Signing off!

Diane already left last night. Now, it's my turn. In just a couple of hours, I'll be headed to the airport. Then a few hours after that, I'll be on the plane to start the first leg home. Yea!

This has been an amazing experience in so many ways. I'll always have many wonderful memories of my time here. Who knows when I may be back here or on the road to yet another place? Life really does take many unexpected turns; it's up to you to enjoy and learn from them all.

For now, kwaheri and aloha a hui hou! ;o)

Last days

Today was our official last day in the WHO office here in Nairobi. It's been a busy week, given that it's our last week here. Diane and I both had all sorts of reports to prepare and write, some for our respective funding agencies (i.e., CPHA for her and CDC for me), and others we both had to write for WHO. But we were both determined to try to finish everything with a few days to spare so that we could sit back and relax before we fly to our respective homes.....definitely a good plan considering that I have to go straight back to my job for the state of Hawaii, and Diane will have to prepare for a short 2-week stint in Ethiopia for UNICEF a week after she returns to Canada.

Well, with all the reports completed and the official debriefing meetings with the WHO Representative to Kenya and with the Ministry of Health staff successfully completed, we decided to celebrate today by going to Carnivore, a restaurant that is what its name implies. We'd been told by various friends and others that it was an experience that everyone should try at least once (unless you're a vegetarian - in which case, they actually have options for those who may still venture there - guess maybe if you're part of a tour group, you may not have a choice). Apparently, they did have more exotic meats previously (like zebra, impala, buffalo, and even giraffe - I could never eat that last), but the government put a temporary ban on those meats. Still, they did have ostrich and crocodile. Funny thing is that they categorized turkey as an exotic meat; our waiter pointed out that for Kenyans, turkey meat is very unusual. They also had plenty of other meats like beef, chicken, lamb, and pork. All of it was pretty good, and it was a fun experience. They cook all the meat on these spits that look like long straight swords. The whole set up is pretty impressive as you can see.

They have a set menu that starts with a soup (today, onion) and then they bring a double decked circular tray that they place on your table. On the top deck, is a flag in the center, surrounded by various sauces for the meats being served. The bottom deck has a bowl of rice, a dish of salad, a bowl of corn salsa,..... Then, they bring you a very hot plate, followed by a yummy hot roasted potato. Finally, various carvers start bringing the meat to your table and cut slabs of meat directly onto your plate (in the picture, this guy had the turkey and is slicing Diane a nice tender piece). Remember that flag on the top of the tray? Well, when you need a break, you put the flag on its side. Otherwise, they just keep coming to your table with all the various meat. When you're really done, you take the flag out of its stand and put it down.

All the meat was pretty good. Amazingly tender and well cooked. The only thing, however, that Diane and I really didn't care for was the crocodile. It tasted kind of like a fishy fish, but the consistency was like maybe pork. Kind of weird. We both agreed that we were glad that they prepared it with a fried batter; made it taste better. The ostrich meatball was actually kind of tasty - like a gamey meatball. Both of us enjoyed the lamb but especially enjoyed the pork spare ribs. Mmmmm.......Och. That was definitely more meat than I usually eat in even a day, let alone two days!

Of course, I had to try their specialty drink, too, called the "Dawa," which means medicine in Kiswahili. Actually, it has honey, lime, a touch or two of vodka, ice, and...OK, I forget...but it kind of tasted like a mojito, but no mint... Well, the important thing was that it tasted good, and, of course, is good medicine for the tummy - especially mine since I seem to have been unlucky enough to suffer four bouts of gastrointestinal upset (is that euphemistic enough for everyone?) during this trip, the last one just as I finished this last field assignment. Ah well, down the hatch!

Just a couple more days, and I'll be on my way home. Yea!

Last day in the field

Yea! It’s a little hard to believe that three months have gone by, and today is my last day out in the field – at least in Kenya. It was a great feeling to give my last talk on acute flaccid paralysis, measles, and neonatal tetanus to the last group of clinicians, get in the car, turn to my driver, and say, “George, let’s go home to Nairobi!” Of course, we won’t be in Nairobi until tomorrow afternoon. It was too late to reach there before dark, and neither George nor I really want to risk driving into the city at night, especially on a Friday night – notoriously the riskiest time for carjacking incidents, and there was another one just the past week. The drive, while doable, is pretty long anyway, so we opted to overnight in Nakuru, about three and a half hours from Kisii. (Nairobi would be another three to three and a half hours from Nakuru.) So I’m enjoying the relative comforts of the Midland Hotel (not too bad –the recently renovated annex is actually pretty modern although the key tends to turn round and round in the lock and the shower tends to run either hot or cold and has a hard time settling into something in between) here in Nakuru, where it’s a rainy afternoon and evening. It seems I’m leaving western Kenya none too soon – the rainy season has begun, which means flooding and impassable roads.
I still have a little over a week before I return home to Hawaii, and it will be a busy week. I have at least three reports to write: the field report for this latest assignment in Nyanza, the mission report for WHO headquarters, and the trip report for CDC (to justify the per diem funding), and of course, there’s the debriefing meeting. But before I go there, here are a few last images from Nyanza.

