are some children that we have never seen without a child on their back.

Older children help plant and tend crops, re-thatch roofs, re-mud walls as well as all of the above chores. There are 2 boys who bring about a dozen cows over to our compound every morning before walking to school (which starts at 8AM). At lunch they come back to herd the cows to the lake for watering and then move them to a new grazing area before going home for lunch then back to school. When they get out of school at 5 PM they change and have about an hour of free time to play soccer (called football here) before they herd the cows and sheep home for the night. Because we're on the equator we have 12 hours of sun and darkness year around so it's always dark by about 6:30 PM. Dinner is usually served at 7PM and then homework is done by kerosene lamp.

And while we're on the subject of school, it's only the "lucky kids" who get to go to school. In Kenya primary school is theoretically free but parents still have school fees, books fees, uniform fees...which many can't afford. All schools require a uniform but shoes are optional. Both boys are girls are supposed to have a close cropped haircut i.e.shaved head. The classrooms we've seen are very basic. There are homemade wooden desks and benches which are shared by 2-3 students. The classrooms are open to the air and have packed dirt floors. The bathrooms are outdoor latrines which are called a "choo". The curriculum is very rigorous with subjects similar to the US- math, spelling, geography, civics, religion, science and 2 languages- Kiswahili and English. Did I mention that they're forbidden to speak their mother tongue of Luo in school? Can you imagine taking classes in a "foreign" language from the age of 7?
The teachers and older students, who are like class monitors, have sticks they use as switches to hit the kids when they act up or to get them to move faster. I've seen them being hit and it makes a big scary noise like "thhhhhhhWAP"! It made me cringe but the kids never made a peep.

Most Luo families belong to a Christian church so children go to church on Saturdays or Sundays. There are Catholics and Protestants like we have in the US but also denominations that are unfamiliar to us. Some wear colored robes (the Legion of Mary) and others wear veil-type white hats with a red cross on them.

And their lives are not all work. Because homes are small and the weather is pleasant, they spend most of every day out of doors. It is safe enough for them to run free without parent's worrying. They know the rest of the village will keep an eye on them. Kids don't have store bought toys so they make their own toys, some of which are very sophisticated. They make airplanes by putting a paper propeller on a long stick and make them "fly" by running into the wind. Boats are made from old flip flops and twigs; balls made out of plastic bags and twine. Slingshots are made in a similar way although they sometimes looked crocheted and other times are made of old inner tubes. Trucks are made using plastic lids as wheels attached to bamboo handles. Girls play Chinese jump rope and cat's cradle, climb trees and swim in the lake. Tires of all sizes are used in a way my Dad described using them in his youth (in the 1920's). Even toddlers learn to roll truck tires in front of them and do so with great joy. I bet they never tell their parents that they're bored.

Kenyan kids also have a very high risk of being orphaned before they grow up. Parents die of so many things- childbirth, malaria, snake bites, HIV.... There are thousands of orphaned kids living in the community. Many times a grandmother is raising them but sometimes it's someone unrelated but kindhearted. Sometimes the kids fend for themselves. We see them when they come into the clinic alone to be seen when they're sick and are so shy that they will barely tell us about their illness. Can you imagine going to the doctor's office alone when you were 7? The kids who are accompanied by someone can be brought in by a parent or a neighbor or even a random adult who had time to bring them in. Children are always well behaved, obedient, and quiet. Sometimes even when they get a shot or are getting stitches they don't cry. When I mentioned it to a woman we work with she said "Africans are tough!". She's right about that.

Now that I've told you how difficult their lives are I will tell you this. In spite of it all the kids here seem to be happy more times than not. They laugh easily, are playful and curious and enjoy little bitty things like receiving a new pencil. Gives you something to think about doesn't it? We think that they don't realize how hard their lives are because they have nothing to compare them with. They don't see images on TV or in movies that make them want what they can't have so instead of feeling deprived they are grateful for what they do have.

So, Sophie, thanks for your great questions and your interest in children living on the other side of the world. I think you'd love the kids here and I know they'd love you too.
Love, Aunt Darcie and Uncle Paul

Obama Fever

2008-10-19T06:09:00.000-07:00

I don’t know if there could ever be a better time to be in Kenya than this election year. The Kenyans are excited, almost fixated, on our election and often stop us to talk about it. When we were in the Masai Mara recently we met a group of Masai men and women on holiday from Nairboi. As most Kenyans do, they asked first if we thought Obama can win. We told them we think he can. Some who had lived in the

for awhile and were well informed about the election process wondered aloud if Obama wins the popular vote could he lose the electoral vote. They asked if we thought the election would be fair or could it be rigged. One man lived in the US during GWB’s first win in 2000 and perceived that he may have “stolen” the office from Gore. Their concerns are framed in part by their own experience in Kenya with "irregular" i.e. corrupt election practices.

Obama seems to capture their imagination and inspire hope that a win by him will translate into something positive for them in Kenya. They're proud of him and his connection to their own people- the Luos here are especially proud of his Luo blood. They have little hope that their own government will uplift their standard of living or create change in their country so they look to our country with hope.

By mid-October Paul and I had still not received our absentee ballots so we downloaded one from the federal website. Colleagues here asked to witness our signature so that their name could be on the US ballot in which Barack Obama becomes, they hope, the first African-American to be elected president.

We’ve seen Obama’s image in many disparate places from the back of public transports like matatus to hanging on the wall in restaurants. A poster in HIV clinics shows him and wife Michelle getting tested for HIV during their 2006 visit. It encourages others to get tested so they’ll know their status and casts a light on the disease to decrease its stigma.

This past Monday Paul and I joined the mobile team again to go to a larger village nearby to give deworming medicine at 3 schools and to do HIV counseling and testing. A table was set up under a large sycamore tree near the lake and using a microphone and small speaker the education staff took turns talking about HIV and encouraging people to come and get tested. The locals were slow to respond. By 3PM they had only seen about 3 people. I whispered to one of our counselors to talk about the story of Obama and his wife both getting tested in 2006. So Joseph talked to them in Luo about Obama and suddenly there was a lot of cheering and thumbs up. Paul and I later learned that the team tested about 50 people and could have tested more had it not grown dark.

OK. Just a couple more Obama related stories. I assume by now only Obama supporters are still reading anyway:) (If you don't support Obama we still love you). Two weeks ago Paul and I traveled to Kisumu to meet our dear friend Jenny who is doing amazing work in HIV care with UCSF. She’s based in SF but spends 3+ months at a time in Tanzania and was able to arrange her schedule to help a colleague present a workshop in Kisumu, Kenya to coincide with our trip there to pick up mutual friends. The first night we had dinner with Jenny and her colleague Catherine at a wonderful restaurant hidden among the trees on the shores of Lake Victoria. Along with soul nourishing conversation and laughter we learned that Catherine had gotten a leather bracelet from a local artist that had Masai style beading on it saying “Obama”. She liked it so well she bought one for Jenny too. I coveted it and had to find that artist so the following day, after the excitement of picking up Becky and Judi at the airport we set out on a walking tour of Kisumu. Along the way we visited the artisan market on the grounds of the museum where we found that the bracelet had taken off. At least 3 artists were now making them –some with American flag colors, some with the green and red or Kenya’s flag and some with African colors. We bought as many as we could find for ourselves and friends at home.

The following week when we were back in Matoso, Becky, Judi and I went with the mobile clinic team to a remote area near the Tanzania border called Saume. It’s one of my favorite places to go because we see so many women and infants but also because there’s a primary school on the same grounds with the rustic church that hosts our visits. On the day we visited we lined up all the school aged kids to give them deworming medicine. One child touched my bracelet that reads “Unite for change…Obama for president”. Just for fun I had them repeat it with me….”Obama for president”…over and over until it was an exuberant chant by the Kenyan kids. They were jumping, clapping, laughing, smiling and yelling “Obama for president” over and over. We all wished we had a video of that.

Update October 28, 2008

As we've mentioned in the past, we start every work day by gathering in the courtyard with the entire staff for a song and a prayer. Afterward announcements are made and if any mail has arrived, it's handed out. This day our long awaited absentee ballots finally arrived. May of the staff encircled us to inspect them. They were very interested to see what US ballots look like and were surprised by many things. They were surprised that we can vote whether or not to retain judges. They were surprised by the number of presidential candidates (we were we!). They enjoying looking at all the amendments and their topics. Later we were able to complete them and get them back to Migori for mailing. Hopefully they'll arrive n time and for now, all we can do is wait and hope.

2008-10-12T06:16:00.001-07:00

The people in East Africa often become infected with helminths or parasitic worms due to poor sanitary conditions. There aren’t water treatment plants here so the people collect water wherever they find it. Lake Victoria is the largest source of water for our patients and communities and on any given day you can see women on the shores washing dishes and laundry and collecting water to take home for cooking and drinking. They are taught to boil their water before drinking it but boiling requires fuel which is in short supply. Sometimes we see people in communities that are farther from the lake collecting water from large puddles or small ponds that arise after a rain.

Lack of waste treatment or sewer systems leads people to use pit toilets or latrines near their homes which can leach into the water table. Farm animals are also brought to the shores to drink water leaving piles of their excrement on the beaches. These conditions put people at risk of becoming infected with different parasites including helminthes or worms.

These infections are so common that it’s accepted medical protocol here to treat all kids every 6 months beginning at 6 months of age. Untreated, the infestations lead to iron deficiency anemia, malnutrition, diarrhea and worse symptoms. We often see kids with the big “belly full of worms” when we’re out walking. The treatment is easy enough- one dose of Mebendazole or Levimasole is often all that’s needed. Our mobile clinic staff goes out to the schools in our catchment area every February and October to administer “deworming” medicine and this month we were able to go along to assist.

Our friends Judi and Becky were visiting from Colorado so the 4 of us rode the 8 AM ferry to the village of Aneko to meet up with the outreach staff. As usual, we attracted a lot of attention on the boat and in the village from curious onlookers. We arrived in Aneko in time to watch people pull in their nets full of fish.

The catch was meager in relation to the number of people needed to haul in the nets but everyone seemed pleased. As we walked into the village centre we saw a man building one of the traditional boats. Known as a dhow, the boats were originally designed after the Arab fishermen and slave traders’ boats that once sailed on Lake Victoria. The boat maker was happy to have us visit and demonstrated how he hand shaped the boat using a tool that looked like a cross between a hatchet and a hammer.He had been hired to come Aneko to build the boat and had been working on the boat only 4 days when we arrived. He hoped to have it completed within the week.

When we arrived at the primary school, our mobile team was already there and getting set up to treat the 150+ students aged 5 through late teens. The youngest kids opened their mouths like baby birds to receive the liquid medicine from Mercyline. Becky, Judi, Paul and I handed out the pill version to the older classes. For the students it was a welcome break from their usual routine and they took advantage of it to goof around and ham it up for our cameras. The education department will continue to dispense the medicine throughout the month of October at schools as well as the mobile clinic sites.

With our work done, we decided to walk instead of ride back to the clinic. Because Aneko is an island we first took a short boat ride across a river. The 90 minute walk took us past a field where 2 adult and one juvenile grey-crowned cranes were feeding. They’re regal birds that are often found is marshy or wetland locals.

Later in the day Becky and Judi helped me post about 350 of our photos on the clinic walls. We’ve taken pictures of people we meet in the clinic and on our walks and always get asked “when can I get a copy?” The short answer is “3 or more months from now.” No one seems surprised.

I sent a CD of photos to my sister Francesca who had prints made and sent them back with our friends. As soon as we started to post them, people crowded around in interest. They no longer worried about being sick or waiting a long time to see a clinician. They were too busy looking at and chattering about the pictures. We had hoped the photos would remain on the wall for a month before people started taking them home. Although that was the message we gave the staff to pass on to our patients, within 2 days all but 5 were gone. People who didn’t get a photo are now asking how they can get one so I may have to do it again before we leave.

THE LIBRARY PROJECT

2008-09-14T03:41:00.000-07:00

Ever since we arrived in Kenya our family and good friends back home have asked what they can do to help the people here. After much discussion and debate we decided to focus on one project that will have a lasting impact on the community- the small lending library on the clinic compound.

I asked our Director of Education, John Chacha to write a short piece to describe the library’s history and importance to the community. In his own words:

The library was started in 1992 after the Lalmba realized there was a high rate of illiteracy in the area. The fact was that many people did not know how to read or write. This was because they did not have the chance to go to school. Even of those who went to school, the majority could not read or write properly because they dropped out before completion of final level of primary education,
class 8.

Lalmba decided to start and operate a free lending library in this compound to uplift the educational standard in this community in order to fight illiteracy. Our library is the only one of its kind in an area of over 150 square km. Over the years, some well wishers from the United States donated some books to our library but unfortunately they were not appropriate for our readers. The mother tongue is Dholuo but students are also taught Kiswahili and English in school. Because the books are outdated and more relevant to someone living in America, our readers did not find them very helpful.

Our plan now is to try to purchase books in Kenya that will meet the needs of our students and our community. Thank you for your help and interest and God bless you.

This is Darcie speaking again…the library here is in a small space and it’s nearly always busy. Locals come in to read the newspaper or borrow a book and school kids come in after class to study or look up information in the 25 year old encyclopedias. In April we met a young man while we were out walking who was in his first year of college. This is a remarkable accomplishment for a child from this community. When he heard we were from Lalmba he thanked us warmly and sincerely for the library and told us it meant the difference between passing admission tests for college and ending up a fisherman in Matoso. It was then that the idea began to germinate.

After being asked every day for a “kulum” or pencil by the local children, my Aunt Marge in CA and sibs in CO and NH sent us many, many pencils to give out. The students and kids love to receive them and we’ve become known at the Kulum Mzungus. Now they’ve started to ask us for books and we’d like to oblige.

Our goal is to raise $1500 which will be transferred to the Matoso account for the Kenyan education staff to purchase books here in Kenya. So, if you’ve wanted to do something to help but didn’t know what to do and want to help us in this project to change lives, here’s what to do:

You can send a tax deductible contribution directly to Lalmba USA at the following address:
Lalmba
7685 Quartz Street
Arvada, CO 80007

Please! Write “Kenya library project” on your check. They will transfer the funds directly to the Kenya project so the staff here can purchase new books. I will report back to you on how much money was raised and how it was spent. You’ve seen pictures “before” the transformation and I’ll also take photos “after” the books and reference materials are purchased. If you have any questions about the project please feel free to email us at birdnsong@gmail.com.

Your gift will help improve the futures of Kenyan kids for many years to come.

Thank you with love and appreciation from Darcie and Paul Meierbachtol, Matoso, Kenya

The Birds and the Bees

2008-09-12T23:57:00.001-07:00

Kenya is remarkable for it's abundant and diverse natural environments which include sea shores, open plains, mountain ranges and lowland equatorial forests. The area in which we live has 2 seasons- wet and dry- with year around temperate climate. All this makes it ideal for hundreds of different breeds of birds.

Although I'm a lifelong bird lover, Paul and I aren't bird watchers in the classic sense of the word. I just like to watch them fly and listen to them sing. But since we've been living in Kenya we've both become avid birders. The birds are remarkable in their abundance and beauty and it seems that every trek into the countryside reveals a new species or two.

We've read there are more than 1,200 bird species in the country. Most are year around inhabitants but many migrate here to escape the harsh winters in the northern parts of the world. We've been quite amazed by the many varieties that can be spotted without leaving the clinic compound. Here are just a few of the birds we've seen in the past 6 months.

