Into Africa

This blog is a unique treat for you readers. We have a special guest writer who is well known to many of you either in person or by reputation as...My Wife. Enjoy her impressions of her visit to the Dark Continent - duh, duh, duh, duuuuuuh!!!!

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Hello Everyone!

I just thought I would write some of my initial impressions of Africa, while the culture shock is fresh and everything is new and befuddling.

Perhaps the most interesting experience was to see how life changes as you move deeper and deeper into the country and out from the cities. Landing in Nairobi was a normal experience: the airport was big and our luggage was slow in coming. I had met a young Kenyan student studying in Austin, TX, on the plane, and he was kind enough to ensure that I got my luggage without trouble. He even called Jeevan to make sure I had made it to Kisumu alive and well. Once I made my way from the international wing of the Nairobi airport and crossed the street (without being run over by a taxi), I could already see a big change. The local part of the airport is frequented by mostly Kenyans and many fewer mizungu (white folk). There were only two mizungu on my flight to Kisumu, and it got me thinking that this is an experience every white person should have. Being absolutely "other" and foreign (more so for me as a blonde, white dwarf) is an intensely bizarre experience; not a bad one, just bizarre. I definitely can understand what Franz Fanon was feeling when he first went to Paris; it is an experience that is quite perturbing to your self-identity.

When I landed in Kisumu, it was a rather small airport at which the baggage claim consists of a sign "wait here for luggage." You are to huddle together like pigeons and wait until they offload the bags and push them to a cart over to you. Actually, it's the most efficient baggage claim I have ever been through! After retrieving my bag, Jeevan and Chacha, a clinic staff member, drove me back to Matoso. However, because it is a six-hour journey and because it is a 40-minute drive to Migori (the largest town near Matoso), we had to stop and do many errands along the way. I was grumpy and tired, but you do what you have to do, I suppose. My flight had arrived around 8am, but with the errands and such we did not reach Matoso until 6pm.

The road to Matoso is the most interesting thing I have ever been on. There is a stretch outside of Kisumu that I think could give children brain damage if they were to experience the ride too often. For 40 minutes or so (maybe it was only 10, but I swear it was longer), the road was made up of asphalt that had once been a lovely road but that had been ruined in damaging rains. It had broken into plum-sized bits and has remained such. The problem is that there is no avoiding them...that's the road! Other than that crazy stretch, it was paved roads until Migori, which would have been fine if there weren't goats, cows, people, and bicycles to constantly avoid. I am very glad I do not have to navigate in a place like this. Apparently, bikes are considered pedestrians, and pedestrians do not have the right of way. If there is a bike coming and you want to turn, you turn: they had better get out of the way. And, other people's cows and goats are expendable. Chickens more so. And, wild birds and other creatures may be stalked and chased down within inches of their lives - if they're lucky.

One of our errands was to stop in Migori so Chacha could gather the Lalmba mail and I'm not sure what else. In any case, we parked the car (which is a Land Cruiser ambulance, by the way) "downtown", the gathering place and a strip of huts masquerading as businesses. I was almost comatose by this point. Jeevan said I had been so deeply asleep before that when they stopped in Migori, he had had to stop my head from slamming into the dashboard - no shoulder belts here, just lap. I don't know if I believe him, but we stayed in the car. The villagers were very curious and made it a point to ensure that their paths crossed by the car. They would pass by and give a sideways glance, and shortly after, I would hear the word "mizungu". While Jeevan is technically a mizungu as far as being a foreigner, he is Indian, and people in larger metropoli like Migori don't seem to disturbed because there is a somewhat large number of Indians residing in Kenya (yay British colonialism). I, however, attract attention everywhere, even if I am just sitting in a car...my blonde hair is like the beacon of a lighthouse, saying, "mizungu this way, mizungu this way."

We finally arrived in Matoso after our trip to Kenyan Disneyland. That's how I like to think of Migori because in one of the hotels - what they call restaurants - there is a giant coke bottle on the terrace. When I say giant, I mean giant. I'm not sure if it's inflatable of plastic, but it's about 10-12 feet tall and maybe 4-5 feet in diameter. Maybe this was jetlag talking, but I swear it was there. I remember asking Jeevan why it was there, and he said, "why not?" I have to say, it did remind me a bit of that weird film "The Gods Must be Crazy", for those of you who have seen it, you'll know what I'm talking about....Ok, Matoso.

