Umeshindaje leo? Translates, I believe, to "How have you won your day today?" The reply to this question, just as it is the response to that of "How are you feeling today?" put to a clearly badly-feeling Kenyan patient... is "Nzuri" or good.
This past week, my final week was the first in the Internal Medicine rotation for a new group of students, still very early into their first clinical year. I found myself excited for the opportunity, the hope, the off-chance of playing a role in laying down the fundamentals... Med Student 101. To say just a few words, set a few examples on those first days on the wards before other examples are available.
At the end of the week, mixed results. I really enjoyed the time spent with this group of students, nonetheless. Ah, the SOAP note. Perhaps an American convention... but a really useful one. (For those of us unfamiliar to wards medicine, SOAP is a format for writing notes in a patient's medical chart... One that should help in thinking (hopefully in a critical and organized way), but thinking at all is the key). Anne apparently had a much higher success rate in getting SOAP notes from her students than I did, but I did have one or two successes.
Our friend Barb, a resident from Utah, pulled off an elaborate contest amongst her medical students on her final day. It involved scoring for content and presentation and required a level of organization of rounds that I can still not fathom. My successes were more modest.
A fourth year student named Lawrence presented a 40-year-old woman, status post two failed courses of treatment of pulmonary TB with a recent tissue diagnosis of an intrathoracic chest wall sarcoma. Bizarro... But we had a really nice discussion of the issues at hand. He was given all of 30 seconds to present before the team summed things up for him and moved on. A sixth year student named Cynthia was given even less time to describe her plan for a uncontrolled diabetic with a foot wound. Ambrose, another fourth year, however, did get credit for diagnosing and fixing a patient's kidney failure... and was all over the patient's medication regimen, thanks to our work together.
Prerounding, which is the fine art of the medical student evaluating a patient on his or her own each morning day after day, is a new and fragile experiment in one corner of the wards, started last month by an Attending physician named Deb Litzelman from IU. It has met with resistance in some ways from the students. It has, so far, bent but not broken. I doubt that this short week will make the difference in whether the "pilot" project lives or dies. I do think that Ambrose now knows the joy of a creatinine, once deranged, again within normal limits.
More recently, Anne, Philip & I orchestrated a feast at the IU House last night. Kenyan students who will shortly be traveling to IU, Brown & Utah joined a few American students & residents for dinner... and did every bit of the work in preparing a huge traditional Kenyan meal. For the price of (delicious) sushi in our beloved Cranston, RI, we fed 25 hungry people. Philip was responsible for talking down the women in the market from the "wazungu" price... to something slightly more reasonable. At one point, we agreed that he would be more likely to get a decent price on peas if we weren't nearby. We separated. The peas were still expensive. Either the demand for peas is way up, or word travels fast when wazungu are in the market. Pictures to come shortly...
Joe
Tuesday, March 17, 2009
Thursday, March 12, 2009
The most comprehensive fight against the AIDS pandemic in Sub-Saharan Africa
We spent the first part of this week in the westernmost part of Kenya, working with one physician (Dr. Dennis featured below) and several clinical officers.
We've spoken to the magnitude of the AIDS pandemic, and to the impressiveness of the AMPATH response, and I think the patient stories we heard on this trip really exemplified both. [Below is one of the clinics, two shipping containers side by side with a thatched roof - the quickest, easiest, and cheapest model found so far]
AMPATH is the academic model providing access to healthcare, and was started by a group including Dr. Joe Mamlin (who I also learned is responsible for the Wishard community health centers in Indianapolis) in 1990. Dr. Mamlin describes the first clinic sort of operating out of one room when AIDS was still relatively unheard of. Now AMPATH (recently a part of USAID) has blossomed to a network of 19 clinics in Western Kenya, providing free anti-retrovirals (ARVs, a common regimen below), prophylaxis against opportunistic infection, food, counseling, and medical care to upwards of 80,000 patients.