African Fish Eagle eating a hen in a tree behind our cook house. These huge predators are very common around Lake Victoria. A pair has built a nest at the top of the tree in front of the clinic and we hope to see some fledgling eaglets in the coming months.

This tall and beautiful bird is a female saddle-billed stork which we saw in the grasses along the lake. It's an uncommon but spectacular bird that likes the wetland area around the lake and is about 5 feet in height.

This grey crowned crane is so exotic looking that you'd think you'd have to go to the Maasai Mara to see it but in fact, we found these birds within a few kilometers from our house. We often walk to the village of Aneko which sits on the lake and has a river encircling the other sides. So, with all that water it's a good area to see wetland loving birds like these.

This little bird on the left is the African Paradise Flycatcher. They're very common in our area and can be seen most mornings hopping about in the mango tree or bougainvillea. His head looks black but is a very deep midnight blue.

This pretty green bird is the Madagascar bee-eater. I've only seen these birds twice in our compound, once while Paul and I were teaching a computer class in the cook house. I grabbed the camera and left him to carry on without me for a few minutes.
Here is the same bird in flight...

Although you can't see it clearly in this picture, the underside of their wings are a pretty ocher color.

The bird below is a speckled mousebird eating one of our guavas. Our cook Joice told us that when the mousebirds arrive the locals know the guavas are ready to eat.

Speckled mousebird in flight

I'll finish up with the kingfishers- first the black and white pied kingfisher on the left, below.Next to it on the right is the woodland kingfisher. It has beautiful vivid blue wings and an equally remarkable red and black beak. They're both very common along the lake shore.

And finally, my favorite bird thus far...the African pygmy kingfisher. We first saw this tiny bird on a walk in the countryside. It was one of the rare times that I didn't have my camera along and I was kicking myself the whole time for not getting a photo of it. Just a few days later Paul spotted this one sitting on our doorstep. He called me to get the camera and I was able to take at least a dozen shots. In fact, it sat there so long we began to suspect it was injured or a fledgling. But after we got a good look at it and it at us, it flew away. I suspect he knew how sad I was to have missed the shot the week before and came by to give me another chance at him.

And now, for an uplifting story about HIV

2008-08-31T06:06:00.001-07:00

You're probably wondering how a story about orphans in Africa and HIV could possibly be uplifting. I don't blame you. A couple months (weeks?) ago I thought the same thing. I saw only the statistics and they were not encouraging. You know, numbers that catch one's attention but leave you feeling overwhelmed with the immensity of the problem. Like this one "Of the 2.1 million children infected with HIV, 90% live in Sub-Sahara Africa". I'm embarrassed to admit that my geography was poor enough that I had to look up the countries that are "Sub-Sahara" to see if that included Kenya (it does, duh!).

One more eye popping stat- it's predicted that 25 million children will be orphans by 2010 due to HIV/AIDS. And those kids are more at risk for being infected themselves because 95% of infected infants get it from their mothers. When I read those numbers I let out a big sigh and thought what a pity it is but what can we do? Well, I think that's what the Downey's thought 10 years ago when they started the Ongoro Children's Home here in Kenya. They knew they might not be able to save all the children but by gosh, they were going to save some of them.

Ongoro is a lovely area right on the shores of Lake Victoria and houses 40 children aged 4 to 15.
The kids live in small houses that serve as dorms. They sleep on bunk beds under mosquito nets. Each has their own foot locker and shelf for personal belongings. They're watched over by "mothers" who work for Lalmba but treat the kids not as if they're a job but as if they're family. They eat in an open, airy mud and straw hut where they're served mostly traditional Luo food- fish, ogali (like grits or mush), sikuma wiki (greens), beans, porridge, milk, fruit.

The mothers do the laundry for the little ones, cook their meals, arbitrate disputes, monitor their health and dispense medications and give generous servings of hugs and cuddles.

There are 5 children who live at the home who have HIV. They were all infected either at birth or in the first year of life. Most have been orphans since they were toddlers and have lived at the children's home most of their young lives. Every 2 months they are taken to the St. Camillus HIV clinic for a check up and to get more medications. In August I went along so I could see the care they were getting there and to look at the system to see what parts we might be able to adapt (steal) to use in our own Peds HIV clinic.

The 5 kids ranged in age from 5 to 9; 3 boys and 2 girls. At first they were a little wary and shy with me. But everyone who knows me knows how much I love kids. I can't help myself- they're just such perfect beings. First I crawled into the back of the truck to meet them all. They were still shy. Then I took a picture and showed it to them. Still shy. Then I had one of them take a picture. Suddenly giggles abound. Aah, I'd found the key! More pictures and crazy poses and we were like long lost friends.

St. Camillus is an NGO that sits in a small town of Sori on Lake Victoria about 1 hour away from Matoso. The HIV clinic sees only kids on Wednesday and when we arrived the waiting area was already full with many kids. Our kids are well known to the staff there and so were greeted and checked in rather quickly. Then the wait began. The mothers went to a class on some topic relevant to HIV care that was given in Luo . I gladly ducked outside to play with the kids. They rummaged through my bag and found a pen and some paper and then took turns leaning on my lap to draw pictures and write their names. We looked for butterflies and picked flowers. We played hand clapping games that date back to my childhood days. Pretty soon other kids wandered over and joined the fun. When they finally called our names I had to extricate myself from a small mob of tiny people.

The physician, Dr. Bertha has her own special love of children which becomes apparent in her interactions with them. They are each examined, medications are reviewed, then the mothers were questioned and had a chance to report their concerns. Two of our children are tiny for their age and have developmental delays. One didn't walk until 30 months old. But, all have grown since their last visit and are doing well from a medical stand point.
The kids know that after their appointment we will stop for lunch before heading home so all become antsy as the visit winds downs. We went to a small restaurant and ordered fish, sikuma and ogali for the children. Once they were settled, we ordered our own meals. As a vegetarian I had 1 option- sikuma and fries. I also had a rare Coke. The children finished their meals as we were just starting ours. The tiniest boy came over, pulled up a chair next to me and wordlessly ate as many fries as he could before stuffing the rest into his pocket for the ride home. He then finished my Coke. Although the mothers tried to shoo him away, I was delighted to share my meal with him.
I felt like his "auntie" and as my siblings can attest, I believe that parents are the keepers of rules which it is my job as an auntie to break.

The Face of AIDS and the Insanity of Bureaucracy

2008-08-31T06:01:00.000-07:00

This is a story that will be hard to believe but I promise you, it’s all true. One day, while working in the clinic, a man appeared at the door carrying a frail woman in his arms. She looked elderly but was in fact only 26. She was tall and so thin that we could see every bone. Her eyes were sunken into her head but still, she had a tiny spark of life in her luminous eyes. In East Africa such devastating disease is likely to be caused by one or two infections- AIDS and TB. This unfortunate woman had both.

As her story was revealed to us we were appalled and yet doubtful that it could be true. Here is what the husband told us…

His 26 year old wife was admitted to a hospital in Migori that I’ll refer to as “St. Elsewhere” with AIDS and tuberculosis. She was started on the intensive phase of TB medications which were to be continued for 2 months. Then she would take the second phase of medications for another 4-6 months. The TB meds were started in the hospital and given for one week. Then she was prepared for discharge.

It was at this point that things went awry. The family was unable to pay her hospital bill so the patient was “discharged into the hospital”. This means that she was discharged from care but kept in the hospital until her family could pay her bill. Sounds a lot like she’s being kept a hostage, doesn’t it?

Because she was no longer an official patient she didn’t receive any care or medications- including her meds for TB. I should add here that TB meds and ARV drugs for AIDS are free to facilities. That’s right. St. Elsewhere gets the TB meds for free but wouldn’t dispense them to her because she was “no longer a patient”. It gets worse (if that’s possible). These patients are not fed unless there is food left over after the “real” patients are served their meals. A couple days before she came into our clinic, and 3 months after she was “discharged”, her family was finally able to pay her ransom…er, I mean her bill and she was able to go home.

In the subsequent days and weeks, we were able to follow the paper trail that confirmed her story and the atrocious “care” given at St. Elsewhere. We’ve talked to many people including a man who monitors TB care for the Kenya Ministry of Health in our district. He was “shocked” and unaware of St. Elsewhere’s policy but claimed he would look into it. As for the patient, she struggled to survive for another few weeks before succumbing to the diseases, another victim of the scourges of HIV, TB and Poverty.

African Portraits

2008-08-16T06:09:00.001-07:00

This week I'll let my photographs of the beautiful African children speak for me. They were all taken within a couple kilometers from our house. The children are open, warm, curious, playful, and sometimes fearful of me or my camera. They love to hold my hands as the first picture illustrates. The best fun begins when I show them their photo. They all laugh loudly and then chatter to each other. Yesterday each child wanted a portrait by him or herself. So, my short walk to stretch my legs at the end of the day took 90 minutes. It was the most fun I've had all week. There's something so spiritual and joyful about being in their midst.

Through the windshield

2008-07-27T07:53:00.000-07:00

So often when Paul and I are traveling around the countryside we wish aloud that you were all with us. So, when we drove to Kisii for groceries on the 17th I decided to take photos through the windshield so you could see this part of Africa through our eyes.
The road from Matoso to Migori is a rutted dirt road but once you leave Migori the road is paved and in fairly good shape which is an anomaly for this part of Africa. Within a few kilometers you begin to see verdant hills planted with sugar cane or banana trees.

The road is a narrow 2 lane which is shared by people on bikes or walking with heavy loads or school children in their matching uniforms.

The most awe inspiring and fear provoking sight are the trucks carrying impossible loads which take up 2/3 of the road. I'm often left chewing on my nails by the time we get past them. You probably read about the small vans known as matatas that we've seen carrying 20 plus 2-5 men hanging outside or onto the back. They fly by us driving in excess of 90 KPH.

You can tell you're getting close to Kisii because the side of the road fills with vendors with all sorts of things for sale. There's produce, luggage, second hand clothes from the US, live animals like hens and lambs, shoes, kitchenware and more.

Kisii itself is a small city with an ever expanding population. Every street is jammed with traffic and pedestrians. Usually when we're sitting at a standstill, people will come over to sell us something or to talk to us. It's all part of the entertainment and keeps us from getting too frustrated by the slowness or our progress.

The round trip takes 5 hours of driving and we allot another 2-3 hours for all the errands and shopping we usually have to do. By the time we get home in the evening, we are covered in red dust, are tired and thirsty and happy to be back in our little village. Sitting on the porch at night, watching the sun set over Lake Victoria we thank our lucky stars that we don't have to drive there more than once a month let alone live there. It was nice to have you along for the ride and hope you enjoyed the journey. You'll never look at grocery shopping quite the same way again.

The Magnificent Masai Mara

2008-07-20T04:51:00.000-07:00

The Masai Mara, or simply the Mara as the locals refer to it, is the most popular national reserve in Kenya. It’s the northern most part of the Serengeti and hundreds of thousands of game animals roam the plains. And the best part? The Mara is a short 3 hour drive away from our village on Lake Victoria.

Paul and I have been anxious to take a break from work and visit the Mara and our chance came over the July 4^th weekend. We arranged with our Project Director to borrow an ambulance which we packed with provisions, a coal burning cook stove, a cooler and REI tent left by previous volunteers. Our plan was to camp near the Oloololo Gate on the western side of the park and to check out the resorts for our next trip.

When we arrived late Friday, we found that we were the only ones registered to camp there. The camping area is actually inside the park so animals are free to graze in the area. We were assured that it’s safe to sleep in a tent and none of the animals would bother us but not to go out walking inside the park. We were also warned not to leave the vehicle when driving.

So, with those assurances and warnings we set up camp and went for a late day game drive. We immediately saw warthogs which crossed the road in front of us then disappeared into the tall savannah grass. Then we spotted a large herd of elephants coming toward the road. We stopped the vehicle on the road and waited for them to cross. There were many large adults, several yearlings and one that looked to be a newborn.

Here’s me breaking rule #1- I quickly regained my senses and got back in the vehicle.

After another hour of spotting animals we headed back to our camp just as dark ominous clouds in the east let loose with heavy rains. By the time we got back to camp our tent and the pads we planned to sleep on were drenched. The tent apparently isn’t waterproof so we went with Plan B- sleeping in the ambulance. By the time we got set up and made a quick dinner it was nearly dark. We looked through the foggy windshield and saw what looked like a dark mass moving toward us. We hastily wiped off the windows and could see through the sheets of rain a large bull elephant grazing nearby. It continued on through the camp grounds, walking within about 10 yards of our vehicle but paying no attention to our intrusion.

Around July or August every year millions of wildebeests migrate from the Serengeti to the northern grasslands of the Mara. The timing of the crossing is based in part on how much rain the southern Serengeti gets during the big rainy season. The park rangers keep a close eye out for the first wildebeests to cross and then spread the word to all the resorts. This year the first wildebeests started to cross on July 3^rd- the day before our arrival. They always make the crossing at the same places along the Mara River where huge Nile crocodiles are lying in wait. Of the first group to cross, many drown when the river is high and those who follow cross on the “bridge” made up of their bodies.
The rangers told us that last year they had very heavy rains before the migration season so the river was running very high. They estimate that about 5000 wildebeests died during the crossing.

On Saturday we hired a ranger as our guide for the full day. We picked him up at 8 AM and headed into the bush in search of the more elusive animals including the black rhino. They were hunted nearly to extinction by poachers who get a fortune for each horn. There are only about 30 left in the Mara so they’re very hard to see. He took us down along the river, through heavy vegetation where we saw hundreds of baboons, zebras, warthogs, hippos, crocs and giraffes- but no rhinos. One of our favorite sights of the day was that of giraffes running on the savannah. They’re elegant, graceful and yet gawky at the same time. We also spotted a pair of lionesses with their cubs sleeping in the bush.

Late in the morning we saw a flock of large birds that turned out to be dozens of White-backed vultures eating the carcass of a warthog. They are often the first to arrive after the hyenas eat their fill. We read that a large group of White-backed vultures can eat an impala in 10 minutes. The very scary looking Lappet-faced vulture arrived later and was large enough to scare off the other vultures- at least for awhile. It was a sight right out of National Geographic.

We drove to the Mara River near the Tanzania border to look at one of the traditional migration spots. We could see thousands of wildebeests and zebras grazing on the other side, preparing to cross. Throughout the day we were constantly amazed as the animals and vegetation of the Mara revealed itself. Our ranger laughed at our frequent joyful outbursts when we spotted something new. “You have never seen a giraffe run before?” he asked us.At one stop I spotted a lizard with remarkably vivid colors which to his amazement and amusement I stopped to photograph. People who live around such beauty and diversity in their daily lives often lose sight of how miraculous their world is.

Our day ended with a beautiful sunset and a hot meal around the campfire. We lay awake listening to the night sounds of the Mara and woke with the sunrise. It was another glorious day and as we got a fire going for coffee we noticed a couple of tourist vehicles entering the park and stopping about ¼ mile away from us. They stayed there long enough to make us curious. We packed up and drove over to find a large male lion lying under a tree and another in the tall grass. We turned off the engine and just watched for about 15 minutes. Then one got up and went over to the buffalo they must have killed the previous night. He turned it over and began to feed on it again. We were far enough away to allow it to eat unhindered but close enough to hear crunching of bones. Once it got it’s fill it went back for a nap. We drove over to the tree once more and just as approached it I realized the second lion was hidden in the tall grass a few short feet from our vehicle. I whispered urgently to Paul to “Back up! Back Up!” I could feel my heart pounding with a mixture of fear and exhilaration at our proximity to that magnificent creature. That morning was the high point of a trip that had many wonderful moments.