We arrive in Matoso, and I made the long trek to Jeevan's hut. Not that long in retrospect, but after 38 hours of straight travel in three calendar days over many time zones (how does that mess with your head?), I was on my last legs. I was then treated to a nice, short, cold shower. They do have solar-heated shower bags, but they were cold - ok, room temperature - by the time I got to them (no sun). It was a nice shower anyway. Then we ate the spaghetti that Joyce, the Lalmba volunteer's (Jeevan's) cook, made. Not bad considering they have probably never had such food. I don't remember much after that...something, something, something...collapse in bed.

Wake up with splitting head. Have to run to latrine ("choo") 100 yards away. Yay! Walking back...legs feel wobbly. Head hurts. Crawl in bed. Jeevan gives me ibuprofen. Feel yucky, stomach hurts. Jeevan gives me anti-nausea pills. Pray to God to make me sleep. Maybe need something to eat. Jeevan brings cheese. Open cheese. Puke at sight of cheese. Have to run and puke in bushes. Puke. Puke. Puke. Crawl back in bed. Pray to God to make me sleep. Sleep. Jeevan wakes me some time. "Some of the staff has been working for two days for a welcoming party for you. You have to come later. You have to dig deep, I'm sorry." Nod okay. Back to sleep. Jeevan wakes me at 4pm. Feel much better. Yay!

I don't know what was wrong with me, but a day of sleep did me well. When Jeevan woke me up at 4pm, we met Joseph, who works with Jeevan at the HIV/TB part of the clinic (the PSC). Joseph took us to the Sea Lodge, which is the local hotel/gathering place. As we walked through "downtown" Matoso, I drew wide eyes and dropped jaws. The word mizungu was mumbled several times, especially by the children who are not shy, and Jeevan said hello. They nervously responded and kept watching as we walked on. Nancy, who is the counselor at PSC, lives at Sea Lodge had prepared a special meal. I was nervous given my throwing up/bathroom incident earlier; I didn't want to offend anyone by not eating...especially since it was beef stew, which is expensive to make and for special occasions. Luckily, I really seemed fine. I ate my beef stew, my grits, my sukuma (kale or greens of some sort), and rice. It was quite yummy. I had sprite and beer too. Then we danced and had a good time. I used many of the same moves Gavyn has seen many times in the department. They thought it was great that a mizungu would let loose and dance so soon to music they don't know. But we all laughed and danced a little past dark (while we didn't have far to go, Joseph lives around the lake a bit, and it's best to get home before too late). Then, before we left, they wanted us to all sit down. Nancy started by saying that they were so happy that I came even though I was not feeling well and that I was so accepting of an invitation of people I did not know. They were happy that I was there with my smiling face and eating their food. Then she said that Jeevan is not like other mizungus and that he is their friend and that they are so happy to have him and that I must be like him too. That made me feel nice. Then Sammy talked and said similar things. Then, it was Joseph's turn. Joseph and Jeevan have really become friends, doing yoga together after work, etc. Joseph wanted me to know that Jeevan really is his friend and that he is a good person. I could tell that they were very sincere about these things, and I was grateful to be part of the moment. Then Jeevan said his piece, and I said mine. I thanked them for welcoming me so openly and kindly. Then we went home. That is perhaps the most generously I have ever been welcomed by strangers.

Since that was Friday, the clinic was closed over the weekend, but since most of the staff live in town or on the compound, several people stopped by to meet Amy Jeevan (that's how you know you are married.. you add the man's name to your name). Then, when they found out I was a professor, they were thrilled that Jeevan has a "clever" wife, and they said I am Professor Amy Jeevan. My title sounds better than Jeevan's: he's just Dr. Jeevan. Word had obviously spread about Amy Jeevan's presence since by Sunday I had met quite a few people.