AMPATH also has several programs in place to help patients establish food security, financial progress, and occupational skills. There is also a network of homes for orphans and vulnerable children. All of this to say that even with this longstanding infrastructure in place, HIV is still rampant, the stigma of being positive remains devastating, and people with families (big families!) are dying every day.
Many of the women we saw on Tuesday were widowed, their husband never being tested or seeking treatment for AIDS. AMPATH clients are overwhelmingly female, and I asked the clinical officer (non-physician, three year diploma, can see patients and prescribe drugs) why this was. He explained that many men in Kenya see illness as a threat to manhood and suffering admirable, and so eventually die at home, never being diagnosed with AIDS, and therefore never disclosing this diagnosis with their sexual partners. (VCT stands for voluntary counseling and testing)
I met one woman, who tested positive pre-natally. Within a year, her husband had died, and she gave birth to her sixth child. Luckily, she was placed on ARVs, and did not transmit the virus to her newest born, the other five children have yet to be tested. We examined the baby, and then addressed the more complicated issue of depression. What will this woman do with no income, six children, and fragile health? All day women with the same story came through the clinic. (This is a scene right outside the clinic in Busia)
Another common theme was the use of protection. All the women, widowed or not, were advised to use protection if their partners' status was unknown. Often they would be shy when addressing the topic, but would eventually admit that their husband wouldn't or "couldn't" use a condom. One woman explained to us that since she had been found HIV positive, her husband married again, and is no longer having intercourse with her. Neither the husband, nor the second wife have been tested.
On the trip, I was reminded of just how rural Kenya really is. Over 90% of Kenyans live in rural areas (below a scene outside the Busia clinic), and that means without water, electricity, or much access to education and healthcare. We had a patient in the hospital today, and the history of present illness was something like this: while the mother was milking a cow, her toddler fell into a well, and drowned for around 10 minutes before he was found. This particular child was doing really well this morning, all things considering.
All of this to say, I find the complexities of the AIDS pandemic overwhelming. AMPATH is pouring millions of dollars worth of resources and brain power into slowing the spread of the disease. I asked Dr. Mamlin if anyone else in sub-Saharan Africa was doing anything like AMPATH, and he responded that there was maybe a program in Gambia, but not really. I can't imagine the devastation in a place without such aggressive testing and treatment. (Between the clinic and the food storage facility)
Further, there are other preventable illnesses killing plenty of Kenyans daily, diarrhea, malnutrition (we consulted the nutritionist on over half of my pediatric patients because they were severely underweight), rheumatic heart disease, and the list goes on. Despite the daunting statistics, I find encouragement in the future of Kenyan medicine. So many of the students I have worked with are really, really good, and their country needs them. I look forward to their eventual takeover of AMPATH or organizations like it. For now, I'll finish philosophizing and say goodnight (one of my favorite, or at least most comfortable phrases in Kiswahili), Lala Salama.
Wednesday, March 11, 2009
Western Province
We returned this evening from two days spent in the westernmost parts of Kenya near the Ugandan border and the shores of Lake Victoria. HIV prevalence near the lake is much higher than in most other areas in Kenya, and AMPATH's focus in the area reflects this fact. After Tuesday morning clinic (more to come from Anne, I hope), Dennis recommended a quick diversion to lay eyes on the lake.He shared his insights into the relationship between the lake & the spread of HIV. Two stand out. Fishermen work hard, staying out several days at a time, and get paid relatively well, especially for an area as diffusely poverty-stricken as any one of many lakeside villages. Young men with money & little else to do often choose to involve themselves in alcohol and sex... hence HIV spreads. And two, the fishermen fish, leaving the wholesaling of their catch to middle men just yards away, at least in Port Victoria. It is no doubt a competitive market (see a sample of Nile Perch on the bidding table below). In cases where the middle men are women, it was suggested that sex may become piece of the transaction. Dire straits to be sure.
Interesting or not, for me these anecdotes highlight the complexity of this pandemic. Antiretroviral medications do a really good job of treating a virus. Poverty & stigma are different and far more daunting beasts to confront. AMPATH, nonetheless, is making remarkable headway.