Our final stop was a planned visit at a Masai village outside the park. We picked up our ranger at the appointed time and drove the short distance to their village. The chief welcomed us and talked to us about their culture. They live in communities of about 50 families and marry only other Masai, although from a different community. They were traditionally nomadic herders and their cattle are still a big part of their culture. Their homes are made of cow dung and they eat only cow’s milk, meat and blood. Some of the women greeted us with a song during which I was invited to stand with them. I felt their song resonate in my chest and it filled me with a sense of joy (which is why I look so goofy in this photo). Some of you old timers will remember Granny Clampett from the “Beverly Hillbillies” singing “I got joy, joy, joy, joy down in my heart” while cooking up a batch of her moonshine. I must say, that captures the moment for me.

I'll leave you with a couple more photos from the Masai village. Safe journeys!

A week in the life

2008-07-10T10:02:00.000-07:00

Sometimes the week goes by so fast that on Friday I have a hard time remembering Monday. This was one of those weeks but somehow I jotted down a few notes so when I’m home in Denver next year I won’t completely forget this amazing experience.

Monday: We’re off to a fast week. Paul’s spending the whole day with our community volunteers. There are about 40 of them and they live in all the surrounding villages and help the PSC (HIV clinic) track people who have dropped out of sight. If anyone misses their TB meds for 2 days or their HIV medications for 5 or more days they are put of the list and targeted by our volunteer from their area. At the beginning of June, there were about 47 people on the list but by the end of June, only 8 remained. The shift in the tide came when Paul began using text messages to contact the CHVs as soon as someone in their community missed a follow up. We never would have imagined that people living in rural East Africa would carry cell phones but many do. They don't have electricity or running water but they have cell phones. It makes sense when you think of it. People who are homeless in America do the same thing. It gives you some point of contact with the outside world.

Paul gave a talk on the history of HIV in Kenya and answered many tough questions which reflected how well these lay people understand the disease. They were shocked to hear the number of people in their area who are or may be infected. They're proud to represent their village and be part of the fight against HIV but they always ask for something tangible. And what they usually get is lots of love and appreciation from us. Today Paul was able to hand out bags with the Lalmba logo which I hear were a big hit.

Tuesday: I am doing a test run of a new data collection system that if it works, may reduce the oppressive amount of paperwork and data collection that needs to be done and reported to MOH (Ministry of Health) every month. It’s tedious but not necessarily boring work. It calls for me to sit in our registration room with Ochieng, filling out forms and taking payment, getting temperatures and weights- and I learn many things:

People who have never seen a bathroom scale often step on sideways or backwards. Many adults try to stand on the dial and one woman kneeled on it.

Thermometers are frightening things when they’re being aimed at your armpit by a Mzungu.

Feet that have never worn shoes are rounder, with toes that are short and splayed.

We have patients who are named Fidel Castro, George Bush, Holy Canaan, Ket Winslet, Jacklin Kenedy, Eunick, Saline, Stalin, Viva and Pissy.

The clinic gives a LOT of free care to kids who have lost one or both parents to AIDS.

Lots of kids as young as 7 come to the clinic alone. Most don't know their own age. They haven't had an adult in their life to keep track of that information. We estimate their age and put it on their record. I wonder if they will now go through life using our guess as their age.

And Ochieng is unflappable. He laughs his way through the day and on this day I join him. His understanding of English spoken with an American accent is marginal so no matter what I ask him, he responds “fine, fine”. I end my day wishing I had volunteered to be a registrar rather than medical director.

Wednesday: It’s our busiest day in the clinic and there are many sick people to attend to. We transport 2 people to the hospital in the first couple hours. Both are severely anemic. The man is passing blood, the child has severe malaria. Both will need transfusions as their hemoglobin counts are down to 1/3 the normal level. A woman has a large facial laceration that just missed her eye. Her jealous neighbor suspected her of being with her husband so cut her with a panga. A teen comes in with a septic wound and swelling to his knee. He delayed coming in because he didn’t have the fee. Today he doesn’t either so we cover it for him. The people keep coming until we’ve seen over 100 patients- a typical Wednesday.

We have a tremendous thunderstorm that starts around 7 PM and rages for 90 minutes or so. There are claps of thunder that are like sonic booms and one strike sounds like it hit something right outside our house.

Midnight: We’re awoken by the guard calling our names through the window. The clinician on- call sent him to get me to come and assist her in the clinic. I throw on a skirt and am there in less than 5 minutes. I find the building in darkness and the clinician attending 3 patients in the observation room using the light of a kerosene lamp. The lightening has taken out the electricity and the lamp gives the room an eerie glow.

The first person she asks me to see was a woman who was hit by lightening during the earlier storm. She has no signs of life and has been dead long enough for the body to be cold. I am confused for a moment, wondering why she called me for such a clear cut situation. Did she feel better having me pronounce the patient dead? I will have to ask her later. I concur that there’s nothing further that can be done and she informs the family. The men immediately lift the body over their heads and run out into the night with the women wailing behind them. It happens so fast and I am still half asleep so for a second I just stand there and let my brain catch up. Then we move on to the second patient.

She too was hit by lightening but has only minor burns and is otherwise stable. She will stay through the night with her family observing her.

The third patient was bit by a snake earlier in the evening and was brought to the clinic in the rainstorm sitting on the back of a bike. The bite is on the ankle and above it are multiple deep lacerations that were made by a panga by someone in the family who was trying to help. This is one of the traditional treatments for snake bites meant to “bleed the poison out”. The lacerations look far more ominous than the original bite. The clinician has already started an IV to administer the anti-venom, given IV antibiotics, a steroid and a tetanus toxoid. The man has been drinking but is fairly cooperative so once he’s stabilized we leave him to his family’s care. We’ll be called if anything changes.
Thursday: I start by checking on our patients. The woman who had minor burns from the lightening strike slept well and is feeling ready to go home. The leg of the man with the snake bite is looking worse. It’s more swollen, tender, and red and the panga cuts have continued to ooze. Now that it’s light, we are able to transfer him to the hospital and we begin to make arrangements. But then a snag. The family isn’t sure they can get the money and wonder if they can take care of him at home. How often people here (and in the US) make health care choices based on money or lack thereof. After much back and forth discussion, we agree to continue to treat here while they work on finding money but warn them not to delay. They can also bring a bike for collateral and Lalmba with advance them the funds. We try to impress on them the urgency of the situation.

By then, the mobile team is packed and ready to leave the compound for Saume which is near the Tanzania border. We stopped first to pick up immunizations and run into problems. The government clinic in Muhuru decides they’re no longer going to give us any immunizations because we’re “stealing all their patients”. This is typical of the bureaucratic BS they are well known for. Our mobile team goes to that site specifically at their request because they were unable to reach the families in the remote region near the border. Now this. Even reasonable Chacha can’t change their minds so while we set up and start to see antenatal moms, Chacha heads back to Matoso to get some of our immunizations. I make a note to schedule an appointment to meet with the MOH people about the immunization problem.

When I get out of the vehicle the school children see me and begin an excited surge toward me. Imagine 100+ kids all running at you, yelling, waving, smiling…it’s bliss. Heaven on earth. I make another mental note to borrow a video camera to record this to watch when I am home and missing them. They’re comfortable enough with me that this time they do something different. Some of them start feeling my arms like blind kids reading Braille. They pinch my elbow skin, turn over my hands and giggle about my nails. It feels nice to have their soft little hands on me.

When Chacha returns with the vaccines, he and I leave the team in Saume and continue on to Lalmba’s remote clinic in Ochuna. We spend a couple hours there with the staff to support and mentor them. I reviewed the antenatal records for the last 4 months and find that 15% of the moms test HIV+. That’s a sobering statistic.

By the time we’re back in the car and heading to Saume to pick up the team it’s late afternoon and we haven’t eaten. We stop in the last little village at the very southern tip of Kenya and sit outside on a dusty road to drink a soda. We watch wordlessly as kids, dogs, cows, motorcycles, and bikes roll by kicking up the red dust.

We arrive back at the clinic after business hours so the compound is quiet. Paul and I are leaving in the morning to go to the Masai Mara and now that the work week is over, we can pack up the ambulance so we can get an early start. Maybe a beer or my latest favorite drink- vodka and Crystal Light- would taste good right now.

Friday 4^th July: Happy Independence Day America! We sure miss you. But not today because, did I mention???, we’re going to the Mara! I’ll write about that later. I’m having too much fun to journal right now.

Monday: Back at work we find sobering news waiting for us. The man with the snake bite was transferred to the hospital on Thursday but died that same night.

And the wife of a staff member went into early labor and delivered twins- one boy and one girl- whom they named Paul and Darcie. The home birth was assisted by a grandmother who didn’t know how to properly tie the umbilical cord and Darcie lost a lot of blood. They transported the mom and babies to the hospital but were unable to save baby Darcie. I felt such sadness at the loss of the little baby who bore my name for a few hours. We immediately offered our condolences to the father, our co-worker. He told us that that is the way life is and they will rejoice that they have a baby son. That’s life in Africa.

And so one week ends and another begins. We miss you all and will write next week about the beautiful Masai Mara.

The Big Rainy

2008-06-21T08:46:00.000-07:00

When we first got to Kenya, the season they call “the big rainy” was just starting. Within weeks everything living seemed to rejoice in the rebirth of spring. Wild flowers popped out in the fields and tadpoles were in every puddle. The birds went into a frenzy of nest building and mating rituals. And boys built toy sailboats to float in the new ponds that seemed to be everywhere.

After 2 months of sporadic and occasionally torrential rains it all came to a halt as suddenly as it started. On May 18^th I took a picture of a late afternoon rainfall that ended up being the last for the season.

The hills are just starting to get brown around the edges and show signs of stress from the constant sunshine.

The vegetable crops are being harvested and we’re enjoying the bounty of our neighbors, the Tuckers. They send us their overflow cucumbers, peppers, butternut squash, okra and greens which we’re very happy to receive and share. Last week we were lucky enough to get a watermelon. It was late afternoon and the guys on the landscaping and maintenance crew had been working in the sun all day. Our cook and I called them over and cut thick slices for everyone. We stood out back enjoying its juicy sweetness and seeing who could spit seeds farthest. Can you think of a better way to end the work day?

Queen for a Day

2008-06-21T08:15:00.000-07:00

On Wednesday the mobile medical team went to the village of Tulu. There’s a primary school close to the church where we were planning to set up our operation. As soon as I climbed out of the ambulance the kids came running.

I must have a huge ego because I never get tired of being treated like a celebrity. Kids swarm around to shake my hand and have their picture taken with me. Believe me, it’s hard to break away when it’s time to get to work.

We saw about 65 babies and toddlers over the next 4-5 hours and when it was time to pack up to leave I decided to walk home to stretch my legs and get some exercise. The Africans laugh at us when we walk just for exercise because of course they get so much exercise just going through their normal day. They’re only too happy to accept a ride back to the clinic. Tulu is a “short” walk from Matoso by African standards. It usually takes only 20 minutes to drive there and about 60-75 minutes to walk it.

I started off across an open plain and immediately heard kids yelling to me.

A group of kids were running full speed toward me and I ask you- who could walk away from that?

So I stopped and waited for them, worked the crowd, took the requisite photos and waved goodbye.

They ran back
across the field waving the whole way and I started off toward home again with a big grin on my face.

Because it was after 3PM, people were taking their afternoon bath, or heading home from school or work.

As the path began a slight climb toward the dirt road a group of girls in their school uniforms greeted me. Each was carrying a large container of water on her head which is likely a part of their daily chores.

I'll leave you with this one image which was my favorite of the day. And by the way, with all the stops to talk to people along the way, took me a full 2 hours to make it home. Worth every minute too.

The One That Got Away

2008-06-21T08:03:00.000-07:00

One of our co-workers invited Paul and I to go out on the lake early one Saturday for a morning of fishing. Paul didn’t attract any attention carrying a long fishing pole and wearing a big cowboy hat. Yeah, right. It was pandemonium and it didn’t let up when we got out on the boat.

Other men who were fishing paddled over to check out his gear and see what bait he was using. After an hour or so they tired of us and went back to their own fishing.

Our guide’s little brother manned the anchor which was a rock weighing as much as he did. Although the size of a 10 year old, at 15 years old he’s already a strong and seasoned fisherman. In spite of that, he and his brother caught only a couple small fish.

The great white fisherman got totally skunked which prompted his brother Rich to promise to send “stink bait” from CO. I hope the fishermen among our readers understand the meaning of that. As for me, these photos were my catch of the day. My camera never lets me down and it’s always better than baiting a hook.

Crime and Punishment

2008-06-14T02:42:00.000-07:00

Three weeks ago: a 9 yr old child came with her mother to the clinic with a terrible story. She had been walking to school that morning when a man dragged her into the bushes and raped her. She was trembling and unable to look at the female clinician as her mother told her story. Fortunately, this kind of crime is unusual in our area where everyone knows everyone else but it can carry a heavy toll for the victim. Because of the high incidence of HIV in our district there’s a chance she may have been infected. And because of stigma, she may have to be moved out of the family home to live with a relative in another community.

But when she came into our clinic, our main concern was her immediate medical needs. Rape victims first need a forensic exam which is only done at a district clinic. Paul was asked to drive them there, accompanied by a member of our RCAR (Reaching Children at Risk) team who works with kids who have lost one or more of their parents to HIV. This little girl had lost her father. She was tested for HIV and started on preventative medicines. The whole process took the better part of the day and Paul never heard the girl speak. He described her as looking like she was in shock. Using a translator he encouraged the mother to bring the child in for counseling.

Paul stayed until she was done so he could drive the girl and her mother home safely. They live in a remote area that is accessed by turning off a dirt road onto a narrow path that meanders through a meadow and then into a large area thick with vegetation. The path eventually became impassable by truck so they walked the last short distance to the family home. It was easy to see how vulnerable a child would be walking in the area unaccompanied.

There isn’t a formal police force in most areas so it’s usually up to the chief or to a community committee to handle problems and crimes. In this case the chief of her village planned to call a meeting that required everyone to attend. He would have the girl come, and in front of everyone, identify her attacker if he was there. The girl didn’t know her assailant but said she could recognize him again because he wore his hair in dreadlocks. She would have to be a very strong girl to get through such an ordeal.

10 days ago: One of our drivers came to the cook house on the weekend to get the keys to the ambulance. He had been told that the rapist had been caught and needed to be taken to the police station by Lalmba. As the story unfolded we learned that our RCAR worker learned who the rapist was and where he might be staying. He called one of our administrative staff at midnight to say he would need a small amount of money to hire 2 men to catch and subdue him. She readily gave her approval.

When the rapist arrived at the district police station he vehemently denied the charges. The police said they couldn’t keep him unless the girl came to identify him. So once again our driver was called into duty. He drove to the girl’s house which was about 45 minutes away and outlined the situation to the mother. With great resolve she agreed to go with her daughter to the station. Once there, the girl easily identified her assailant from a line up of 4 men prompting the man to confess and ask for leniency. The police told him he would be taken to District Court in the AM and sentenced to 7 years in prison. The cowardly rapist begged our driver to get some money to bribe the mother to drop charges. I believe the driver laughed in his face.

