The Ultimate Chapter, The Final Farewell

For those of you loyal readers who have all but given up on the epilogue to this African saga, I have finally gathered my wits about me for a brief moment to at least note down a bit about the experience State-wide. As some of you know, I have begun my fellowship in Hematology/Oncology. It has been a tumultuous beginning, and unfortunately, the night is darkest before the dawn and that dawn will not even begin to peak its head for another 10 months or so. Therefore, this night will be one of the longest that I will have known.

More than just the challenges of initiating myself into a field I know almost nothing about, immersed in a caustic environment, yet again separated from my wife, is the culture shock of the medical system itself. I experienced this contrast before when I began my ER rotation after returning from my sojourn in the Himalayas in early 2007, treating and diagnosing patients w/ nothing but my physical exam skills (pitiful though they may be, but surprisingly better than that of my Kenyan colleagues), some rudimentary diagnostic instruments like my stethoscope and a single otoscope/opthalmoscope for the entire camp, and of course the collective experience of myself and my colleagues. After I returned from that experience, I was immediately thrust into the most defensive field of medicine - the ER - where $1000 work-ups for a simple headache were commonplace, where 95 year old demented folk were admitted to the ICU. At the time, it was more a curiosity than a shock because I had really been only on vacation from the American travesty of a medical system during my time in India.

Now, however this transition back to the US is a bit more awful. Here we are in supposedly the richest country in the world where we routinely condemn people to death because they cannot get their cancer care covered. At the same time, we will spend literally millions of dollars on another person so that we could possibly buy them a few more months of misery. The discrepancies are disgusting and typical of the American medical system where everyone is to do what he can, and just because we can do something it means we must do something, and when somebody protests then the full force of the academic hierarchy comes crashing down upon you to highlight your ignorance and inadequacy as a member of the team. Such is the reality that greets me after the challenges and triumphs of my time in Kenya.

Still, the choice of pursuing this field at this institution was mine. Yet, the current reality does not at all serve to be the last taste of this blog for my beloved readers; it is only to demonstrate the importance of having pursued this escapade across the world in the first place.

The accomplishments in Kenya could not have been realized without the support of so many people. Dr. Dave Leonard was the first one to have identified me as a potential recruit for Lalmba at a party celebrating our successful completion of a crash course in Global Health. He and his wife were lecturers for that course and he served as sort of a reluctant recruiter; reluctant in that he did not know if someone such as I with such a short time of commitment would necessarily be a good fit for the organization. Then Dr. Marc Seidman decided I was worth an interview after talking to me on the phone, and voila it Hugh and Marty also thought me worthy enough to send me over for what they considered such a short time.

However, thanks to Hugh and Marty and their faith and confidence in my abilities and their satisfaction with our progress at the site, they were willing to send me back a second time to ensure a stable transition for the new volunteers. As a consequence of the intervening political crisis, our evacuation from Matoso, and my missing my plane flight back to Kenya, I now have the dubious honor of being the most expensive volunteer in the history of Lalmba.

Of course the success of any project cannot be exalted without the heroes who have blazed the way prior to my arrival and who will continue building on what little foundation that I have added in my short time. In this particular case, the names of Paul and Darcie Meierbachtol will be ones to remember as those who were able to take up the mantle and pursue the smoothest transition one could hope for from one medical director to another.

The expatriates often get much of the congratulations with regards to the work. However, they are simply an instrument for movement. The actual movers are the Kenyans themselves. I try to always emphasize to them and to anyone else who will listen that it is their dedication to the clinic that really keeps it going.

And the well wishes, concern, and encouragement of my family also made this journey possible. Without Dad's ability to facilitate communications during the political crisis and everybody else's good vibes pulling for us to make it out safely, things could have been much hairier. And to go along with that, the hospitality of Tom and Marge Tucker and Holly and Tony in Arusha made our escape that much easier to handle.

And to PJ and Howard, who's compassion and generosity support the fulfillment of such adventures. Their faith in the greater good and the concept of "pay it forward" have been an inspiration to us. I plan to continue to embrace their vision.