On Monday I met the rest of the staff and was welcomed again during the "greeting". The clinic opens at 8:30, but everyone arrives around 8am to greet each other and for the morning prayer. It is a Christian prayer, but sung in the Luo language. It was beautiful, even though I have no idea what was going on. I think the idea of a greeting is lovely and that it will hopefully not be lost with "progress". The community is extremely connected here, and it made me melancholic for something we do not have easily in our fast-paced life in the US. While Dr. Jeevan was working, Professor Amy Jeevan spent the rest of the morning on Monday talking with Joyce about her family and helping her cook as much as she would allow. The clinic closed early on Monday because it was Christmas Eve, and Nancy stopped by to say hello to her "new friend". I had brought pictures for Jeevan, but I showed them to Nancy and Joyce. We had also showed them to Joseph and some others over the weekend. I have never seen people be so honestly interested in photos. It took a long time to look at 20 photos. They wanted to know why I was doing such and such and where we were... then, they would just look and study the photo. It's so nice to see people slow down and really experience things. It's a lesson for me.

The rest of the week we have pretty much alone. Christmas was a holiday, of course, as is today, the 26th. I showed myself to be a good mizungu and cooked Jeevan a nice meal. For breakfast we had pancakes. And, he requested chicken curry, potato curry (or gobiless "aloo gobi" - no cauliflower available), and chapati. I also made a vanilla pie with meringue topping. Not bad for no electricity! I think I worked all the calories off whipping the egg whites by hand. I cooked all day and treated myself to a gin and tonic (they have some booze here for special occasions). I must say, Martha Stewart would be proud of Professor Amy Jeevan. No measuring cups, no electricity, different ingredients...and everything turned out well! It's nice to know that when the apocalypse comes or when the U.S. finally uses up all our non-renewable resources, I can survive. And, as Jeevan said, he will survive as long as I will. One of the guards stopped by as well as the driver, Daniel, who will take us on safari. As he was leaving, he said my food smelled good and congratulated Jeevan on having a wife who can cook. That is the real Kenyan test for a woman: can she cook? I seem to have passed several tests: Nancy said I am beautiful; Joyce said I am clever (i.e. smart); Daniel said I can cook. Dr. Jeevan can keep me. Yay!

The 27th and 28th are also public holidays this year because of the elections on the 27th. Because people often work far away from their home village (as far as Nairobi), they must find transportation back to their village to vote, which is very important to them. It is quiet here this week then. But, Jeevan and I leave on safari on Saturday, and we will be gone for six days. If I don't get eaten by a lion, I'm sure I'll have more to write and photos to post when I return to the U.S.

Now that I have written a novella and most of you have long since given up, I will sign off for now. Hopefully, I will have much more interesting National Geographic-esque things to write next time. Less anthropology/sociology, more wild life discovery.

Hope you all had a Merry Christmas!

Professor Amy Jeevan

Bagged cats, dead flies, and screeching banshees

I finally caught the cat. For those of you who don’t remember, there has been a black and white cat that has been plaguing me ever since my arrival here in Kenya. Initially, it was like a pet of the other volunteer. She would feed it and a second cat that also used to hang around. Unfortunately, that black and white cat was a nuisance, as she would make this high pitched mewling sound regardless of how much you fed her. When the other volunteer had left, I would chase it away by throwing things at it. It would indeed run away but like a battered woman it would come back for more abuse. Then, I thought if I just fed it once in awhile it would shut up and be grateful. That just made things worse. Finally, I decided to eliminate the problem. The first time, we rid ourselves of the cat, one of the guards had taken it to his home. The stupid cat came back to continue bothering me and have things thrown at it.

When I knew I would not be rid of it in any conventional way, I decided to trap it and give it to one of the guards who figured he could use it at his home to trap pests. Animals in rural Kenya are only kept for utilitarian purposes. There is no such thing as a pet around here. Anyway, now I had a plan in terms of how to get rid of the cat. The first time I caught it, we wrapped it in a towel and tied it up. It escaped and came back to the compound. The second time, we stuffed it into a box, taped it shut, tied it closed. And somehow she escaped again. As I had explained to Marc, the overall medical director, I am the cat’s catcher not its keeper. I was able to trap it again using the same techniques, but this time I was the stupid one to let it slip though the door when I had gone back into the cookhouse to stuff it into a sack that I finally procured. Now, the cat was getting quite weary of me. She would still meow that stupid high frequency cry of hers, probably just to annoy me, but she would not enter the cookhouse to be trapped anymore, no matter what type of bait I used – bread, milk, brownies, popcorn – nothing would make her come into the cookhouse of doom. Finally, a few days ago, I tried to feed her some milk in a bowl outside. She wouldn’t run away from me which was an interesting development in itself. And so I was able to give her the milk outside and maintain her attention by continuing to pour milk into the bowl. With my left hand, now covered in an oven mitt, I was able to grab her and throw her into the cookhouse very quickly shutting the door. At the time, I did not think there was any chance of success and so I wasn’t wearing my jacket to as a means of protection for my body. So, I donned my jacket, grabbed a broom, pushed the cat into a position where I could grab her again and stuff her into the sack. It was a win, win, win, situation: I got rid of the cat, the cat found a home where she wasn’t despised, and the guard got a useful animal. The guard’s home is 5 kilometers from here and I hope that is enough distance from here that the cat won’t find her way back. I have emerged VICTORIOUS!!!! I white bagged the black cat!