The very next day the rapist was taken to court and found guilty of the charges and sentenced to not 7, but 14 years in prison. Justice can be swift in Kenya. No lawyers, no appeals, no hope of wiggling out of it. Now we pray the girl remains HIV free and is able to continue living at home and going to the school in her village. Only time will tell.

Josie's Big Day

2008-06-14T02:25:00.000-07:00

You'll have to indulge us a little while we brag about our granddaughter Josie. She graduated from preschool this week and her future looks very bright. She can write her name (and that's saying something when your name is Meierbachtol!), address and phone number. She knows her colors and her alphabet and well, she's not only smart but she's just plain adorable.

Here she is making her parents proud...

And the moment she waited all day for....

Photo of the week

2008-06-06T10:01:00.000-07:00

What could be the cause of such excitement?

Look closely and you may see the answer reflected in his eyes...

Mobile Clinic goes to Saume

2008-06-06T04:13:00.000-07:00

Our education department goes to about 6 sites every month to provide health care to moms and babies who would otherwise have trouble accessing care. Today we went to the village of Saume which is only 1 km from the Tanzania border. We packed up the ambulance with immunizations and supplies and 6 staff members and headed out for the day.

First stop: the mobile clinic drops maize off at a village on the way to Saume.

We set up inside an old church which is right next to a primary school with ECE through 2^nd grade. We'll perform antenatal and well baby exams,do immunizations, give out multiple vitamins and Vitamin A and de-worm kids and pregnant moms.

As soon as I got out of the vehicle the kids came running, wanting to shake my hand and
have their picture taken.

As soon as the flash went off they all turned and ran away from me.

This is a very busy site so by the time we arrived we had dozens of
moms and babes waiting. They’re always so patient and grateful
which makes it a pleasure to be there. I love being able to see newborns all day too.

I was working with another staff member but we quickly
realized that if they were seen by him they would then line up to see
me too. They wanted their baby to have an exam by the American
"Daktari".

But first the babes get registered and weighed on an old grocery-type
scale hanging from a beam by one of our volunteers.

And after my exam they go to get any needed immunizations.
You’ll notice on the wall behind them is the class schedule written
in chalk.

The school doesn’t have its own building so they teach
outside on clear days and inside the church during rain.
Here the kids are being taught under a tree.

Some of the older kids are taught in a separate area in the shade of
another building. The teacher told me her started the school with his
brother and one other man. They now have 5 teachers and are self
supporting. The children bring containers with water to drink
and late in the day they use them to sit on as you see below.

The photo below shows a lesson written on the wall inside the church.

Kenya has some of the most beautiful women in the world.

The mothers asked if they could have their picture taken
with the Mzungu Daktari. Hope you enjoyed riding along
with me today.

A good day to be born

2008-06-02T05:17:00.000-07:00

Today is a holiday for the Kenyan staff so Paul is taking call as the ambulance driver. Early this morning he was notified that he may have to drive a laboring woman to the hospital. The clinician on call was checking the mom at the clinic and said she would send word. We walked down to the clinic to see if we could be of assistance to her and found her preparing to deliver the baby. The woman was fully dilated and wanting to push. Although she was a tiny little slip of a woman, she had delivered 4 other children so we knew there was not going to be much time to get everything ready. Paul had just managed to help the clinician slip in an IV when the woman started to push. Juliana ruptured the membranes and with the next push we saw that the baby was crowning. One more good push and he slipped into the world. He gave a lusty cry and was cleaned then wrapped in the mother’s own kganga which she wore to the clinic. Paul rubbed the baby to warm him and kept watch over his airway while Juliana delivered the placenta. I was just her “gopher” handing her whatever she needed.

Juliana has delivered babies since 1993 but this was just her second delivery since coming to Matoso about 3 years ago. The first delivery happened on the floor near the clinic door. We were relieved that Paul didn’t start to drive her to the hospital and have her deliver on the way.

A few hours later, Paul was called to drive the mother, baby and family members home. He drove across a dirt road until it turned into a narrow cow path and then across a large open savanna. From there the path became narrow again and closely bordered on both sides by tall vegetation that scraped the sides of the ambulance. It was lush, isolated and beautiful back in there. Finally, they arrived at a stream that looked impassable by vehicle. The husband tried to encourage Paul to drive through it but Paul’s many years of driving 4 wheel drive roads in the mountains of Colorado has made him an expert at assessing what’s passable and what’s not. This stream was not.

Paul lifted the mom out of the ambulance and with the help of some men from the area, the husband got her and the baby safely across the stream. Before Paul left he was asked what his name is and upon hearing it the father of the baby declared, “my son’s name is now Paul!”

Women’s Work

2008-06-02T04:46:00.000-07:00

Saturday, May 30, 2008

“It sounds like they’re taking snowboard lessons up there” were Paul’s first words to me this morning as we listened to the scratching and sliding on our tin roof. A pair of doves has made a nest under our eaves and just after dawn every morning they and a group of their friends land on our roof to add their cooing to the symphony of morning sounds.

Since we were up so early and there was slight cloud cover we decided to take a long walk in the countryside. Today is the start of a 3 day weekend for the clinic staff. Madaraka Day is June 1^st and celebrates the day in 1963 when Kenya gained its independence from Great Britain. On holidays and weekends a skeleton crew is left in the compound to take call for emergency medical care and this morning, as we left for our walk we saw the clinician on call attending 2 sick patients. We were told one arrived the night before and a third had been driven just after daybreak to the hospital in Migori by one of the clinic drivers. As is often the case in ER’s across the US, holidays can be busy times at our facility.

A woman was sitting at a small table near our
front gate with 2 children selling bananas, tomatoes and mangoes. Dozens of women were already at the lake washing clothes, dishes, children and themselves. As we walked on the road leaving Matoso we saw women cooking on outdoor braziers, working the fields, herding goats and cows, carrying heavy loads in their arms, on their backs and heads.

Families who live away from the lake have to carry water to their compound for cooking and drinking and this chore falls to the women. One woman told us she makes the trip at least 3 times on a typical day using a bucket that once held 17 kg of lard. That means she carries water that may weigh about 37 lbs on her head walking uphill three times every day. It gives new meaning to the phrase “women’s work” doesn’t it?

As we arrived at Lidha Beach and made the loop heading toward home along the lake we saw women drying tiny omenna fish that had been caught the night before.

Another woman was sitting on a large flat rock above her family compound making flour out of dried cassava root using a method that is probably the same technique used since the beginning of time.

She ground it once using a rounded rock in her hand, then sifted it using a wooden box with a screen on one side and repeated until the flour was just the right consistency. Can you imagine sitting in the sun of the equator for the better part of a day just to make flour?

This blog isn’t meant to minimize or negate the contribution that men make to their families. But in Africa, as in so many other places around the world, women’s work goes from sunrise to sunset and is the glue that holds the family and community together. So today we give these women their due in words and photos.

THE STRANGE SAUSAGE TREE

2008-05-26T06:27:00.000-07:00

I am one of those strange people who collects found objects during our walks and travels. I like pods and have some that date back to our honeymoon in Portugal and Maderia as well as the rain forest in Costa Rico and the woods of North Carolina. I have beach glass from Lake Erie and Sorrento, Italy. Rocks that are pretty, rocks from the Great Wall and rocks that have fossil imprints. Fallen bird nests, seashells and discarded shells from crustaceans all share space on our bookshelves.
So its natural I suppose, that one of the first things I investigated when we arrived in Matoso
was a tree outside the cook house that appeared to have pods the size of giant sausages.

They turned out not to be pods at all but large fruits. When asked, the locals told me it’s a common tree in parts of eastern African and the author Alexander McCall Smith of "The No. 1 Ladies' Detective Agency” fame mentions them in his book as being in Botswana as well. I was told that the fruit is harvested for its medicinal powers and is valued for treating babies with “poor blood”. I assume that means anemia and the reason it’s used for this purpose is because the flesh is blood red in color. When I looked the tree up in an online guide I learned that the fruit is used as a poultice on wounds but is poisonous when eaten. It’s also added to beer brews to aid with fermentation.

I thought it looked like a sausage tree and found that's what it's called in guidebooks too. The fruit grows to lengths up to 50 cm and hangs from long, remarkably strong stems. The flowers are quite beautiful too. They were in bloom when we arrived and looked like purple orchids to me. They are reported to last as long as 2 months.

I also read that some African tribes regard the sausage tree as holy. Important meetings are held under the shade of the Sausage Tree and objects cut from the timber are worshiped. But the locals told me to be careful when standing under the tree lest a sausage drop on my head and kill me! I won’t be bringing one of these giants home with me but I thought you’d enjoy seeing them.

WITCH DOCTORS IN MODERN AFRICA

2008-05-26T06:04:00.000-07:00

We awoke on Wednesday the 21^st of May to the news that a mob of 300 men rooted out and killed 11 so-called witches in 2 villages not far from Kisii. Kisii is 2 hours from where we’re living and working and is the town we drive to when we need to buy a lot of groceries as we did last week. Most of the residents are from the Kisii tribe although there are now many people from other parts of Africa living there too.

I scoured the online news sources for more information but in spite of the story’s unusual and sensational appeal, I found very little reportage the following morning. Even the NY Times gave the story but a short paragraph. The mob had a list of purported witches, 7 women and 3 men aged 75 or older. They were burned to death, some after having their throats slit or their heads bashed in.

The story was so shocking that, in the middle of the day as I was going about my clinic business, I’d find myself staring at the lake wondering about those murdered “witches”. And about that violent mob. How could a group of 21^st century men get so impassioned about an ancient belief that they could resort to violence against 75 year old women?

It wasn’t until Friday afternoon that the clinic was quiet enough for me to talk to a few of my co-workers about it. In Kenya, any conversation starts with pleasantries. We talked of the weekend and our plans to drive to Migori. A bucket was sitting nearby and Daniel asked me if I knew how to carry it on my head. I gamely played along, trying and failing to balance a bucket for even one minute. The remaining patients all enjoyed our playfulness, with the women laughing at my ineptitude with such a simple thing. Sammy remarked that it would give them something to talk about the rest of the day. There’s very little they enjoy as much as seeing a Mzungu being silly.

At the right moment in the conversation I told Evanys I had read a news story about the witches and asked what he could tell me about it. He knew the story and had strong beliefs about it. He told me that these people were killed because they had caused the death of many other people. They were well known in their community and had practiced evil for many years. They made the children stupid. They could cast a spell on someone resulting in their death. They could poison food while a person was eating and cause it to decay in their stomachs. They could take epilepsy from one person and cast it into another person. They stirred up trouble wherever they went and they cheated people out of money.

Evanys said that times were changing and that people who were educated could not be hurt by the witch doctors. He said that although he was immune to them, they had very strong powers and needed to be stopped from hurting other people who fell under their powers. He felt it was right and just to weed them out but stopped short of advocating murder.

At the clinic he often finds himself in the position of discouraging such primitive beliefs. He said he tells people “no one is out to get you. You are sick. Take your medicine and you will get well”. He told me of a friend who, when he visited 2 months ago, was on his death bed. The man’s wife was very worried and thought her husband had HIV but the husband believed someone was trying to kill him and had paid to have a spell placed on him. He consulted a witch doctor who told him certain people in his family and in his community were trying to kill him. It caused many bad feelings. Evanys convinced him to go to a clinic and found out 2 weeks later that the man had been diagnosed with TB. He was on medicine and was starting to feel stronger. He acknowledged that Evanys was right but still clung to his ideas that he needed to appease the witch or he might put another hex on him.

The Daily Nation, the Nairobi daily paper had dozens of online comments about the murders in the days that have followed. Many Africans who live in western countries wrote to say that people in the west condemn these killings because they don’t understand the reality of witchcraft. Many gave witness to stories of illnesses and deaths “known” to be caused by witches. Many stated in essence, “I don’t believe in witchcraft myself but I know witches are very powerful and hurt many people”. These were people who participated in online discussions from computers in countries far from their native homes. People of the 21^st century. People who hold unshakable beliefs about the dark power of witches and spells. That is the paradox of Africa.

Saturday in the Kenyan countryside

2008-05-17T05:36:00.000-07:00

After 3 days of sleep interrupted by late night Pentocostal fire and brimstone broadcast over a pair of gigantic speakers, Paul and I both awoke this morning feeling sluggish and grumpy. I should explain. There’s a small open building just a couple hundred feet from the perimeter of our upper compound. About every 4-6 weeks, a couple who are Pentocostal preachers arrive and set up camp for 3 days to preach every evening from 9 PM until 2AM-or later. This never happens on a weekend- it’s always during the work week. So, we had just survived the third night of the third visit by these preachers in 2 months and were feeling very testy.

After coffee we felt better. After reading a few emails from home we were even better. And by 9AM we were ready to set out for a mood altering walk in the countryside.

We took a route that is becoming well known to us. First, as we leave the compound we greet our fellow staff members who live in the upper compound. (Paul and I are n the lower compound). Then we leave through the green iron gates and merge with the “traffic” entering and leaving Matoso. The traffic consists of a few bikes, a few women headed to the lake with large buckets on their heads filled with the week’s laundry, a couple of kids selling bananas and mangos and a couple of kids just waiting to spy their first Mzungu of the day.

After we greet one and all we head east, away from the lake and up the hill into the countryside. It’s a beautiful day, with huge white cumulus clouds in a brilliant blue sky.

There are men on bikes carrying maize and piles of timber. Two men herd a half dozen donkeys loaded down with bags of sand for construction. Coming across a dry field is a man riding a bike in his best dress shirt with a beautiful woman sitting side saddle on the back. We meet a boy with a homemade slingshot who runs to show it to us and asks if we want to buy a few ears of corn. We didn't carry money with us and tell him maybe next time. He's very happy with that response and runs back yelling "maybe next time!"

We pass several people on their way to church. One woman wears the white head scarf with the red cross stitched on the front which we’ve been told means she a member of a Protestant denomination.

We come upon a group of women resting under a shade tree for a few moments before they continue on their journey to church. They’re dressed in their best dresses and are carrying suitcases for reasons we can’t fathom. Perhaps they walk a long way to get to church so plan to stay overnight with a relative before heading back home. Two of the older women rise to greet us. We shake their hands and using our best Luo we greet them by saying “oyare”- good morning. They continue to talk to us while we politely nod and smile. Then when I know of nothing to say back to them I pull out the camera. They’re delighted to have a picture taken and pose beautifully for me. When I show them the picture of themselves they all laugh and cluck appreciatively. I say “erokomono” or thank you- to them and then “ariti”- bye-bye. They are still chattering about us as we disappear over the next small rise in the road.

Our route now makes a large circle and heads back toward the lake and the big tree. The big tree is a local landmark and one frequently used to give directions or describe where one lives as in "take the path past the big tree and look for the first cow path next to the big orange boulder".

We discovered this ancient tree the very first week we were in Kenya and it continues to be a place we visit often. In the dry season the tree sits in a dry, shallow bowl surrounded by grazing lands and a few family compounds. In the wettest part of the wet season we found it completely surrounded by a large lake. And now, as the wet season abates, it is on the edge of a tiny lake which is now surrounded by lush swampy grasslands full of water plants where dozens of large white egrets were grazing.