Finally, last and arguably the most important person to make all of this possible - the establishment of a streamlined HIV/TB clinic, the initiation of a consistent teaching curriculum, the encouragement to start computer training, in short all accomplishments and even goals to be pursued - is Professor Amy Jeevan, Chair of the Modern Languages Department at the University of Indianapolis and the most wonderful woman in the world. Without her constant encouragement, her willingness to work a whole year in a new job with barely any back-up, her acceptance of my need to go back to Kenya to finish my work despite the political tumult, and her understanding that this was an innate urge of mine to fulfill this dream of international travel, health care, and intrigue, and of course her financial support as my sugar momma, none of the progress during my time there would have been made. Really, she was the the keystone of the whole operation.

It is to all of you that I dedicate this last chapter. And from this vantage point as traveling doctor, I bid thee farewell, as I now fully commit myself to the future of hematology and oncology.

Thanks for everything.

Transition

Reverse culture shock is definitely a documented phenomenon. For some, it is so severe that they are unable to even live in their home country after a relief work experience overseas. In my case, it has always generally been mild. The consumption orientation of societies especially the States, the waste, the chosen ignorance of my home population, they are all hard to stomach after 8 months in Africa. However, after having returned to the States so many times following trips to so many other countries, the gravity of the reverse culture shock even after a trip as long as this past one has definitely been mitigated and much easier to weather. Of course, it is also much easier to glide back into one's culture when you have someone as supportive as Amy and as joyful as the dogs to help you along in the activities of daily life.

Overcoming jet lag turned out to be a quick process. Despite my insistence on youth both emotionally and physically, the effects of transoceanic travel have become harder to simply brush off. Yet, on this return, a visit to a party that forced me to stay awake and the novelty of physically playing video games on the new Nintendo Wii console for hours on end allowed me to transition to this new time zone within 2 days. Consequently, I could not use jet lag to justify my perpetual need to sleep and nap; Amy would have to simply deal with the fact that the normal Jeevan has returned in all of his somnolent splendor.

Initially, the starkest contrast was the infrastructure. The fact that there were paved roads, so many cars traveling at seemingly insane speeds, no chickens, goats, and cows running around in the middle of I-70, a lack of significant potholes threatening to tear off axles, the ubiquitousness of street signs - these were all such a shock to see. Granted, Kisumu is a fairly well developed city but it cannot even compare to the infrastructure of our basic suburbs, especially after it got looted and razed in the aftermath of the elections (the city has recovered significantly from those events, fortunately).

Overall, I got mostly used to the abundance, the drive to consume everything in sight like a bunch of parasites, the speed of life, the necessity of getting so many things done regarding the start of my fellowship. Yet, even as I write this the one thing that I still have trouble fathoming is the amount of day light that we have. In the first few days, I was amazed that we would be in bed by 9 pm or so reading and it would still be light out. Even last night when we were out to dinner with friends, I was judging the time that we should leave the restaurant by the amount of daylight that was outside. When I suggested that it was time to go based on my observation of a deep twilight, all 4 of us were surprised to note that it was 10 pm. Jeez. The regularity of the diurnal cycle in Matoso was so consistent - sunrise at 6:30 am, sunset at 6:30 pm - this enormity of sunlight is not only disconcerting but it also foreshadows the paucity of natural illumination that I will experience in the winter. I'll probably need a light box in St. Louis just to accommodate this reliance on a steady sun cycle that I've developed on the so-called "Dark Continent." I definitely won't be calling it dark when winter comes around this year.

I am glad that I left some time after my tenure in Kenya to allow for a transition to this life state-side. Realizing now how much preparation both mentally and logistically that needed to be done for my move to St. Louis, I would have liked even another month to spend at home with Amy and the dogs, my nuclear family. Probably, I could have picked up some moonlighting to replenish the savings that were drained to facilitate this contribution of blood, sweat, and tears to this worthy cause. I am so glad to say that Lalmba Kenya and I worked so well to accomplish worthy goals, and that Paul and Darcie are such excellent people with whom to leave a legacy that will be nurtured to even greater heights.

The Voyage Home

I apologize for the delay in this entry. I try not to flatter myself, but I would presume that at least some of you loyal readers would be interested in my transition back to the rat race that characterizes the American lifestyle.