However, it seems that when one bothersome situation is resolved another one decides to take its place. Among the various Christian entities here, one of them is the Pentecostal Church. And for some reason, they have taken it upon themselves to be one of the most annoying groups on the face of the planet. They insist on blasting their loud, horrendous, screeching voices across the villages with the loudest and poorest quality loudspeakers that they can find. And they always make sure that the people who do the screeching are the worst screechers they can find. Not only do they have the voices of dying donkeys when they sing but those people even attempt to make their voice sound even more broken and disturbing during the song – I guess to make sure that no one can sleep around them. On numerous occasions, they will continue their appalling evangelizing until past 3 am on weekdays! I realize that there are very few sources of steady employment here, but weekdays are weekdays for everybody. It’s as if they are trying to avoid salvation by annoying the gods so much that they will eventually be banished from paradise to a place where their awful rendition of music will be appreciated as a punishment for the rest. They will definitely be welcome in hell as colleagues and collaborators rather than victims.

And if the shrieking Pentecostalists aren’t enough, we have had this unrelenting rain that comes off and on in downpours. Right now, it certainly doesn’t rain but it pours. When it strikes the metal roofs of our dwellings, it feels like your head is inside a snare drum during a drum roll. I have been awaken so many times during these torrents, and I cannot go back to sleep until it eases. For those of you who know my slumbering proclivities, you can imagine how bad this noise really is.

And the rain doesn’t stop its irritation at the noise but it contributes to one of the worst smells of decay that I have ever experienced. The lake flies have decided to come out and die on our doorstep. And in their death, they have decided that the rain and their corpses shall merge to create the most offensive olfactory concoction possible. The horrendous smell is stifling in and of itself, but we have had to endure it for 5 days now. We have had too much rain and too little sun for the rotting bodies to dry out and allow us to breathe fresh air. Maybe, I should have left the cat alone.

The Arrival of Royalty

On the day of Hugh and Marty’s arrival (the founders of Lalmba; they visit Africa twice a year to check on things), I had a surprising encounter in the cook house. As I walked to the refrigerator, I was greeted with the unusual site of a charred table and smoke-blackened wall. Apparently, some how the hose to one of the stoves ignited. When I happened onto this burnt situation, the gas cylinder was still leaking. Interestingly, no one had used that particular stove recently. Furthermore, it’s amazing that nothing more exploded considering the second gas tank was right next to the leaking one and a third tank connected to the fridge was also nearby. I was also surprised that none of the guards noticed a fire burning in the cookhouse. Maybe, it was a spontaneous flash burn. We’ll never know for sure. At least the cookhouse still exists and it didn’t go the way of the rumors; when I started work that morning, somebody said, “I heard the cookhouse burned down. But I think I still see it standing.”

Hugh and Marty visited us with Carrole, the project director from Ethiopia. Their visit was nice and quite refreshing. It was a break in the routine of being the only person around in the evenings after work. Marty did most of the cooking while we were here and I ate extremely well. Hugh was a bit surprised that I wasn’t always hungry when I was alone fending for myself. He marveled at the amount that I did eat at meals, considering the quality and quantity of food is not comparable when Marty is not here. I just told him that my appetite is proportional to the quality of food. I am more hungry when there is good food and less hungry when there isn’t, and my metabolism compensates.

Among the many things that Carrole had told me about Ethiopia, the most disturbing is the fact that they have carnivorous ants there. I read this book here called Poisonwood Bible. It’s about the Congo. At one point in the book, everybody is running from the village because these carnivorous ants are on the march. They end up eating some of the livestock. Apparently, just before Carrole’s departure, the staff had to reassure the children in the orphanage because during one of the nights, these crazy ants devoured the chickens! Man, I’m glad I’m not in Ethiopia.