Tulikula samaki kwa ugali halafu tulishiba,Joe
Sunday, March 8, 2009
Mtoto alihifadhi chupa yangu ya maji baridi
Another weekend spent taking in the sights and sounds of Eldoret is winding down. A slow Saturday followed a night of dancing. Philip & I completed several more interviews and are drawing ever closer to the end of our schedule of interviews. (I neglected further updates since my earlier concerns about approval for our study. To fast-forward, though it didn't feel like it at the time, we have been making progress and do expect to complete Part One of the study in time to make our flight out of Nairobi. Further details to be found in written and hopefully published form... likely many, many months from now)
From there, I joined Anne in the dorm room of her friend, Lillian, whom she was taking up on an offer to teach ugali-making. Ugali is a staple of the Kenyan diet for several reasons, I'm sure, the most important being that Kenyans seem to really love it. We delved into Lillian's own ugali-making education, ugali preferences and pointers... and finally enjoyed a really good dinner. Dan, forgive me for having forgotten the name of the Tongan version of ugali, and please comment and answer me that question.
Sunday morning, we got up for the 10:00 mass at the Cathedral (pictured below with Margaret, who works at IU house, and two of her children) in Eldoret.
We were in a packed church, alive with music and praise. The whole of the service was in Kiswahili, and fast, so we were unable to understand much of what transpired. Luckily, mass format doesn't change much, so I was able to gather, then pass on to Joe, what people were likely singing and saying. The choir, on their third consecutive mass, was wonderful (listen to a few songs below). From what we could tell, there was an emphasis on addressing the food shortage in Kenya, so grocery/market bags were placed up at the altar during the offering, and there was a special collection for the food bank. I think that one of my favorite things about being Catholic is that we are everywhere, and often doing good work.
In the afternoon, we left town for a hike with Philip & Robina at Mlango Falls.
Always the gentleman... That's Philip helping Robina while carrying Anne's bag and the blanket that I insisted on bringing.
We followed a well-worn path downward following the course of the waterfall. The path quickly ended, and the four of us scrambled over a few more large boulders and had a seat. Nothing overly strenuous, Anne managing quite ably in the flip-flops I might have warned her against wearing. Moments later, literally from above where we were sitting, a young boy emerged, smiling widely in a what appeared to be a combination of the joy of climbing on rocks and the pride of being admired for doing so with such ease. To look at these kids, it is immediately clear that they spend serious time climbing around in this waterfall. The skin on their knees and shins is thick & scaly from hours of rubbing against and sliding over rock. They moved as comfortably on narrow ledges and wet, smooth rock as I once did on the flat, green grass in my backyard in Carmel, IN.
The crevice he first climbed down looked like something that I could manage. Only after barely managing it did it dawn on me that his ability to climb to or from a particular perch did not correlate well with my safety there.
There was no place amongst this massive assembly of boulders in the waterfall that the most daring of the group (on the left above) couldn't get to with ease. With only minimal exaggeration, he walked up a 30-foot vertical rock face with nothing but bare feet. Eat your heart out, Climb Time. The little baby down-climb you see me in below was legitimately frightening. He can be seen smiling down from above.
As we were climbing up out of the rocks, I dropped a waterbottle into the water. Lightning fast, he's out of sight... until a tiny hand snatches the bottle just as before going over and out of sight with the current. He and his friends were rewarded with all the snacks we had with us.
Last but not least, in an effort to keep some focus on our main purpose, though one of many, in traveling to Eldoret, a picture of Anne hard at work "clerking" a pediatric patient.
Tomorrow, we head west to the towns of Kisumu, Busia & Port Victoria for the early part of the week. We will be shadowing a Kenyan physician and soon-to-be Brown intern named Dennis. Hopefully, we will be able to repay his hospitality when he leaves his home & family to move to Providence and internship in June. Chas, sadly, Port Victoria will be the closest we get to Mfangano Island for now.