There, on the edge of the lake, were a handful of boys with fishing poles. They saw us approach and waved to get our attention. We found that they were fishing for small mud fish. Mud fish can live in the mud during the dry season only to emerge when the lakes fill with rainwater again. (Paul recognized them from a National Geographic program but neither of us expected to see such things in real life). The fish were the size of fingerlings so it would take a lot of them to make a meal. But there are worse ways to spend a hot morning in Africa than sitting under a massive tree with a fishing pole in your hands.

The last leg of our walk took just 15 minutes and brought us in a full circle back to our compound. We bought mangoes from the children by the gate and greeted our colleagues again before walking to our cook house. We had been gone about 2 hours but the change in our outlook was complete. The grumpiness of the morning was gone and we could again be grateful for having clean, cool water to drink and a refreshing shower at the end of the dusty trail.

What Mzungus are...

2008-05-17T05:31:00.001-07:00

One day Paul and I were having a discussion with one of our clinicians, Juliana. Juliana’s a strong woman with a sense of humor to match. She’s smart and also outspoken- a trait not shared by many of her African sisters. Those are some of the reasons she’s our in-charge in the HIV clinic.

She was explaining to us why the patients often want to talk to the Mzungus or come to clinic on a day when we’re there. She told us that patients believed that we Mzungus had some special knowledge, some special power that set us apart from our African counterparts.

I laughed out loud, knowing all too well how we Americans sometimes exude an air of confidence when we’re really flying by the seat of our pants.

Undeterred, Juliana tried to convince us this was a belief deeply seated in the cultural fabric of their community. To make her point Juliana said this: “Mzungus are”…pausing to slap the back of one hand loudly into the palm of the other …”next to God!”

We all laughed at this. Our African colleague recognized the absurdity of this as well as we did. I have to admit, it makes our job a whole lot easier. We just have to be white and show up. The bar couldn’t get much lower than that!

An African Death

2008-05-12T00:33:00.000-07:00

She came into our clinic for the first time on the day she was to die. Not much is known about her other than she lived in our village, had HIV and had been sick for some time. She was on the young side of middle age by American standards. In Kenya, where the average life expectancy is down to 47, it could be said that she was in the winter of her years. She was sick enough to need hospital care but for reasons she never shared with us, she decided to wait, not to go that day. She went home and before the sun set over the lake, she was dead.

It was a Friday night and we didn’t yet know her fate as we left the clinic that day, all of us anxious to be home, slipping into flip flops, relaxing into our weekend plans after another tiring week.

As darkness settled in along the lake we heard a sound rising up from the village. It was a sound we’d never heard before but its raw mournfulness compelled us to turn our heads toward it. It was then we knew- it was the sound of women wailing.

We didn’t connect the sorrowful sound to the patient we had seen earlier but knew that somewhere, someone had died. Men added their voices by drumming a low, rhythmic beat and chanting. It continued long into the night and in the morning we admitted to each other that several times during the night we lay awake in the darkness listening to the tribal sounds.

On Saturday we saw that a pergola of sorts had been built on a small rise overlooking the village. As we left the compound to walk in the countryside we saw a few of the men from our staff sitting under a tree watching the rites. We stopped to speak to them and it was then we learned the funeral was for the patient from Friday. They too knew little about her. She was just one of the many people here who die much too young. She had already been buried but the mourning would continue through the weekend and turn into a celebration each night, ending at dawn on Monday morning. As Christians they honor the dead according to their faith but as Luo they chant and yell into the night to scare off “Death” who may still be lingering about, waiting for another victim.

On Monday as the staff gathered for our morning greeting and prayer I looked around and saw the fatigue in their faces. None of us in the compound slept well that weekend. We were all unwitting participants in marking the death of another African.

Men are from Mars...Survey results

2008-05-12T00:12:00.000-07:00

As our regular readers might recall, a few weeks ago we were reviewing the quarterly statistics with the staff when it was noted that family planning (FP) services in our clinic fell below Kenyan goals. Paul asked if male patients were being asked about FP too which led to hoots of laughter. We joined the staff in a lively discussion about the FP beliefs of African men and sharp differences in opinions were expressed along gender lines. I suggested that we construct a survey to determine just what men do believe and if and how they practice FP.

Four of the staff, 2 men and 2 women, came up with initial questions to ask men. Some of the women’s questions had an in borne bias. For example, one question asked “Why don’t you men use condoms?” The men’s questions were less biased but were phrased in a way to lead the respondent to the ideal or desired answer. After a week, they gave me all the questions they had amassed and asked me to choose the best questions. I reminded them of the survey’s goal, added some guidance on writing unbiased questions and then sent them back to work on it some more.

The final questionnaire isn’t prefect but it did result in some interesting data. It starts with asking basic demographics, allowing us to look for differences or similarities amongst men of different ages, marital statuses and educational levels.

It then asks questions regarding the number of wives they have and the number they desire; the number of children they currently have and the number they desire; and if they know about family planning, what they use if anything and whether their partners are happy with the method. The final question asked the man if his wife were to become pregnant, would he accompany her to the clinic visits.

They distributed the surveys to men who came to our clinic and also to men in other communities. They got 115 responses, the majority of which were men in the 18-30 year old group (48%). Only 8% were over 45 years of age. A full 66% reported being married with the majority stating they had only one wife (though a few had 3-4 wives).

90% of all men reported they had heard about FP and 84% thought it was good. But how many reported practicing some form of FP? Across all groups the number was similar- about 53%. That was true for all ages, all educational levels, all marital groups. Why did so many think FP was good and yet barely half of them use it? The answer may be in how they answered the questions about desired children. In all age groups, the majority of married men (47%) reported having 4 or more children. And when asked how many more children they wanted, 42% said they’d like 4 or more additional children. One man said he’d like 20.

Are their partners happy with the method? 77% thought they were. Would they accompany their wives to clinic if they were pregnant? Yes, said 85%.

Now came the really interesting part. As we began to dissect and discuss the data people’s interpretation of it split the group along gender lines once more. The men proclaimed the results clearly demonstrated that things are changing, men are marrying fewer women and are being more responsible in helping prevent HIV by using condoms. They claimed this in spite of facts and data to the contrary.

Only 53% use any form of FP and of those only 60% were using condoms. A few stated they use oral contraceptives, a few use Depo and a few use withdrawal. The numbers didn’t add up. How to explain the discrepancy? Much discussion again ensued until Dr. Jeevan walked to the board and wrote “men are worthless liars”.

This outrageous statement had the desired effect. First, it broke the tension in the room and got everyone to laugh and second, it allowed them to acknowledge the possibility that what men said they did and what they actually did in their lives may be 2 distinctly different things.

The women believed this to be the case all along whereas the men still didn’t believe it (damn the statistics!). The female staff embraced the beliefs that women have more children than is healthy because their husbands want too many children. In days past, having many children meant one was wealthy. Men still brag about their father having 7 wives and 46 sons. Although the younger men on the staff believed the times were changing, in practice men may be closer to their grandfather’s generation in beliefs than they think.

They also strongly believe that prevention of HIV hinges on women having more rights and choices in FP matters. As one clinician stated “they must be empowered”. They shouldn’t have to be exposed to HIV because their husband refuses to use a condom, but they often are.

By the end of the discussion we had three suggestions on the table. One, create a survey to determine women's FP beliefs and practices; two, provide more FP counseling to men at the time they are seen in the clinic and with HIV counseling and testing and three, invite men to accompany their wives to antenatal appointments so they are more intimately involved.

So gentle readers, stay tuned and we will give the women their own voice in an upcoming blog.

Traveling the Tanganyka Trail

2008-05-07T06:53:00.000-07:00

Last Sunday, one of our staff offered to take we three Wazungus (plural for Mzungu) on a day trip in honor of Jeevan’s final weekend in Kenya. Daniel has been a driver for 17 years at Lalmba and is also cross trained to work as a pharmacist, an immunization technician and an assistant in the treatment room because let’s face it- in Africa nothing goes to waste. Especially not even human potential.

He agreed to meet us in the compound at 7 AM sharp but as all Americans are cynical types, we each placed bets on what time he would actually arrive. We were all pleasantly surprised when he arrived on American time-only 15 minutes late (Jeevan won that bet). Daniel also had planned an ambitious tour beginning with a cave that was an ancient dwelling- supposedly used by humans 1000 or more years ago. To get to the cave we drove the Tanganyka “highway” (a rutted dirt road) to the very end of Kenya where you can throw a rock and have it land in Tanzania. The very last village at the end of the road was actually named something in Luo that means “end of the road”. It reminded Paul and me of our short visit to Homer, Alaska. People in the village were shocked- as they often are- to see not one but 3 white people in their midst. We parked near some large rocks that looked as if they’d been rounded by tumbling through a massive river a million years ago. Daniel asked me if we have big rocks where we live. I downplayed the fact that we live near mountains that are known as “The Rockies”.

As we got out to hike the short distance to the cave, kids came running toward us and then over took us, wanting to lead us to the site. It was a good sized cave that had 2 entrances- we supposed , ideal for fast escapes. The people who lived here 1000 years ago had access to fresh water and fish but rocky land so probably subsisted on fish and other meat rather than grains. There weren't any ancient petrographs on the walls. It was just a simple cave made remarkable by the knowledge of the ancient ones who once lived there. After more photos of the cave and kids we headed off to our next destination on the tour.

Paul and I were riding in the back of the Land Cruiser ambulance. We had the foresight to bring along extra cushions to sit on as every rut and pothole caused some jarring. Sometimes Daniel wouldn’t see a speed bump until seconds before hitting it causing bone-crunching, kidney-busting jarring. To be fair, Jeevan did offer to trade places with us but Paul and I, for some reason I can't fathom now, kept declining saying “no, really, we’re OK”. But I digress…

The next sight on our tour was the “power plant”. This was very exciting for Daniel as is the possibility of having electricity some day. The river Kujo was dammed resulting in 25-30 foot spillway. There was a narrow metal bridge crossing the river that although stable, made scary creaking noises with every step. Our guide was very proud of the progress being made in our region toward eventually bringing electricity to Matoso. It will be life changing in ways that are both good and not-so-good. The one person in Matoso who has power through a generator disturbed our night time peace by opening a bar that shows televised soccer games or DVD movie or just playing really loud music. So imagine when everyone here has that capacity. Oy vey!

The third sight was supposed to be an ancient stone building but after driving on roads that were nothing more than cow paths and across muddy fields for another 2 ½ hours we convinced Daniel to bag it. By now it was already almost 2 PM and so we stopped for lunch in a little “hotel”- which our regular readers will recall is what they call a café- on a dusty street in a modest village near our final sight- the Ruma Game Preserve. The Ruma was the place we had been waiting all day to see and time was running short. As is usually the case, the hotels make 1-2 things every day and that’s what’s on the menu. And as is also usually the case, those 2 items are always the same things- either a fatty beef “stew” or a fried fish, served with sakumawiki greens and ogali- the lump of pasty, tasteless porridge that is ubiquitous on Luo tables at dinnertime. Paul and I declined lunch as we had packed cold pizza, oranges and cupcakes which sounded much better to us. After this short delay we were finally on our way to Ruma.

Although it took us 8 hours to get there, Ruma National Park is only 2 hours away from Matoso. It’s a small- just 120 square km- and infrequently visited game preserve that is home to the world’s only population of roan antelope. We read that just 50 years ago they could be found all over Kenya and today are down to less than 100 animals. It cost we Mzungus $20 each (which is still quite a deal) to get in while Daniel paid only 100 shillings- about $1.30. By the time we paid and entered the park we had only an hour left before we had to start for home. We are forbidden to drive after dark because the roads are too dangerous.

But we made the best of our time there. We very quickly saw a herd of what we thought were hartebeests but later learned were topis- antelopes with dark, almost purple patches on their hind quarters. Just a short distance later we saw the roans. The have a distinctive black facial pattern. And as we continued on we spotted our first giraffes. We ended up seeing a large herd of Rothschild giraffes- caught in the sweet, low light of late afternoon and against the dark sky of threatening rain clouds. That’s when I declared to Daniel “I am now a happy woman!”

We drove home in the waning light, quietly ruminating over the sights of the day and feeling that now we had seen Africa (andcounting the minutes until we could get out of the vehicle).

Medical update

2008-05-03T06:47:00.001-07:00

The past few weeks have flown by as we prepare for the final step in our transition to being the new medical directors- Jeevan’s departure. He flies home to his wife Amy, their two dogs and a new fellowship in hematology-oncology on May 7^th. Paul and I feel so lucky to have had such a long orientation with him. He’s been a great teacher to us and to the staff and a very funny and easy man to live with. We’ll miss our card games, our shared meals, our memorable ‘60’s style “rap” sessions where we solved all the problems of the world, our movie nights, his smooth moves on the dance floor and his wonderful, exuberant laugh. Tomorrow we’re planning to take a final day trip to a nature preserve and a couple other sites with our “guide” Daniel, who is on the staff here.

So many of you have asked us what kinds of things we see in the clinic and what do we do day to day besides nap and chase the cats with our blow darts. I’ll try to answer some of your questions in this blog.

Paul was asked to focus his attention on our PSC- the Patient Support Center- the clinic that cares for our patients with HIV and/or TB. Jeevan spent his time here building the foundation for the program which is currently caring for 400 patients a month. The goal is to increase that number to 1000 by the end of 2008.

The clinicians see patients in all stages of the disease in the PSC and are challenged to provide good care without the benefit of having routine labs and other diagnostic studies we have in the US. We’re lucky to have an array of antiretroviral and TB drugs available to our patients. This was a huge step forward in HIV care in East Africa. For the rest of 2008 Paul will work with the staff and Community Health Volunteers to track patients who have disappeared or stopped taking their medications to get them back into treatment. Paul and the staff will also find ways to increase HIV testing in villages and to refer newly diagnosed patients into care. He has a lot of good ideas to motivate the CHV’s and to get their communities more involved. One of our biggest challenges will be to try to get a pediatric HIV program off the ground as part of the PSC. I’ll write more about that in coming months. It’ll be an interesting year for him. He’s also in demand as the teacher for our beginners computer classes and will offer other educational topics to the staff throughout the year.

My focus will be on the main clinic and our outreach sites. Rather than see patients myself I’m in the role of a collaborator and consultant to the clinicians. The nurses function as nurse practitioners or physician assistants but they lack the education and training in some cases to fully fulfill the role. Much of what they learn is on the job so they look to the American volunteers to provide ongoing education and clinical supervision.

The clinic usually has 3 clinicians on duty during the week and they see up to 100 patients a day. They see a variety of illnesses but most are far from the everyday garden variety we'd see in most US clinics. Kids don’t come in with just colds and ear infections.

Some of the patients we saw last week…a 7 year old girl who was so anemic that her nails and tongue were pearly white. She had sickle cell anemia. I looked at a slide of her red blood cells and she had very few normal cells. Most were the characteristic shredded, comma shaped cells. Her blood count was very low but not low enough for her to qualify for a blood transfusion at the hospital. We treated her with folic acid, vitamins and updated her immunizations. We’ll try to see her on a regular basis.

A woman needed stitches yesterday after being slashed with a panga by her husband’s other wife. A young man had big sores on his body for 5 months- he had undiagnosed HIV. Our staff was called to transport a couple of kids who were poisoned from eating a plant called cassava. They suddenly were unable to walk but luckily are doing fine after their stomachs were emptied. What else? Let's see...there are often people who come in with poisonous snake bites. One tragic case we saw a week ago was a woman who was 32 weeks pregnant and started having seizures at night. By the time her family brought her to the clinic the next day she was unconscious and had dangerously high blood pressure. She had eclampsia which is a frequent cause of maternal deaths. Paul rode with her to the hospital but the woman and her baby died later that day.