During the visit, all of the mizungus (foreigners) went to the children’s home. I discovered that our visit was 10 years to the day of the opening ceremony for the home. They had a visitor’s book that we filled out, and we saw H&M’s signature there 10 years ago that day. Cool. It’s neat when you’re part of history, even if it is to be a small event.

Their visit was fruitful. Much of their time was spent discussing budget issues. Amazingly, after every single meeting that we had, we decided upon a solution and plan of action. It seems that even though things operate on Kenyan time (30 minutes to 2 hours later than the appointed time), Kenyan meetings are far more productive than the American counterparts. Or perhaps, it’s just Lalmba Kenya where the management team is extremely competent and effective.

H&M were encouraged and encouraging about the changes made to the PSC. I’m glad that they also think that I’m doing a good job. And really, I’m just managing and doing some training. Most of the ideas and all of the actual implementation are by the Kenyans. Since I’m not bogged down with everyday worries and duties, I can concentrate on the big picture and help others see it so that we can come up with a solution together.

Well, now I’m the lone Mizungu again…until Amy comes for a visit. Then it’s party time in the Serengeti!!!

My observations of Luo culture

These are some basic facts about the Luo people:

-They are polygamists. Almost all tribes in the country are polygamists. Here, the wives live together generally in harmony.

-They have no culture of circumcision. I don’t know if it’s cultural for them not to circumcise.

-Their last names are related to the time of their birth in the astrological, seasonal sense. Consequently, many people have similar names.

-Their language is Dholuo.

-They are a Nilotic people with a Nilotic language, i.e. of the Nile. They migrated south from Sudan and are presumed to be descendent from the original Egyptians.

-Many Luo also live in Uganda and Tanzania.

-Their people are “rabble rousers” but not violent. Many of the original famous revolutionaries were Luo. Apparently, the shield on the Kenyan flag is a Luo symbol. I haven’t verified that, though.

-They have a unique practice of wife inheritance, in that when one brother dies, the other living brother inherits his wives. This practice perpetuates the HIV epidemic.

-One can marry girls when they are as young as 14 years old. I don’t know if girls can be married at younger ages.

-Women are not allowed to inherit land. Therefore, a family must have a boy survive to adulthood. This prompts the birth of many children.

-Women do ALL the work: cook, clean, bear the children, raise the children, fetch the water, build the houses, etc. Therefore, a family is in very deep trouble when the woman dies.

-Traditional healers were popular, but their popularity has waned over the 20+ years that Lalmba Kenya has existed. However, people still use them. I’m not sure how effective they are, for we always get the failures.

-HIV prevalence here is between 30 and 40%. This region has always had one of the highest prevalence rates in all of Kenya.

-There are Luo in Southern Uganda and Northwestern Tanzania. In fact, we get many Tanzanian patients. It seems that our medical care is superior to that which is available in Tanzania.

-Many people only speak Dholuo knowing very little Kiswahili or English. This particular monolingualism means that these people can go nowhere in the world outside of this area around Lake Victoria.

Some general Kenya facts:

-They gained independence from the British in the 1960’s. After independence, they cooperated with the British to form their government

-Moi was the second president of the country. He was a dictator and disallowed fair elections. People did disappear during his rule, but he was not so violent that everybody feared for his life everyday. The first “fair and free” elections were in 2002.

-Primary school is up to Grade 8. It is supposedly free, but it seems that all of the ancillary costs of books, uniforms, etc. make it very expensive.

-Things are quite expensive in Kenya. In most developing countries, Westerners experience an increased buying power. Not here. Everything costs the same here as it does in the States.

-Kenya has one of the better and more stable governments, economies, and societies in East Africa.

If any of you look up more information about the Luo after reading this entry and want to send me your comments and thoughts so that I can compare them to my experience, I would be happy to receive those e-mails.

A tale of two patients

Earlier this month we had an eventful day that led to some clinical dilemmas. Just as I was going to lunch, a patient arrived being carried by her family members. She didn’t look so hot and Dolith thought it would be a good idea for me to stick around. It was 1:05 pm. Well, it turned out that she had a ruptured ectopic and a surgical abdomen, and so we transferred her to St. Camillus. The road was very bad, and the patient had a rough time getting there as every bump undoubtedly caused her considerable pain. We didn’t have any narcotics to give her. Normally, I don’t go on these ambulance rides, but apparently there were two RCAR (Rescuing Children At Risk. It’s a program that takes care of children who are in dire straits, almost orphaned, gives them education, ensures their diet, etc. They have over 1000 kids in the program.) kids in the hospital and the management wanted to see if I could get them discharged, as they were being treated empirically without any diagnosis on the horizon. One had been there 5 weeks and wasn’t getting better.