Excited to get home to see the Hoosiers in the post-season,
Joe & Anne
From there, I joined Anne in the dorm room of her friend, Lillian, whom she was taking up on an offer to teach ugali-making. Ugali is a staple of the Kenyan diet for several reasons, I'm sure, the most important being that Kenyans seem to really love it. We delved into Lillian's own ugali-making education, ugali preferences and pointers... and finally enjoyed a really good dinner. Dan, forgive me for having forgotten the name of the Tongan version of ugali, and please comment and answer me that question.
Sunday morning, we got up for the 10:00 mass at the Cathedral (pictured below with Margaret, who works at IU house, and two of her children) in Eldoret.
We were in a packed church, alive with music and praise. The whole of the service was in Kiswahili, and fast, so we were unable to understand much of what transpired. Luckily, mass format doesn't change much, so I was able to gather, then pass on to Joe, what people were likely singing and saying. The choir, on their third consecutive mass, was wonderful (listen to a few songs below). From what we could tell, there was an emphasis on addressing the food shortage in Kenya, so grocery/market bags were placed up at the altar during the offering, and there was a special collection for the food bank. I think that one of my favorite things about being Catholic is that we are everywhere, and often doing good work.
In the afternoon, we left town for a hike with Philip & Robina at Mlango Falls.
Always the gentleman... That's Philip helping Robina while carrying Anne's bag and the blanket that I insisted on bringing.
We followed a well-worn path downward following the course of the waterfall. The path quickly ended, and the four of us scrambled over a few more large boulders and had a seat. Nothing overly strenuous, Anne managing quite ably in the flip-flops I might have warned her against wearing. Moments later, literally from above where we were sitting, a young boy emerged, smiling widely in a what appeared to be a combination of the joy of climbing on rocks and the pride of being admired for doing so with such ease. To look at these kids, it is immediately clear that they spend serious time climbing around in this waterfall. The skin on their knees and shins is thick & scaly from hours of rubbing against and sliding over rock. They moved as comfortably on narrow ledges and wet, smooth rock as I once did on the flat, green grass in my backyard in Carmel, IN.
The crevice he first climbed down looked like something that I could manage. Only after barely managing it did it dawn on me that his ability to climb to or from a particular perch did not correlate well with my safety there.
There was no place amongst this massive assembly of boulders in the waterfall that the most daring of the group (on the left above) couldn't get to with ease. With only minimal exaggeration, he walked up a 30-foot vertical rock face with nothing but bare feet. Eat your heart out, Climb Time. The little baby down-climb you see me in below was legitimately frightening. He can be seen smiling down from above.
As we were climbing up out of the rocks, I dropped a waterbottle into the water. Lightning fast, he's out of sight... until a tiny hand snatches the bottle just as before going over and out of sight with the current. He and his friends were rewarded with all the snacks we had with us.
Last but not least, in an effort to keep some focus on our main purpose, though one of many, in traveling to Eldoret, a picture of Anne hard at work "clerking" a pediatric patient.
Tomorrow, we head west to the towns of Kisumu, Busia & Port Victoria for the early part of the week. We will be shadowing a Kenyan physician and soon-to-be Brown intern named Dennis. Hopefully, we will be able to repay his hospitality when he leaves his home & family to move to Providence and internship in June. Chas, sadly, Port Victoria will be the closest we get to Mfangano Island for now.
Excited to get home to see the Hoosiers in the post-season,
Joe & Anne
Saturday, March 7, 2009
East African Pop Culture Weekly
A few tracks that are, as far as we can tell, very popular with the young people in Kenya. The first is a song by a Tanzanian singer named Z-Anto. The song is called "Binti Kiziwi", which translates roughly to "Deaf Girl". The music video will explain.
The second tune, called "Nyota Yako", is one that packed the dance floor at a club in town called Places, our late night destination last night. We were told today that Places caters to a "more mature" crowd than the club that is more popular with the medical students. Anne & I were the oldest people in the place. We were quick studies and blended in on the dancefloor in no time at all.