A 9 year old girl was brought in by her mom with a report of sudden onset of weakness in her legs and difficulty walking. She needed support to stand and had to walk by rocking back and forth on her legs. After gathering what information we could by our history and exam we suspected that she may have TB in her spine. We sent her for an x-ray at the hospital.

There's occasional cases of malnutrition but in general we see very little of it. Usually we find the moms are young and are poorly informed about the nutritional needs pf their infants so they feed them too many starches and not enough protein.

The everyday things we see here are unusual in the States. Malaria, worms, measles, whooping cough, rabies, even the various types on TB are a rare diagnosis at home. So I’m also a student and the staff my mentors.

The last thing I'll mention is the program to prevent transmission of HIV to infants during pregnancy and after delivery. It's shocking to have so many of our pregnant moms test positive for the virus. We don't have a clear picture of how many infants have been infected but we hope to have a better idea as we move forward with the Peds program. So I'll work with the staff to strengthen that program.

So that's a little taste of what we're doing here. As the year goes along we'll provide updates from time to time but we also enjoy your questions and com.

Photo of the week

2008-04-26T22:37:00.000-07:00

Paul and I take so many photos every week that it's usually hard to choose just one. But this week is an exception. Paul and I took a 2 hour walk through the countryside last Saturday. We passed a small pond where the women were bathing the children and doing their laundry for the
week. We got the usual reaction from the kids- they yelled "Mzungu" and came running out to
greet us. So the first picture was of that small group of kids with khangas (brightly colored cloth wraps) around them.

When I got home and downloaded the photos I noticed that one child had a very special presence about her. She stands with confidence and to me, looks like she could be the future queen of an ancient tribe. I cropped the photo so you can see it more clearly. Take a look and see of you don't think she's really special.

Hopping on the Internet superhighway

2008-04-26T22:08:00.000-07:00

One of our goals for our year here is to introduce the use of the computer to as many of the staff as possible and to mentor a select few to make them proficient. With the exception of our administrative staff, only one person uses a computer and he is at a beginner level. Since Paul is the computer sensei, he works one-on-one with Jenipher, the assistant project director. But every Friday we jointly hold a class for 4 staff (they're such beginners that even I can help teach). We started with one person from each of 4 departments: PSC, clinic, lab and education.

This past week was their 3rd lesson and as promised, we introduced them to the Internet. The Africans here live in a way that really straddles 2 centuries- the 19th and the 20th. They don't have electricity or indoor plumbing but they do have cell phones. Information about their community is spread by word of mouth. News about their country or the world comes in the same way from people who have read the paper or listened to the radio. They are aware of movies and TV but have very little exposure to them. There are no movie theaters anywhere outside of Nairobi that we know of and there's a rare TV in cafes in larger towns.

So imagine if you will, that you live in such a way and suddenly a Mzungu turns on a computer and all the news of the world lies in front of you. Imagine the shock and excitement you'd feel when you type in "politics of Kenya" and get >800,000 hits. There in front of you are photos of your leader, news of the new cabinet, archives of the entire post election crisis. That will give you a sense of what we witnessed on Friday. Their amazement was exhilarating for us as well.
At the end of that session, Evanys stood up and proclaimed "I am a changed man. I am no longer Evanys, I am Evan!"

Member's club

2008-04-26T09:20:00.000-07:00

Jeevan and a few of the Kenyans get together every few weeks on Friday night to celebrate the end of the week. They call this group "member's club" and members are selected seemly at random with the only qualification being the desire to dance with abandon. Last night Paul and I were invited to join them (perhaps because they were meeting at our cook house?) and had a great time.

First they all had to be introduced to the famous PVC blow gun mentioned in my last blog. The guys recognized the fun potential almost immediately. They asked how was it made? What do you use for darts? And do you have any more PVC pipe? Then all took turns shooting darts at the trees. Then the boat on the lawn. Then the cow that happened by. After they all got their fill and had each had one to take home we moved indoors for music and dancing. Soon almost everyone was up dancing to reggae music and trying to sing along. When Paul pulled out his guitar and played a few rock ballads the Kenyans danced and yelled their approval. The big finale was the song "written" on the spur of the moment by Paul called "member's club". He made up verses about some of the members that brought howls of appreciation. The entire group joined in to sing the chorus (me singing off key and loud per usual). We ended the night early but with a plan to throw a farewell members club night for Jeevan before he leaves in 10 days.

Boys and their toys

2008-04-22T07:24:00.001-07:00

When Paul and I arrived at Matoso, one of the first things our cook asked Marty was whether we were "cat people" or not. There have been volunteers who kept strays in the cook house which drove Joyce crazy. Now there are stray cats that loiter outside our cook house and huts, meowing at all hours of the day and night and generally making a nuisance of themselves. Not only are they pests but they could also carry rabies ( I tell you this so you don't hate us for what I'm about to divulge).

Before we got here, Jeevan tried to rid the compound of some of the cats. He would leave food out every day, moving it closer and closer to the door until finally it was inside the cook house. Then, he slammed the door, trapping the freaked out cat in the house. That turned out to be the easy part. He then had to spend hours trying to catch the cat in a sack so a co-worker could take it far away from here. After all that work, he was able to relocate a trio of cats but as luck would have it, the most annoying cat found it's way back to Matoso a few days later.

He decided it was time for drastic measures. He asked someone to pick up a length of PVC pipe when they ran into town for clinic supplies. He cut a piece about 1 meter long to use for a blow dart device with the idea of blowing seed pods and pebbles at the cats. The pods didn't work very well so he and Paul spent the next couple of days experimenting with the design of the dart. They made paper cones to fit over nails and then covered the tip in masking tape to keep it from mortally wounding the cats. They'd practice aiming at trees and the backsides of cows to fine tune the aerodynamics of the dart.

They got so good at scaring the cats away that within days they ran out of targets. Of course, that didn't stop the boys from having their fun. Jeevan just moved on to shooting at anything in the yard- cows, sheep, pigeons, chickens, goats (in his defense, the animals barely notice they're being hit). When a hen came in to peck at the crumbs on the floor, Jeevan jumped up and grabbed his tube. The chicken ran for the door with Jeevan hot on her trail and me right behind him yelling "run chicken, run!"

PS- you can read Jeevan's version of this story on his blog...www.jeevanmd.blogspot.com

Do you know day it is?

2008-04-21T04:26:00.000-07:00

Our sister-in-law Julie asked us whether we were still happy with our decision to come to Kenya and if the experience was what we thought it would be. She also wondered if time was flying or crawling by. Her questions stimulated a long conversation between Paul and me and here’s what we would say.

Yes. We are unequivocally happy to be in Kenya. It’s not exactly what we expected but what experience ever matches your anticipatory musings about it? It’s better in many ways and not as good in a few. It’s still hard to believe we are here. At times we have looked at each other and asked “ Can you believe we’re in Africa?” Our reality is so dramatically altered that it makes it hard to wrap our minds around it. It feels like we’ve been here much longer than 6 weeks. Not that we want time to fly by but our perception of time is altered too. This very morning I asked Paul if it was Wednesday.

We laugh about wiping insects out of our coffee cups in the mornings and the occasional extra protein we get when one flies into our mouths or lands in our cooking pot. We like falling asleep to the sound of waves and are starting to get used to the other interesting sounds at night. Hard rains keep us up at night but then as volunteers we can nap in the day if we need to. We don’t mind sharing our quarters with salamanders and geckos and I enjoy the hens that come in to the cook house to peck at crumbs or the birds or bats that sometimes fly through. It’s very easy to get used to living compatibly with nature.

We wish we were 20 years younger in health and vigor but otherwise feel this is the perfect time in our lives to be here. Having a bit of experience and the mellowing that comes with time has made our transition much easier. Time moves slowly here. The days linger, there’s no rush to do anything. There’s always tomorrow. We feel very relaxed and are learning to enjoy the simple things in life- like how delicious a fresh pineapple can taste.

Here's another lesson. Recently we asked to have a leak in our roof fixed and the maintenance crew came by 2 weeks later to fix it. Being Americans we were a bit surprised that it took 2 weeks to get it fixed but if we asked ourselves whether the delay really mattered we’d have to say, in all honesty, that it didn’t. It’s TIA- time in Africa. I think we Americans worry too much about things that don't matter a bit. And so one of the lessons to be learned here is to lighten up and let go. Jump into the stream of African life and just go with the flow, wherever it takes you.

There is a lot of disease due to infection here yet we have not been sick a day (knock wood). We take Doxycyline every day to prevent the #1 cause of illness- malaria. We drink rain water that is collected in a cistern and then filtered. We wash our dishes from tap water that comes directly from the lake then leave them outside in the sun to “sterilize”. We shower using lake water but are careful to keep our mouth closed.

We miss our families and friends so having Internet access has been a real blessing. Our son Kevin moved back to CO from TX and we wished we were there to greet him but he emailed today to say he is there safe and sound. My sister Michelle got married this past weekend and my siblings Francesca, Karen and Jim flew to NH for the celebration. We wished we were there but having Karen send funny emails several times during the weekend made us feel as if we were. What did previous volunteers do without it?

The Kenyan people are much more welcoming and generous of heart than we could have imagined. The reaction we get when people first see us is both a source of joy and amusement for us. We still enjoy the way kids yell in excitement when they see us then run at us to try to be the first to shake our hands. Sometimes though we wish we could walk unnoticed in the village or countryside. It would be nice to have a “cloaking device” to make ourselves invisible.

We're so insulated from news that we didn't even know if both Democrats were still in the presidential race until our friend Kim told us so. We sometimes are able to pick up VOA or BBC newscasts on the radio and also check Internet news at times. People in Kenya are very interested in the US race because of both Clinton and Obama. Bill Clinton was and is well liked here and that goodwill is extended to Hillary. And of course having an American presidential candidate with a Kenyan father is very important to the locals. They wonder aloud if Obama has a chance to win in America. It’s a good question. His name is common enough here that one of the staff in our lab is named Samuel Barak Obama. (we also met a young boy who told us his name was George Bush. Paul thought he was kidding and responded “and my name is Osama bin Laden”. The laugh was on us when we later found out he really was named after our president).

The work is interesting, challenging, frustrating, eye opening, satisfying and even sometimes boring. Jeevan spent his months here making the Patient Support Center (PSC) a well organized system for addressing the needs of our HIV infected adults.

He created such a stable operation that when he returned after the crisis, he found the clinic had run smoothly in his absence. He had made himself redundant by making the staff self sufficient. That’s the #1 goal of volunteers. Now our mission is not to screw it up.

The PSC provides medications to prevent opportunistic infections (infections that take hold when a person’s immune system is depleted) to every adult with HIV, and antiretroviral treatment (ART) to those who need it. Our clinic gets the antiretroviral medications (ARV’s) indirectly from the CDC. The money comes from PEPFAR – the President’s Emergency Plan for HIV/AIDS Relief- through the CDC, then through 2 NGO’s (non-government agencies) in Kenya who subsequently purchase the meds and give them to our clinic for free. (I promise- no more acronyms) Before PEPFAR no ART was available at our clinic and so there’s some unease because the funding is only secure through 2008. Will the next administration continue funding?

There are so many organizations funding work in Africa that it’s hard to keep it all straight. The big question is…has it made a difference? There’s a well documented link between poor health and poverty so has battling disease in poor countries for the last 20 years improved the economies of those nations? Can you address disease prevention if basic needs are not met? If there are 900 million people in Africa and even 10% are infected that’s 90 million people who need treatment. We know in Kenya the life expectancy has dropped by 20 years in the past 20 years. In other words, life expectancy for Kenyan men was 62 in 1988 and is 42 now, 37 in some regions. That’s in spite of great strides in the prevention and treatment of other diseases like malaria.

So what has changed? Here’s one thing. In the 1990’s Lalmba Kenya lost about 10-12 staff to HIV. Now, even though 50% of our staff is infected, they are all in treatment and all doing well. So that’s a small victory for Kenya but a huge success for those individuals.

Next time I'll write more about the work here for our medical friends. Keep your feedback and questions coming. We like hearing from you.

Luoland

2008-04-13T06:39:00.000-07:00

The people who live in this region belong to the Luo tribe. They came to this area in around the 16^th century and speak a Nilotic language, Dholuo. They’re the third largest tribe in Kenya and many members of Parliament, as well as new Prime Minister Raila Odinga come from this tribe. There are also Luo in Uganda and

Tanzania

Traditional culture is still an important part of the Luo’s daily life, but that is changing. The way a child receives a name is related to the position of the sun when they are born. For instance, Atieno is a girl child born at night, Akinyo in the morning and Achien’g is when the sun is high. Akeyo is a name given during harvest time. The first letter of the name indicates gender. “A” signifies a woman and “O” a man. So a man born at night would be named Otieno. This is usually their last name with their first name being either a Luo name like Cawa or an English name like Juliana. We’ve also found that some people, but not all, are called by their last name. For example, John Chacha is known as Chacha and Jane Sakuku is simply Sakuku. We don’t fully understand the rules or manners dictating this so we just follow everyone else’s lead.

It raises an interesting dilemma in the clinic too. So many people have the last name of Atieno that the staff files patient charts under first names instead of last. And because birthdates are often unknown and no one has an address other than a village name, people must be further distinguished from one another by the names of grandfather and fathers. So when we pull a patient record we might ask, “are you Mary Atieno from Otho, granddaughter of Owya Ochien’g?”

The controversial practice of wife inheritance, whereby a man’s wife is inherited by his brother after he dies, was originally started as a way to ensure that the family of the deceased would be cared for. A woman who refused would lose her land, her home and her children. This practice continues but we’re told it’s losing favor in light of it’s connection to the spread of HIV. Kenya also passed laws giving women more rights, including the right to own land. This isn’t a widely practiced law but at least it’s a start in the right direction.

HIV/AIDS has had a significant impact on the Luos. As I’ve mentioned before, this region has the highest incidence of HIV in Kenya. Cultural practices and beliefs contribute to the spread of the infection as do ignorance and social taboos. Adoption was an unknown concept in the past. Orphans were immediately and casually absorbed by the extended family or neighbors. The extended and large family structures accommodated this until the AIDS crisis left villages with too many orphans and not enough care giving adults. In some cases children are left on their own. Other times an elderly woman will look after them. And a tiny number are raised in an orphanage where they can stay until they’re older teens.

Social faux pas and how to avoid them

The Luos are very warm and welcoming people. As I previously described, they greet each other every morning before work by gathering in a circle outside the clinic. They then sing a song together and then say a short prayer. When they meet you again later in the day they will greet you again. Both men and women hold hands with each other while walking but people of the opposite sex should never display affection, or even hold hands in public. It’s bad to point at someone with one finger but OK to use the whole hand. It’s bad to pass something or eat using your left hand (poor Paul).

Kenyans have a different sense of personal space. They stand much closer to talk and may actually lean into you. They have a different understanding of time too. Last week we had a meeting scheduled for 9 AM with several organizations. The earliest group arrived at 10:30, the next at 11AM and the last one came at 1:30 PM. No one said “sorry we’re late” either. It’s TIA- time in Africa.