My misgivings about African transport are well justified and the return legs of the trip on the Dark Continent were typical of that third world experience. After bidding all my adieus to the staff and Paul and Darcie on the morning of my departure, Marico, Nancy, and I boarded the Landcruiser to drive to Tanzania. My flight was actually the day after our departure from Matoso, but considering that it was relatively early in the morning, we figured it would be better for me to spend the night in Musoma so that there would be no delay on my part to miss our flight. Before reaching the hotel, we stopped at the airport so that I could verify the departure time. No one spoke any English which is often the case in Tanzania but eventually I did find the flight schedule. It said that departure would be at 10 am.

We went to the hotel where we dropped my stuff off in the hotel room. Then we decided to have a bite to eat before Marico and Nancy headed back to Kenya. None of us had anything to eat that day. We ordered our food, and then lo and behold 2 hours later we actually receive something to eat. And believe me the quality of the food was not worth the wait. It was a similar experience at the Nyanza Club in Kisumu. It seems that if you eat in a "fancy" hotel, service is supposed to be atrocious.

I slept well, woke up, and had my first hot shower that did not come out of a bag. I ate the provided breakfast and met my taxi to take me to the airport. When I got there, nothing was going on. There was no one waiting, no one to take my ticket, no one that had anything to do with getting passengers on a plane for travel. The taxi driver suggested that we go to the Precision Air office that was nearby. And so we did.

When I got there, the person did not speak any English and the taxi driver had to help translate for me in his broken English. It seemed incongruous that a person who has computer skills, who interacts with people who book international flights at least to other destinations in East Africa like Kenya and Uganda where not everybody speaks fluent Kiswahili, where the instructions on the tickets and manifests are all in English had more difficulty communicating with me than the Taxi Driver who does not necessarily need English in his field of work.

Finally, the lady gave me a ticket that had a different time on it. I stopped at the airport again to verify that I had not made a mistake. Indeed, the schedule at the airport and the actual schedule were 3 hours different.

The people at the hotel took pity on me and actually let me nap in my old hotel room despite the fact that they had already made it up. This long part of the story is to highlight the many facets of "TIA" (This is Africa) - incompetence and disorganization juxtaposed with friendliness and kindness. What an interesting place.

At the airport, the people charged me extra for my bags because I exceeded the weight that they normally allow. These rules disregarded the fact that I was an international traveler. I actually did not even have enough money for the charge. So they took everything except for approximately 2 dollars and just re-calculated the weight for the other passengers that were underweight and it all worked out. Jeez.

Once that plane took off, I was able to breathe a sigh of relief. Getting to Dar Es Salaam was going to be the most difficult part and it was. The rest of the trip home went fine. The Dar-Amsterdam flight was so empty that I could stretch out in the row; the Amsterdam to Detroit flight was completely full; the Detroit to Indy flight was full but very short. And then I was able to see Amy for the first time at the baggage claim. The prize at the end of the journey for a weary traveler. However, I think Amy would have preferred a shorter hug so that she could breathe.

The Last Members’ Day

Yesterday was my last get together as a member of our Members’ Day. It was a nice party and it lasted pretty late for our normal soirées. We didn’t get back to the compound until past 10:30 pm.

Typical of African time, all the participants did not get there until about 6 pm even though work ended at 4:30 pm. We sat outside drinking soft drinks and talking. Finally, Paul opened our “meeting” with our Members’ Day song that he composed at our last meeting. We danced and enjoyed ourselves for the rest of the night.

Nancy & Co. prepared a send-off meal for me. It consisted of typical Luo fare – rice, ugali, sakuma, and boiled chicken. At the end of the meal, as the guest of honor, I had the privilege of eating one of the chicken feet. Darcie took a picture of me with it in my mouth. It looks pretty damn funny. It didn’t taste like much. There was hardly any meat on it. It was weird to eat the foot especially with the inner talons still attached. They remove the outer ones.

Then we just danced the rest of the night. The whole of mother nature and father sky was cooperating with the send off. The sky was alight with as many stars as I’ve seen in a very long time here. With the rainy season, the clouds prevent enjoyment of the cosmic splendor. Even a large portion of the milky way was visible. Darcie invited us down to the lake edge where we saw a fireworks display of fireflies. And in the distance we could see the city of lights created by the boats fishing for omeyna (a type of very small, bad tasting fish) with their lanterns. It was definitely a time for reveling.