Furahi,
Joe
The second tune, called "Nyota Yako", is one that packed the dance floor at a club in town called Places, our late night destination last night. We were told today that Places caters to a "more mature" crowd than the club that is more popular with the medical students. Anne & I were the oldest people in the place. We were quick studies and blended in on the dancefloor in no time at all.
Furahi,
Joe
Usiku katika Eldoret
Here's a taste of the live music scene in Eldoret at a club called Sesia. Joe and my dance moves fit right in...
Tuesday, March 3, 2009
Mount Elgon
We headed to Mt. Elgon last weekend, a national park on the border of Uganda, and Kenya's second highest peak. Mt. Elgon is home to elephants, buffalo, and other wildlife, although their numbers have been in decline for the past two decades because of illegal poaching. Our trip began serendipitously with this view early on in the drive.
We spent about three hours in the matatu being entertained by the sights and sounds of small town Kenya. The two videos below feature a real-life "looking out the window of a van" view... minus the bone-jarring man-sized potholes.
We arrived at the campsite after dark, and woke up leisurely to an incredible view of Endebess Bluff. Shortly, you will see views from the top of that very bluff... the end to a short but fairly burly uphill climb on Saturday. As evidence, one of our companions vomited on the hike both up & down... likely in large part due to an elevation above 11,000 feet. We set out from Eldoret with our sights set on climbing to the Mt. Elgon's highest point in Kenya, up above 14,000. As it turned out, the guide who assured us he could get us to the summit didn't know what he was doing. His matatu wasn't suited to get us much further than the park gate. To paraphrase Dr. Mamlin, living in Kenya is like being in a boat and bailing all the time... if you stop bailing, be prepared to swim. Swimming, in this particular instance, could not have gone better.
Dr. Mamlin, his wife Sarah Ellen, their Kenyan son, Dino, and his friend Dave were also staying in park cabins, or bandas, right next door. We had learned a few days prior that Sarah Ellen had first encountered Dino, while on a home visit several years ago. She was taken by his family's small house that had been turned into a museum. As a small child, Dino had collected hundreds of specimens of insects, butterflies, birds, fossils, and natural life, perfectly preserved and labeled. This amazing talent provoked the Mamlins to sponsor part of Dino's education, including an undergraduate degree from Indiana University. Dino (pictured below) is now finishing his Ph.D. at Harvard. We were happy to have him around, and he earned his title as the "premier naturalist in all of Kenya." He also wrote the parks service guidebook on Mt. Elgon. That's no exaggeration. He is the author of the official Kenya Wildlife Service's guide to Mt. Elgon, and he was our guide for the day. At one point, he slowed the car to observe a swarm of butterflies. When asked to identify them, he rattled off four different species present in the swarm. Headshaking and admiration followed.
The day began with a drive into the park, stopping for the a little "birding" from time to time.
With Dino, and his friend Dave, who happens to be a professor at Harvard, specialist in orchids, former rugby player and free diver, we explored the caves of Mt. Elgon. Kitum Cave is apparently the fictional origin of the Ebola virus, according to some book called the Hot Zone. We were assured that Ebola has never been documented in Kenya, though it was found in nearby northern Uganda. At no point since our time in Kitum Cave have Anne's or my mucosal surfaces hemorrhaged... which is encouraging.
It also had bats! They were screeching and zooming around, and really creeped me out.
We were able to see remnants of cape buffalo and droppings of elephants, but none in the flesh (which is probably a good thing)!
The second cave featured more bats, and some great photo ops. Here's our friend Barb.
It also had a waterfall that Joe indulged in.
In the afternoon, we were taken to a bamboo forest in the park, with blue monkeys, colobus monkeys, and olive babboons.
We then hiked to a vista from which you could see clear into Uganda.
We're beginning to think that the natural beauty of Kenya is endless.