The curse of the lake flies

2008-04-12T06:11:00.000-07:00

Every few weeks we see a black cloud emerge way out on the lake that signals another hatch of lake flies. That's when we start praying that they get blown to Uganda instead of to Matoso. So far we've been very lucky. Very lucky that is, until today.

Lake flies are part of the legend of Matoso. The ex-pats like to tell stories to the newbies about the worse lake fly infestation they've ever experienced. It usually involves flies that are so thick you can't you can't breath without inhaling them etc. So today, when we spotted the ominous dark cloud over the lake we felt that sense of dread. I didn't look forward to breathing in bugs but maybe they'd blow over to the Uganda side. But as we were walking I found myself searching the lake to see if they were coming closer. Every adult I passed was asked "lake flies?" as I'd gesture toward the lake. They'd smile benignly at me and nod yes, as if to imply "what's the big deal?" Haven't you ever seen flies before?
By the time we got home there were small clouds of flies in the compound but we were relatively lucky. Instead of the usual trillions of flies, we had only a few hundred thousand, give or take a million. And the good news? They don't bite or sting and don't even live that long. Probably provide good eating for the fish and birds too so I guess they're tolerable. Thought you'd like to see a couple photos of what I'm talking about.

Men are from Mars, Women are from Venus

2008-04-08T07:31:00.001-07:00

Our clinic in-charge person, Willis, called a staff meeting this morning to review the end of quarter statistics. The Kenya Ministry of Health (MOH), like all government agencies requires certain reporting to be done monthly and quarterly. The data includes the number of ante-natal visits, the number of vaccinations given, the top 10 diseases seen in our clinic etc. One item had to do with the number of people who received family planning counseling.

That percentage was below MOH goals so we discussed how the data was collected and if it was an accurate reflection of the services provided. Paul asked if the number included male patients who were counseled on FP options. The staff erupted into laughter. Counsel African men in family planning or condom use? Preposterous! The woman on the staff believed that men not only don't accept counseling on these topics but they prevent women from accessing FP services. It turned into a lively discussion with the men stating the belief that African men do want to prevent HIV transmission, do use condoms, do want to have fewer children etc.

I suggested that we design a survey to ask the opinions of men around these issues. The survey would be conducted on outreach and in the clinic and men of all ages would be included. We got 4 "volunteers" to design a survey that they will then bring back to the group in one week. Everyone agreed on one thing- HIV transmission is tied to the sexual practices and beliefs of the men and women in the community and no one really knew for certain what those beliefs are.
I'll share our findings in a month or two.

End of life and other cultural issues, part I

2008-04-08T07:21:00.000-07:00

Last weekend while we were walking in the countryside we met a young man named Jacob. He told us he went to school in Migori but was called home by his family because his father is quite ill. One thing we’ve learned here is that there are no “patient’s rights” per se. The family makes all the decisions for a patient and because women have little or no legal standing or rights, the decisions often fall to the oldest son. That was the case with Jacob. Although he is only 15 he was the one bearing the responsibility for the care of his father.

He told us he planned to walk to Matoso on Monday and try to arrange for his father to be picked up and driven to the closest hospital- St. Camillus- which is an hour away over very rough roads. He told us that his father had been ill for 2 months and was now unable to stand. We suggested that he bring his father to our clinic first to be evaluated first and if he needed to go to the hospital, his transport would be arranged.

Jacob did bring his father in the morning by lifting him onto a bike and using it as a wheelchair to walk him the 1-2 km to the clinic. As it turned out, the father was a patient in our Patient Support Center (HIV clinic) and was in end stage HIV disease. He was emaciated and extremely weak, his breathing was labored and his heart rate rapid. After evaluating him it was readily apparent that there was nothing the hospital could do for him.

With the family gathered around the patient, Dr. Jeevan explained that their father was dying and he would be given medicine to make him comfortable so he could be taken home to die. Jacob lobbied for his father to be taken to the hospital. He stressed that he was responsible for his father and wanted him to go and that his mother wouldn’t accept him being sent back home without treatment. As we continued to talk it became apparent that he believed that if his father didn’t go to the hospital he would be perceived as a bad son; one that didn’t do enough to save his father. I assured him he was a good son. I explained that it was unlikely that his father would make it to the hospital and he would suffer greatly from the ride over the rough roads.

But what else can I do for my father, he asked? Take him home where he will be surrounded by family and let him die in peace. Take care of your mother. Comfort her. Your father is in God’s hands.

The family acquiesced and after the patient was given a couple doses of pain medicine he was driven home by our staff where he died later that same day.

At a staff meeting that afternoon the subject of end of life care come up. We were all asked if it was better to send a dying person to the hospital, knowing nothing can be done or was it better to send them home to die among family? In America I would know the answer most of my colleagues would give- send them home. So, I was caught off guard when the entire Kenyan clinical staff chose to send the patient to the hospital to die. Their beliefs reflected Jacob’s- that everyone should die in the hospital and sending them home makes the family look as if they didn’t do everything possible for their family member. They would suffer shame in their community.

I immediately became concerned that the care we gave to Jacob and his family wasn’t culturally appropriate. Had we broken our own rule to always listen and respect the wishes of the patient and family? Had I been too coercive?

I talked to the staff about the philosophy of hospice or palliative care but it’s not a concept that has been integrated into patient care in this part of Kenya. Kenyans are more familiar with death than we are in America. They often give a history of losing children, spouses, siblings and parents at early ages due to infectious diseases and other causes but are uncomfortable having them die at home. We ran out of time to continue our discussion but it’s a topic that Paul and I will continue in our educational sessions in the coming months with the hope that we’ll come to understand their culture better while opening their minds to other alternatives to end of life care.

The neighborhood school

2008-04-05T11:31:00.000-07:00

We walked up the road Saturday morning and decided to take a look into the schools while the kids were gone. They typically go to school for 3 months on and one month off and should have been off in April but because of the crisis in early 2008 their schedule is a bit behind. As we were looking into the rooms a boy came by and offered to give us a tour. His name was Jeffrey and is 9 years old although he was more mature than most 9 year olds. He told us their school day starts at 8:20 AM and finishes at 4:30 PM. They study math, English, biology, social studies, history, religious studies, Kiswahili and PE. They also take debate once a week. They're forbidden to speak the mother tongue of Luo at school and are punished if they do so. The texts are in English and so thy're trilingual at an early age.

Jeffrey said that the parents pay for their uniform and also pay a school fee to the PTA to help pay for teachers' salaries. Children start school at age 6 and their classroom is in an unfinished mud and wood building with a few old desks and a dirt floor (see photo). The primary classrooms are a bit posher with a blackboard at the front of the room and many desks and bench seats. Each class has about 50+ pupils.

The brightest students are sent on to secondary school which is also on the same campus. Graduates of secondary school have to wait one year before they start University and so some of them teach in the lower grades during that time. Students who don't qualify for University become "fundi's" (spelled phonetically) which means craftsmen or tradesmen, or they work on their family farm.

chameleon

2008-04-04T07:15:00.000-07:00

Last night this little guy was minding his own business when 3 Mzungo's surrounded him with cameras flashing. All he wanted to do was fade into the background. I love his little toes and bug eyes.
The eagle is either Bert or Ernie- one of two African Fish Eagles that live in the trees near our house and entertain us by catching fish, stealing lines of fish in the village and dive bombing other birds. I think he's got a bird in his talons in this picture.

Meet our BFF Joyce

2008-04-04T06:52:00.000-07:00

Joyce is the one person who has made our life here in Kenya so much easier. She works in our cook house from 8 AM to 4:30 PM every M-F just to take care of the ex-pats. She cooks lunch for the 3 of us every day and often bakes bread, cakes or cookies. She cleans the cook house and does our laundry twice a week (by hand, in a big plastic pail out back). Her cooking is pretty versatile and from working at Lalmba for 10 years she’s learned to cook for the American palate. She’s made personal pan pizzas and brownies as well as traditional Luo food like rice, beans and sakumawiki. She is very even tempered and laughs easier like most of the Luo we’ve met. She tells us interesting things about everything from the bugs on the floor to the fruits in the trees. For instance, she showed us the mango tree growing just outside our front door and told us when the fruit is ready to eat. There’s another tree called a “mapear” (spelled phonetically) that has small green fruits that we can eat when they get a little riper. And she’s taught me how to fry fish and saute sakumawiki. I took her picture and told her I was going to introduce her to our family and friends and that made her very happy.

Retail therapy

2008-04-03T07:28:00.000-07:00

We’d been in Matoso for 3 weeks when we realized that we hadn’t spent a shilling since we left Nairobi. That’s not natural! Add to that the fact that our food supplies were depleted and we were sick of rice and beans and you have a great reason to go to town. So, on Saturday Paul and I joined 4 co workers for a trip into the closest “big” city- Migori. We met at 8 AM so we could get our errands done in town and head back before the usual big afternoon rains started. The trip takes an hour, over rutted dirt roads but the scenery was beautiful. The fields are intensely green and people were out planting or grazing their animals and enjoying the sunny day.

The city of Migori isn’t a city in the truest sense of the word. We heard there are 600,000 people in the district but other than basic amenities like gas stations, post office, hospital, and government offices it’s entirely lacking in places to shop (as you can see from the photos). The 2 grocery stores were sparsely stocked with canned goods and only the most basic food items. Tea was available, coffee was not. Canned baked beans could be found but no dry beans. Milk- yes; eggs-no. No to cheese and fresh produce. No to veggies, yes to peanut butter.

Paul and I found very little that was on our shopping list so our colleagues took us to the market area where individuals were selling the limited items that they grow themselves. One seller had only beans, another only tomatoes. Several were selling the sakumawiki that is similar to collard greens and eaten most days by Kenyans. We’ve learned to like it too so we bought 2 bags full, already cut into thin strips and ready for sautéing. We bought 8 green oranges for 40 Ksh (about 70 Ksh/$1) ), one butternut squash for 30 Ksh, large bags of both lentils and red beans for 300 Ksh, a pineapple for 100Ksh etc. We didn’t find anyone with carrots, mushrooms, or zucchini. Must be out of season but after several hours of shopping we had a small selection of fresh produce- enough to get us through at least a week.

The Kenyans who live near Lake Victoria have a limited but healthy diet. They eat a polenta-like corn meal mush with sakumawiki and fish nearly every meal except breakfast. If you remember, that consists of sweet chai and fried bread dough. The diet is supplemented by rice and beans and whatever fruits or vegetables are in season. It’s healthy enough and varied enough that we rarely see malnourished kids. That’s not the case just a dozen km from here at our sister clinic in Ochuna. The patients are mostly from Tanzania and lack the protein that fish provides. The staff there sees children who have kwashiorkor- malnutrition from protein deficiency or marasmus- malnutrition from insufficient calories.

I thought we’d have no trouble finding fresh fruits and veggies in the area but since nothing is shipped in, we can buy only what is in season. In our little town of Matoso we can buy tomatoes, scallions, sakumawiki and bananas. Not much else. The storeroom in our cook house is well stocked with soups, pasta, condiments, canned veggies, boxed milk, juice and Tusker beer. For everything else there’s a big grocery store 6 hours away in Kisumu. Someone usually goes there every 3 months or so. I think I said this before but it’s interesting to live lives that are so intertwined with nature that our diet reflects the season. I know there’s a big movement in the US to eat locally and let me say this- it isn’t as easy as it sounds but if you’re willing to compromise on variety, you’ll never eat another hot house tomato.

Starry, starry night

We’ve had 3 days without rain and the fields around our area are just starting to dry out a bit. On Tuesday night the sky was clear of clouds for the first time since we arrived. There’s very little ambient light so the sky was filled with millions of stars. We stood outside and looked at the heavens, trying to identify the constellations. The night guard joined us and was amazed to see the stars through binoculars for the first time. In the middle of the night I woke up and went outside. There was a string of twinkling lights out on the lake from the fishermen in dhows and millions of stars in an otherwise pitch black sky. It was magical.

There's a troubling new night noise. Since the rains, frogs are appearing everywhere. Tadpoles are in puddles, tiny frogs are clinging to the walls in our house and huge toads are clogging the ditches. At night they all make different sounds but there's one that gives me the willies. It sounds exactly like the violins in "Psycho" at the moment Norman was stabbing Janet Leigh in the shower. You know what I'm talking about? Some breed of frog makes that exact sound and it scares me every time I hear it.

Going Mobile

2008-03-28T08:27:00.001-07:00

After doing health outreach in the Denver metro area for 5 years I was anxious to see how it was done in rural Africa. On Tuesday Paul and I got the chance to ride along with the mobile team to the village of Arombe. The team loaded up one of Lalmba’s Land Cruisers and hitched a trailer on the back filled with bags of maize to drop at a village along the way. Nine of us squeezed into the vehicle and set off. Our first stop was at a “hotel” which is what the Kenyans call a small restaurant. The staff there knew we were coming and had prepared a sweet chai tea and fried bread. The bread was similar to the pizza frite my dad would often make and the tea was milky, hot and delicious.

A half hour later we were again on our way 4 wheeling over dirt back roads and through rain swollen fields. Paul and I got the honor of sitting up front next to our driver and director of education, John ChaCha. The other six were being tossed around in the back but had a great time talking and laughing together. It was like being at a Roseto family gathering with everyone talking at the same time. Add some Kenyan music that sounds akin to Mariachi music and you have a picture of our trek.

As we came through a clearing we saw our outreach site- a long stone building. Inside were 36 adults listening to a Community Health Worker (CHW) talking about infant nutrition. As she fielded questions we set up to do antenatal and well child exams. One corner was cordoned off with a huge tarp for antenatal exams. I joined the clinician, Moline and a health educator, Mazeline behind the drape. First, Moline asked questions about the woman’s past and current pregnancies then had the patient crawl up on a wooden table for her exam. There we checked her BP, listened for fetal heart sounds and measured the approximate size of her womb. The women were often accompanied by the local TBA (traditional birth attendant) who would be with them for their home birth. She was a warm, middle aged woman who had a caring and wise presence about her. I thought how much comfort she must bring to the laboring women.

While we were seeing the pregnant women, Paul was helping some of the team see the babies and toddlers. They threw a rope over a beam to hang an old fashioned grocery type scale with a sling. Each babe was carefully weighed and then given the needed immunizations (IZ). The Kenyan IZ schedule is greatly abbreviated compared to ours in the US. They receive 3 doses of oral polio, and of a pentavaccine (DPT, Hep B, HiB) and one dose of BCG to prevent TB during the first 2 years of life. The staff also give out infant Tylenol and vitamins, laundry soap and prenatal vitamins.

The mobile team was assisted by 2 elderly gentlemen who told me they started the first mobile site some 20 years ago. They asked if we knew Bob and Gruffie who were instrumental in starting the clinic some 23 years ago and are still fondly remembered by many, many people in the area. We were happy to report that we did know them and would pass along their greetings. They then asked us to take their picture and to have it printed for them, if you please. I was happy to oblige although I’m not sure how I’ll get the prints. I may have to have them sent from the US. At any rate, it was a fun, interesting and highly successful outreach.

The rainy season hit full force this week. It started raining last night and continued through the better part of today. It seemed like a monsoon type rain, or maybe hurricane level without the winds. Anyway, a BUNCH of rain fell in a short amount of time. It flooded the upper compound where some of the clinicians have homes causing water to flow into their living and cooking areas. We also learned that patient attendance is inversely proportional to the amount of rain we receive. This morning the rain was so fierce that all our patients stayed home. Paul, Jeevan and I stayed in our cookhouse and had a brain storming session while our cook Joyce baked spice cake. It felt a bit like being at summer camp.