At the end of the evening, there was much speech making. Everybody had some amount to drink except for me. As some of you know, I dislike beer. Anyway, I had done my fair share of Members’ Day drinking the week before. That is for another story. But with the booze, came the longest and most meandering toasts I’ve ever heard. I think it took an hour just to listen to everybody articulate their fuzzy thoughts. It was fun, albeit prolonged.

That was one party. We have another one in the works for Monday. The beginning of the official goodbye. At “greeting” on Tuesday morning will be the ultimate farewell. Parting is such sweet sorrow.

Rain, Rain Go Away

We are in the middle of the rainy season here. And what a season it is. Every afternoon we get rains that range from a slight drizzle to a torrential down pour. The entire compound is a mess of mud, soggy grass approaching the level of swamps, slippery sidewalks of slime, and bovine urine run-off. It’s a total mess.

The overflow of the rain was getting so bad at the upper compound that some of the clinicians were in danger of floating away. Or at least their furniture was. Their entire rooms were flooded with water. They were standing in water, cooking in water, their kids were sleeping in water, and some of them had to sleep on tables because they couldn’t sleep on the floor. Luckily, Tom Tucker from Agape, took his tractor and dug large drainage ditches on the sides of the road directly above the compound that re-directed the flow of water away from our Lalmba staff.

Often the rain has gotten so bad that it doesn’t even come down, it assaults you in horizontal sheets of water spikes. The water will bathe your feet as you are trying to sleep inside your room within the confines of your mosquito net. It will shower you as you deposit your dishes in the kitchen sink. It will blow windows open knocking condiments off tables and endangering your precious electronics.

And that’s on a good day.

The other day when the rain was coming down so hard that I ate dinner with my headphones on to mitigate the attack on my eardrums, we had an easy time of it. However, one of Jenifer’s trees fell down onto one of her buildings causing some damage. A papaya tree in front of the Tuckers’ house collapsed and took another tree with it. The tree was dead and so they had to cut it away and now the Tuckers’ entrance looks much sadder without the arborial decoration. And while Jackson was about to eat his dinner, the metal roof on his house blew clean off! Here he was about to enjoy a meal and then suddenly the entire inside of his house is exposed to the elements. He had to rush around like a headless chicken to rescue his furniture and such and place it in another one of his buildings. Now, he has a temporary replacement roof that leaks making his original home more protected from the outside but nevertheless uninhabitable until he can get another iron roof.

There is so much water here that the ground is completely saturated. In the middle of the day when it is dry and 85 degrees, water will still be leaking out of the ground on to the sidewalk trying to find its way to Lake Victoria where it will be welcome. Twice before, there was so much water flowing on the walkway towards our houses outside the cookhouse that we named it the Lalmba River.

When we returned from a trip to Kisii for supplies the other day, the drive from Migori took us almost 2 hours because the road was so overwhelmed by all the water. Numerous bridges were covered with water. One section of the road was entirely submerged in almost a couple feet of water just below our running boards. Daniel, in seventeen years working as a driver for Lalmba, had never ever seen that much water over this section of road. He was not concerned about the many semi-washed away bridges but this sight was definitely a new one on him. Sometimes being the first volunteer at so many things is not what it’s cracked up to be; the possibility of being the first one washed away into the depths of Lake Victoria by a flash flood is not my idea of fun. Stupid rain.

My Animal Fiefdom

As many of you know, the animal kingdom has not been the most kind to me during my stay here. Pigeons climb on my roof scratching away so loudly that I cannot sleep. They try to build nests right outside my window cooing and flapping their wings at dawn. The cat that I bagged and removed to a far away village came back to continue to plague us – granted it took it 3 months to find its way back but the bottomline is that it’s back. Chickens come uninvited into our cookhouse and jump onto our sink and fridge when we try to chase them away. Rabid bats find there way into our homes to hang out and give us the willies. All in all our coexistence has not been that of mutual tolerance.

Not wanting to let these silly creatures get the best of me, I asked Jenifer to get me some PVC pipe from Migori so that I could make a blow gun using the technique I learned from my young friend Devon in Arusha. Jenifer obliged me and I embarked on constructing my instrument of fear. While I was in Arusha our targets were plastic bottles and tree trunks. Consequently, there was no harm in using nails as our blow darts. However, even though I want my sleep uninterrupted by annoying cooing and my meals undisturbed my feline yowling, I am not a sadist wanting to maim these bothersome creatures. So, initially I try to use seeds with paper. But that didn’t work. Then I went back to the nail method. They definitely flew very well and would have been very effective in ridding myself of these pests. But like I said, I wanted a nonlethal method. Finally, I decided to tape wads of paper over the nail part. I tested it on a cow and it worked great! He just snorted and went on his way. Now I could deter my opponents with nondeadly force!