We ended the day with a waterbuck sighting, actually several waterbuck sightings.
After the sunset, the group, principally Barb, fixed steak, potatoes, and roasted vegetables all over campfire. We talked over South African wine and Tuskers on Kenyan politics, medicine, and our experiences thus far.
We've been back to the wards the past few days, and I am already stumped on my first pediatric case. Anyone know why an afebrile patient on phenobarbital (for an unknown reason) with hepatitis would have a seizure?
Tutaongea badai,
Anne & Joe
We spent about three hours in the matatu being entertained by the sights and sounds of small town Kenya. The two videos below feature a real-life "looking out the window of a van" view... minus the bone-jarring man-sized potholes.
We arrived at the campsite after dark, and woke up leisurely to an incredible view of Endebess Bluff. Shortly, you will see views from the top of that very bluff... the end to a short but fairly burly uphill climb on Saturday. As evidence, one of our companions vomited on the hike both up & down... likely in large part due to an elevation above 11,000 feet. We set out from Eldoret with our sights set on climbing to the Mt. Elgon's highest point in Kenya, up above 14,000. As it turned out, the guide who assured us he could get us to the summit didn't know what he was doing. His matatu wasn't suited to get us much further than the park gate. To paraphrase Dr. Mamlin, living in Kenya is like being in a boat and bailing all the time... if you stop bailing, be prepared to swim. Swimming, in this particular instance, could not have gone better.
Dr. Mamlin, his wife Sarah Ellen, their Kenyan son, Dino, and his friend Dave were also staying in park cabins, or bandas, right next door. We had learned a few days prior that Sarah Ellen had first encountered Dino, while on a home visit several years ago. She was taken by his family's small house that had been turned into a museum. As a small child, Dino had collected hundreds of specimens of insects, butterflies, birds, fossils, and natural life, perfectly preserved and labeled. This amazing talent provoked the Mamlins to sponsor part of Dino's education, including an undergraduate degree from Indiana University. Dino (pictured below) is now finishing his Ph.D. at Harvard. We were happy to have him around, and he earned his title as the "premier naturalist in all of Kenya." He also wrote the parks service guidebook on Mt. Elgon. That's no exaggeration. He is the author of the official Kenya Wildlife Service's guide to Mt. Elgon, and he was our guide for the day. At one point, he slowed the car to observe a swarm of butterflies. When asked to identify them, he rattled off four different species present in the swarm. Headshaking and admiration followed.
The day began with a drive into the park, stopping for the a little "birding" from time to time.
With Dino, and his friend Dave, who happens to be a professor at Harvard, specialist in orchids, former rugby player and free diver, we explored the caves of Mt. Elgon. Kitum Cave is apparently the fictional origin of the Ebola virus, according to some book called the Hot Zone. We were assured that Ebola has never been documented in Kenya, though it was found in nearby northern Uganda. At no point since our time in Kitum Cave have Anne's or my mucosal surfaces hemorrhaged... which is encouraging.
It also had bats! They were screeching and zooming around, and really creeped me out.
We were able to see remnants of cape buffalo and droppings of elephants, but none in the flesh (which is probably a good thing)!
The second cave featured more bats, and some great photo ops. Here's our friend Barb.
It also had a waterfall that Joe indulged in.
In the afternoon, we were taken to a bamboo forest in the park, with blue monkeys, colobus monkeys, and olive babboons.
We then hiked to a vista from which you could see clear into Uganda.
We're beginning to think that the natural beauty of Kenya is endless.
We ended the day with a waterbuck sighting, actually several waterbuck sightings.
After the sunset, the group, principally Barb, fixed steak, potatoes, and roasted vegetables all over campfire. We talked over South African wine and Tuskers on Kenyan politics, medicine, and our experiences thus far.
We've been back to the wards the past few days, and I am already stumped on my first pediatric case. Anyone know why an afebrile patient on phenobarbital (for an unknown reason) with hepatitis would have a seizure?
Tutaongea badai,
Anne & Joe
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