When I received the records, the work-up was limited by the facilities and the therapy was driven by a shot-gun approach. Despite the “prettiness” of St. Camillus, their lab is not what I would have expected it to be. As internal medicine docs, tests are our friends and there were none at this hospital. They couldn’t even do blood cultures. When I was reviewing the records, there wasn’t much to go on, and St. Camillus did not have much more to offer, and so I had them discharged with the hope that there would be some way to diagnose the problem and possibly fix it.

Our next step was to proceed to St. Joseph’s hospital aka Ombo. This hospital has been here for a long time, since even before Matoso Clinic was even started. In fact, the first volunteers worked there for three months to get the feel of taking care of Kenyans before opening the clinic. These initial medical reports are fascinating from a historical perspective and they are all primary sources.

Well, I digress. We took them to the other hospital where I ordered a battery of tests, well, a battery of tests for them. In the end, I got about half of what I wanted. And we had to spend 8 hours at the hospital waiting for the lab techs to process them all. Wow. This is our referral hospital.

As expected, I was only able to narrow the differential diagnosis in these two patients. One had some issue with her gallbladder. Whether it was infected or not, she would need some sort of procedure or CAT scan to determine what to do next. The second one required a repeat ultrasound that we couldn’t get until this week. Regardless, they needed more detailed work-ups at the provincial hospitals – the referral hospitals for the province.

Now, the whole management of resources comes into play. The point of the RCAR program is to maximize the survival potential for the maximum number of kids, not to spend thousands of shillings on a few number of kids. As I was discussing the patients with the Lalmba medical director, we were trying some other therapies in the mean time trying to decide what the definitive course of action should be. Unfortunately, the patient with the gallbladder issue died a few days ago. We were having some issue with transportation and I was informed that she was not doing well. They were able to pick her up and bring her to the clinic. A brief evaluation revealed that she was dying. Thankfully, we were able to get her home so that she could die with her family. I learned that she died later that night.

The other one did get her ultrasound and it looks like she has lymphoma but needs a biopsy in order to confirm or discount this possibility.

The frustrating aspect of these cases is the lack of resources even at the so-called referral hospitals. They don’t even have full chemistries including bicarbonate, something that we use frequently to help determine the acid-base status of the patients. Part of the problem is the expense of automation. All these lab studies have to be processed by hand using special kits. And even then, they don’t necessarily get it right. Furthermore, it is much easier to manage patients when the resources of the patient are very limited. When a patient says, I cannot go to the hospital, then the options for us are fairly limited but straightforward. However, when we are spending thousands of shillings for further evaluation, it is difficult to know when to stop, when is such and such money too much money.

Well, I guess that is the nature of our work here. Sometimes you win some and sometimes you lose some. The wins feel really good and overall the work here is extremely gratifying, and the losses, well, one has to take them in stride. We can’t save the world, but we’ll keep trying one person at a time.

A day in the life of Medical Director Jeevan Sekhar

6:30 am – Roosters start crowing. Then the donkeys start braying. They sound like somebody is killing them. The cows start mooing. I curse them and go back to sleep.

7:20 am – Alarm goes off. I curse it and hit the snooze button. It comes on again. Another whack on the snooze button. Then at 7:45 am, I extricate myself from the warm confines of my bed, emerge from the mosquito net, and stumble out into the wider realm of my bedroom.

7:45 am – I take my malaria prophylaxis and afterwards perform the morning hygenics.

8 am – Morning prayer by the Kenyan staff. Someone starts off in song, the others participate. Then there is an actual prayer done in Dholuo (the language of the Luo people). Despite the different denominations, everybody here is Christian and is happy to praise Jesus for their circumstances.

8:30 am – Go to the PSC (Patient Support Center – just a reiteration for those of you who may have forgotten the acronym explained in the earlier entries), warm up the computer and await the patients.