Paul saw my initial success and he created a blow gun for himself also. Currently, between the two of us, any creature threatening to impose itself on our serene existence will receive the full force of our Mizungu wrath. I have successfully pelted chickens, cats, goats, cows, and pigeons. And today, Darcie pointed out that the entire periphery of the cookhouse is free of these terrible animalian menaces. Unfortunately, I did not think I would be so effective and had planned on honing my hunting skills. Now we must start to roam the compound looking for our prey. Such is the life of the great, brown hunter.

Darcie will be writing a companion piece and she will even have pictures (but don’t believe every word she says!) ayearinkenya.blogspot.com

Wedding

This event happened a few weeks ago. Nancy had invited me to her youngest sister’s wedding. Nancy and her family were going to take a cockroach at 6 am on the wedding day to get there. Joseph, who was also invited, and I decided against that ridiculously early departure. We figured we would take a transport from Otho and walk there at a more humane time of day.

We got to Otho around 9:30 am. It’s about an hour walk. We were told that the wedding would begin around 11 am. However, TIA. Through some of the conversation that was around us, Joseph concluded that he should make some phone calls. We discovered that Nancy and Evans were still at their home at Sea Lodge! They hadn’t even left for their own sister’s wedding yet.

So, we decided to save our money and wait for them. The waiting took awhile and a Matatu showed up, and so we decided to use that to get to Lwanda where the wedding was being held. We got there around 11:30 or so. Nothing was going on. The stupid wedding did not start until almost 1:30 pm. Joseph and I just sat there for another two hours. Nancy and Evans didn’t arrive until almost 1 pm.

Then the place got packed. It was so crowded that the ventilation became non-existent. People had crammed themselves outside the windows, stifling any chance for air movement.

Nancy’s Dad showed up with his three wives. Then the awful, loud, boring, repetitive Luo music started up. The groomsmen, the bridesmaids, flower girls, and little usher boys, or whatever they are called, all walked in this slow gait to the rhythm of the music. They would only take a step with each measure. In addition to all the waiting prior to this march of the slowpokes, I had to now sit there and endure this soporific procession to repetitive Luo music.

During this ceremony, I was also stuck with holding a baby. The hall became so crowded that the mother decided to sit on the floor. People were squished so close together that she had little room for holding the baby in the middle of this crowd. Earlier, I had taken some pictures of the baby and the aunt, who I initially thought was the mother, for they made a very picturesque couple. It didn’t mean that I wanted to be stuck with the baby worrying the whole time whether it was going to expel some noxious fluid on me from one of its many orifices. Jeez!

As a result of this unsought-after maternal responsibility that was thrust upon me, Joseph borrowed my camera and became the resident photographer – well 1 of 4 or 5. And he had this cool responsibility shooting pictures and I was stuck there with this little kid. Thankfully, it wasn’t crying. Actually, it started but then I was spared having to console it. I quickly gave it up to the mother.

After the seemingly endless procession finally concluded, the pastor embarked on a ministerial tirade that also felt like it would last forever. It definitely went on for over an hour. Probably, the experience would not have felt so interminable had I understood even a single word. The audience laughed occasionally, and so it seemed that there was some fun to be had.

Eventually, my patience was stretched to its maximum. I had breathed nothing but body odor for four hours, listened to this uninspired music that sounds like every other Luo composition, and endured this inability to move because of this 10 pound baby sitting on me, and so I finally sent a text message to Joseph citing that I was hungry (and I was because I hadn’t eaten anything yet that whole day) and asking when would this thing end.

He and Nancy rescued me. We were first in the food line, and in the end we got lucky and hitched a ride back to Matoso with the hired car Nancy and Evans used to get to the wedding in the first place.

And that, boys and girls, was a traditional Luo Christian wedding.

For those of you who will continue to need your Africa fix, Darcie has also created a blog for their trip out here. The address is ayearinkenya.blogspot.com And you can also subscribe by e-mail.

Enjoy!