Without the sun shining, within a day we’re without electricity. My electric toothbrush is dead (a foolish thing to bring to Africa but my dentist would be proud), our computer is running on battery but the screen is getting dimmer and dimmer, and we don’t have cell phone service so no internet connection. The guy who makes the $100 computers that can be powered up by winding a handle knew what he was doing.

Earlier in the week we went walking and met a young woman heading to the lake with a tub full of dishes on her head. She spoke English very well and told us her name was Judy and she was 12 years old (she looked 18). She asked our age and when we told her she exclaimed “It is a lie!” We assured her it wasn’t. She again expressed disbelief. (Was she being kind or were we the oldest people she ever met?) I asked about her mother’s age and she told me she was 30 but already dead. She had been killed by “some people”. We told her how sorry we were and Judy told us she has 4 siblings and she is the oldest. Her youngest sib is just 5 years old. Her father is…drum roll…80 years old ! Judy is most likely the care giver of her family. She said she was in 8^th grade so this may be her last year of school unless the impossible happens and she finds a way to go to secondary school.

As we were parting she asked us for something. Did she say pants? Pence? Pans? Finally she rephrased it. Could we give her some “writing implements”? Oh, pens! We were asked by Lalmba not to start buying for people or we would be inundated with requests. But I think that just this once we’ll make an exception and buy this special girl a few “writing implements”.

Easter Weekend

2008-03-23T00:53:00.000-07:00

It’s been a quiet week here on Lake Victoria. There haven’t been any more cases of cholera in the clinic but plenty of other interesting things. Malaria is still the #1 reason for seeking care and nearly everyone is tested for it. Prenatal protocols call for treating for malaria twice during pregnancy which can be tough to accomplish since women don’t seek care until late in second or third trimester.

A ten year old boy came in this week and had been bitten by a dog about 6 weeks ago. His family took him to a traditional healer but he developed rabies. By the time he was seen in our clinic there was nothing to be done. He died almost upon arrival.

Many dogs and cats have rabies here and post exposure immune globulin should be given right away and followed up with 4 more doses. The rabies vaccines and immune globulin are very expensive both in the States and here in Kenya. Our vaccine cost Kaiser $150 each and we received 3 doses. Here the immune globulin costs the clinic about 1300 Ksh per dose and costs the patient 1000 Ksh which is cost prohibitive for our patients.

**Addendum- We've had some questions about the rabies protocol so here's some clarification. The clinic gives the first dose of immune globulin whether or not the patient can pay for it. That gives the family time to come up with money for the remaining doses. If possible, the animal is tied up and watched for signs of rabies for 10 days. If none develop, then you're done- no further treatment is required. If the animal shows signs of rabies, the remaining 4 doses are administered. Unfortunately, there isn't an animal control type agency in the district so no reports are filed. but the staff said they see 1-2 cases per month.

The most unique injury we’ve seen came in on Friday night. The Kenyan staff has a 4 day holiday so we’re alone here with one driver/guard and one nurse who takes call. The guard came to get us late Friday to see a patient with a gunshot wound to the chest. Apparently he’d been shot accidentally by some men who were trying to kill a hippo. Not a history you hear very often in the US. Paul and I worked to get vital signs and do a simple exam, jockeying for position with the 18 family members or friends crowding around the cot. The nurse got an IV started, I dressed the wound and we sent him off to the hospital. I’m not sure if he made it. We may never know.

You may wonder why they were trying to kill the hippo. Hippos spend their days in the water but come ashore at night to feed. They’re voracious eaters and we’ve been told that the farmers hate them because they can eat their entire crop as one day’s meal. So, sad as it is, they’re often shot when spotted on land.

Saturday morning we set out for a long walk in the countryside. Just 50 feet from our front gate was a toddler with the big belly full of worms (see photo). We’ll try to get him in to be treated when the clinic reopens on Tuesday. We saw several other children on our walk with the same problem. It’s so common that the clinic protocol is to treat children every 6 months, even if they’re not symptomatic. All pregnant women are also treated once during pregnancy, regardless of whether they have symptoms.

The majority of the people in Kenya are either Seventh Day Adventist or Catholic. Saturday is the Sabbath for SDA and we passed lots of people walking to church in their finest clothes. Women wear beautiful dresses or skirts and men wear dress shirts and suit coats. It was very hot this morning but the men pedaling their bikes dressed in suit jackets didn’t seem to mind. We’re the only ones who suffer in the heat.

It’s the start of rainy season and every day starts out overcast. By 10 AM it’s sunny and hot. In the afternoon a breeze kicks up off the lake and after sundown it starts to rain. There’s so much rain at night that it literally keeps us from sleeping. The heavy rains have been leaking through our house’s tin roof and soaking the bottom of the bed. I have been waking up with damp and cold feet. The maintenance guys plan to fix it but in the meantime Paul readjusted the mosquito netting and moved the bed about 2 feet. That kept us dry last night.

The rains have an effect on the clinic too. People didn’t come in for a few days because they were planting their fields after the first rain so we were slow the latter part of the week. It’s interesting to have our lives so intertwined with nature. We wake up at dawn, eat what’s available at the market and have a busy or slow work day depending on factors in nature etc.

AND NOW A WORD ABOUT CRITTERS

There are 2 eucalyptus trees outside our house that are home to dozens of hanging nests. They’re made by the male weaver birds who hang upside down to make the “L” shaped nests. If the female bird finds the nest is not up to her standards she loosens the ties and sends it falling to the ground. Every week we find several of these rejected nests on the ground.

There are also 2 Lake Eagles who live in our area. They make a racket squawking in the morning but also keep us entertained by coming to eat the fish they catch in a tree near the cook house.

Every night we crawl under our mosquito netting to read by flashlight or headlamp. Tiny gnats are able to squeeze through the netting and fly around our lights and heads until we finally give up and go to sleep. We sweep up a dust pan full of the same tiny gnats from our floor every day and wipe them off our table before every meal. They’re a nuisance but otherwise not of consequence.

Since the rains started we hear a loud chorus of frogs at night along with the usual insect sounds. While walking yesterday we came across a giant millipede similar to the one Sophie, Chloe, Isa and Phil pooled their allowance to buy a couple years ago. The kids here find lots of things to do outside. One boy was sailing a homemade boat on a big puddle. He made it out of a discarded flipflop, a bit of plastic and some wood scraps and it worked really well. I'll try to post a photo of him.

We also spotted out first Monitor Lizard but barely managed to get one picture before he saw me and took off running. Boy can they run!

Our first day in clinic

2008-03-18T05:58:00.000-07:00

The staff starts every work day by gathering in a circle outside the clinic. As each person arrives they go around the circle to shake hands and wish every person a good morning. We do the same. Then someone leads us in a song. One day it’s a traditional Luo song and the next day, it’s in English. Someone then leads us in prayer, then any announcements are made before we head in our separate directions. It's a wonderful way to start the day.

The clinic received 4 people with cholera over the weekend so there’s an emergency meeting where the chief nurse gives an overview of the infection. This is followed by a discussion of how best to manage a potential epidemic, how staff will be taken care of if they get sick and where to isolate the patients. After the meeting a cholera “ward” is set up in the education building. They have 5 cholera beds so any overflow patients will be placed on the floor or in the courtyard. 1992 was the last big epidemic and Hugh said they had patients lying in the yard with IV’s hanging from the trees. We all hope it won’t come to that.

I spent the rest of the day shadowing one of the nursing clinicians. She was seeing prenatal patients who typically were already in the late second or third trimester with no prenatal care. They all planned to deliver at home with a TBA- traditional birth attendant. TBA’s were embraced and supported for years by the government but for some reason, Kenya has decided to do away with them. They want everyone to deliver in hospital. Since this is impossible for a hundred different reasons, the woman all plan to do what they’ve done for generations and deliver at home.
One woman was 32 years old and 29 weeks into her 9th pregnancy. She had 5 living children. She is expecting twins and hopes to have a C-section so she can also have her tubes tied. As the nurse said “the problem with African women is that they aren’t empowered”. Women can only practice family planning surreptitiously so a tubal ligation would be perfect. If that doesn’t work she’ll opt for Depo-Provera.
As we were ending our morning a woman came into the clinic screaming for help. She was carrying a hefty and healthy looking toddler. He was lethargic and having trouble breathing. She said they took him to a neighborhood “pharmacy” (could be operated out of someone’s home) and got him a shot for malaria but his condition worsened. Within minutes of his arrival he was seizing and respirations became shallow. The nurse started an IV and gave him medication to stop the seizure while I tried to keep his airway open by “suctioning” him with a bulb syringe. There’s no emergency equipment available. In fact, we didn’t even have a stethoscope or thermometer close at hand. He may have cerebral malaria and was transferred to a hospital 1 hour away. That hospital doesn’t have any emergency capabilities and I was told not to start CPR on anyone because there’s no where to send them for advanced care.

In the afternoon we again see all the morning patients to review their lab work. They were all checked for HIV and one test came back positive. The patient was 26 and in her 6th pregnancy with 5 living children. I watched the patient’s face as the nurse explained the results to her in Luo but I couldn’t tell the moment that she was told the news. She accepted the news in a matter of fact way- I was told she didn’t expect it was at the same time, wasn’t surprised by it. No one really knows how many adults in this area are infected but it may be as high as 40%. She was started on medication to prevent transmission of HIV to her baby and will try to get her husband in for testing.

How to draw a crowd

2008-03-18T05:55:00.000-07:00

Sunday- We took a long walk on a path that follows the lake and then cuts inland past a number of family compounds. The area sits at 4200 ft. and the surrounding countryside is covered in rolling hills and small family run farms. Kids, chickens, goats and cows all run free. Some girls were gathering sticks and stopped to stare at us and shyly ask for a photo. When I showed it to them they broke into a fit of giggles which brought kids out of the woodwork. Pretty soon we had a posse of a couple dozen kids, all wanting to hold or shake our hands and have their picture taken making a silly pose. Then the young moms came out with their babies wanting their photos taken. When we tried to leave all the kids followed us so I started to sing (in my terrible voice) and found they could mimic me perfectly. It was actually a lot of fun but here’s the lesson of the day- don’t carry a camera unless you want to draw a crowd.

A compound is land that was traditionally farmed by one family. The families are essentially squatters as they don’t buy the land but it becomes theirs by virtue of their occupation of it. As sons are born and then marry, the land is subdivided to accommodate each family. The girls can’t own land and when they marry become the property of their husband’s family. If he should die she is inherited by his brother. A man can have several wives and this is one reason why HIV has spread so efficiently in this part of Kenya.

Saturday in Matoso

2008-03-15T06:18:00.001-07:00

We woke up this morning to hear that the clinic received two cases of cholera overnight. It's the first cholera in this district in a couple years and fortunately the patients are doing very well. They received oral rehydration fluids and kept overnight but are ready to go home this morning.

We're having some meetings with Hugh, Marty (Lalmba founders) and Jeevan ( the American MD) to learn more about the operation and our role here. We're in the cook house and chickens keep trying to sneak in to peck at crumbs on the floor. It's beautifully warm and breezy-we got a little rain last night which sounded so loud on our tin roof.

I'll try to upload a few more pictures. One of our house, a few of the kids- the orphans will be in the red uniforms and the other kids are from our village of Matoso.

Arrival in Kenya

2008-03-13T23:32:00.000-07:00

March 12, 2008

We arrived safely in Matoso on Wednesday night after 3 long days of travel. We stayed in Nairobi overnight on Tuesday then flew on to Kisumu, Kenya where we were met by the American volunteer doctor Jeevan and the Lalmba Program Director Marico. They never drive the 6 hours into Kisumu without having a long list of errands to run. So, first we stopped to pick up truck parts and a new blood pressure cuff. While standing outside the store we saw our first Masai warriors, walking down the side of the road and wearing the characteristic red robes. I was so stunned to see them in the city that I failed to even take a picture.

Next we stopped at the Natamatt, a large grocery store to buy provisions. They told us to pick out what we thought we’d need but there were so many unusual and unknown products and we were so tired that we came home with things like chocolate and oranges. They told us not to worry as there’s a lot of provisions in the cook house at the compound that we can supplement with local produce.
The drive from Kisumu to Matoso takes 5-6 hours on a 2 lane and often rough road. The most interesting thing to me was the number of people traveling on foot and by bike along the side of the road. Kids in school uniforms, men pulling huge wooden carts full of sugar cane, women with tall baskets or pots on their heads. We passed vans and buses so full of people that men were hanging from the side of the vehicle. We saw small farms with the round mud huts with thatch roofs called tukuls as well as the more “modern” stone or cinder block houses with tin roofs. And every time we passed children they would yell “Mzunga”!! -which means white person- with the same excitement that we would have if we spied a zebra. We were the only Mzunga we saw once we left Kisumu. We were told that we'll meet people here who have never seen a white person before. The sight of us so scared a toddler yesterday that he howled in fear until we left the area.

We’ve been warmly welcomed at the Matoso compound and made to feel comfortable. The big surprise is that they installed a bathroom in our house before we arrived so we don’t need to use the communal bathroom. Nothing could make me happier. We have a veranda were we can sit and look out at Lake Victoria. At night we fall asleep to the sound of waves and wake up before dawn to the sound of birds and insects. It’s so loud that it’s impossible to fall back asleep, although Jeevan told us he’s learned to sleep right through it so maybe we will too.

This morning we heard a deep grunting and walked down to the lake to see our first hippo. There are mongoose, monitor lizards that grow to 5 feet and lots of beautiful birds. The weather is surprisingly comfortable with warm days and cool nights. There's nearly always a breeze off the lake too. We're told that soon the rains will come but for now it's dry and pleasant. At night we sleep with our windows open and a big net over our bed to keep the critters out. It gets chilly enough in the early morning that we need to pull a blanket over our shoulders. Not what we expected from equatorial Africa.

How it all started...

2008-03-02T10:40:00.000-08:00

March 7, 2008

We're just days away from our departure for Kenya where we'll be working for a year in a rural medical clinic. Paul and I have talked about working in Africa for years but it suddenly was clear that there would never be a better time for us to go then now. Almost as soon as we made that decision we began to question our timing. Kenya held an election on December 27, 2007 that was widely reported to have been flawed. The opponent, Raila Odinga had a large early lead but as the results rolled in, President Kibaki declared himself the winner and held a hasty inauguration for himself.

This was followed by weeks of rioting and killings along tribal lines. At the date of this entry, more than 1000 people are reported to have been killed. On the very day in February that we booked our flights, the Peace Corps made the decision to pull out the remainder of their volunteers in Kenya. Our families shared our concerns even as they continued to offer their unwavering support.

But the arrival of Kofi Annan brought an air of hope and after a month of contenious negotiations, an agreement was announced. Kibaki and Odinga signed a pact agreeing to work together to form a coaltion government. Kibaki will continue in the role of president while Odinga will take on the role of Prime Minister.

So, the trip is on. We'll leave for Nairobi via Amsterdam on March 10th and arrive in Matoso on the afternoon of the 13th. It will be the beginning of the rainy season but the temperatures are said not to vary much throughout the year.

We'll be working at Lalmba's Matoso Clinic which is located on Lake Victoria about 9 km north of the Tanzania border. (To find out more about Lalmba, go to their website: http://www.lalmba.org/)

We hope to be able to keep in touch by the internet and this blog. So stay tuned.