9 am – Often on a Monday, we are dealing with the critically ill who have stayed away from the clinic until the weekend has passed. I guess they don’t want to inconvenience us during our time off with their acute attempts to die. (We are indeed open at all times for emergencies. Few people avail themselves of those extended hours.) Some we send to the hospital, others we manage on our own and get them from unable to sit to sitting or unable to stand to standing and then they go home. We don’t have inpatient capability.

10:30 am – Break time!! The Kenyans have chai. I have a Coke and brownies (compliments of Joyce).

11:00 am – Back to work refueled and rejuvenated.

1:00 pm – Lunch time! We usually eat in about 20 minutes. I use the rest of our hour break to have a nice little Siesta. Ha! – you didn’t think there would be much European influence here outside of British colonization did you…?

2:00 pm – More work. The afternoons are generally slower, as the patients tend to cram themselves into the morning. As a result, with the new streamlined approach to patient care that we devised, we can theoretically see 50 patients a day with the current staff we have.

4:30 pm – End of work. I usually do my e-mail at this time or study snippets of Go that I can glean from the net.

6pm-8pm – The time to communicate with my family in the States depending on the day. Done either by chat via internet or phone (assuming the network is working).

8pm – Eat dinner, read.

9pm or so – Evening hygenics.

10 pm – beddy bye…

Kill bugs Vol. 2

For the above, I depend on the spiders, the geckos, and the bats. Unfortunately, the spiders are scary ugly, the geckos relieve themselves in my room, and the bats might carry rabies. Oh well, beggars can't be choosers.

I have received some complementary remarks recently while I’ve been here. Both Moline (the current clinician in PSC) and Jackson had mentioned that it would be nice if I could stay longer. Moline went so far as to recommend that I stay and work here permanently in Kenya. Of course, it would never happen, but it is nice to know that I am appreciated and that people like my work. Perhaps, they say that to everybody. I’ll pretend they don’t.

Last week, we had a tough day. The dreaded ethical decision came up. Not one, but two critically ill patients who up on our doorstep in the morning. One with a septic wound with a blood pressure of 52 systolic (that is very low and I was amazed she could walk), and the other a lady with diarrhea and a BP we couldn’t obtain. Both had no means to pay for the transport to a hospital let alone any subsequent hospital bill.

Initially, I didn’t know what to do. Joseph inquired of Management about what resources we could use for these patients. The goal of Matoso Clinic, as it should be, is to give the basic amount of care to the largest of amount of people – none of this ridiculous ICU stuff that we do in the States. However, similar to the States there are surprisingly legal implications to dropping people off at hospitals. In the case of the first patient, we needed to get her family’s consent to hospitalize her. If we did not and they didn’t want to pay for the hospital bill, apparently it’s their prerogative, and they could shift the responsibility of a multiple thousand or hundred thousand schilling bill to the Lalmba association. Plus, on that day there was a shortage of vehicles. In the end, I made the executive decision that whatever charity funds that Management was going to free up to subsidize the transport and the initial admission fee, we would use to pay for our own resource utilization. We slammed fluids and antibiotics into the patients and then gave them all their medicine free when they left the clinic. Man, what a stressful day. Resource management at its most critical, literally.

Surprisingly, one of the stories has a happy ending. The lady who came in with the septic leg, who we then discharged to walk all the way home after opening the wound so that it would drain, returned on Friday to attend the Q&A session that Joseph holds every month regarding HIV care. Amazing. It’s just a reflection of the hardiness of these Kenyan people.

Over the weekend, I learned how to drive stick shift. Daniel taught me how. Of course, I’m learning on the wrong side of the car, but hopefully I can adapt when I get to the States. The pedals are in the same order with the accelerator on the far right and the clutch on the far left. The gear shift is also in the same order. However, that means that First is furthest away from me with Reverse being closest. On a car driving on the Right side, First will be the closest and Reverse will be the furthest away. Therefore, even though the gears are in the same order conceptually, kinetically it will be the opposite, while the pedals will be the same.

Anyway, I was able to get up to 4^th gear and 60 km/hr. I only stalled out twice. The main challenge was trying to get into Third. For some reason, I kept putting it back into First and we couldn’t accelerate. After we figured out the problem, I could accelerate pretty well. Daniel suggests that when we next have to transport a patient to a hospital, I can learn about what it entails to admit a patient, and then I can practice driving on the way back. I look forward to it.