It never ceases to amaze me how the women in Nyanza walk around so easily with what sometimes look like precarious and heavy loads on their heads. I've even seen some carry long bundles of wood without even needing to use their hands and turning this way and that, seemingly without a thought or worry that whatever is on their head will tumble down. The funniest thing I've seen is someone carrying her umbrella (lengthwise, of course) on her head. It's just natural for them.

This is an example of medical records in one of the hospitals. We keep hard copy records in the States, too, but often, these days, there's electronic back-up or some other back-up (like microfiche) of records. Can you imagine trying to find a patient's records in these stacks? Then again, interestingly, every person keeps a notebook that contains the clinicians' notes from every outpatient visit. Hospitals and clinics apparently don't keep patient medical records (unless they're a private institution, and even not all of them do); people keep and carry their own medical records with them - except for inpatient records. Then, the hospital keeps those. Trying to review, or actually find, clinician notes for research or investigative purposes would be a challenge here.

The countryside here is such a stark contrast to Wajir. Many of the people here are farmers, so much of the land has been turned to agriculture. The result is that much of it has been developed and looks amazingly green.











Unfortunately, that also means that they seem to be indiscrimately destroying much of the natural forests and therefore endangering the natural wildlife, not to mention that one day they'll find that they don't have wood for burning. Sad. But it's hard to argue with them about environmentalism when these people are focused on survival...
On another note, it's a good thing I finished my mission before any serious rains began. The countryside may be beautiful, but I wouldn't want to get stuck someplace indefinitely.
Everywhere we went, markets were bustling. It was amazing to see the huge crowds and all the things being sold.
I just wonder, so many people selling the same things (every time you slow down or stop near where people are selling things, so many of them would come toward the car and hold up bags of carrots or bunches of pineapples or bags of beans) - with so much competition, are they really able to sell enough to live? Really, when you're bombarded with so many of them, how can you choose from whom to buy? (Funny and smart thing: some of them gathered by the side of the road near speed bumps, where people have to slow down - good place to try to sell your produce and wares.)

By the way, in case you're wondering, most of my pictures were taken through the car window. After all, I'm not here as a tourist, and I don't have the luxury to stroll the countryside or the "streets" and stop to take pictures anytime I'd like. Usually, we're trying to get from one facility to the next, and traveling over these roads and distances is definitely not like traveling back home.

Soon enough, I'll be home where I left behind concerns regarding avian and pandemic influenzae. Oh, those concerns are here, too, but they're not quite as prominent as other things like ethnic violence, HIV/AIDS, measles outbreaks, poverty, etc. Still, those in public health and health care are aware. My colleagues and I only half joked about the risk all the chickens running around the hospital grounds in Suba might pose if avian flu made its way to this country (unlike in Hawaii, people here do live among, catch, and eat the chickens running around here - weird to see farm animals like chickens and even pigs living on the grounds of a hospital...)

By the way, while I'm on the subject of birds, like Hawaii, or even more so, Kenya is full of amazing bird species. These are pictures of some on the grounds of the hotel where I stayed in Homa Bay. (Called the Tourist Hotel - nice exterior and seems clean initially, but I wouldn't necessarily recommend it. Or if you ever end up there, would only pay for the cheaper option as anything more than a single is not worth it - dead bugs all over my room, even in the sheets, and dead ants all over the breakfast bread just to start...)

Towards the end of my time in Nyanza province, there was an awful road accident just outside of Kisumu, a head on collision between a matatu (minivan taxi) and a semitrailer. Something like eight people including two children were killed; some were decapitated! Anyway, the accident resulted in a crackdown by police. Police checkpoints along the roads here are commonplace. Ostensibly, the police are supposed to check to make sure vehicles and drivers are roadworthy and fine people or pull vehicles off the road if they aren't. Unfortunately, most of the time, the police are just looking for a "small bribe." During the crackdown, they got pretty serious. It was interesting that road traffic the day after the accident was scarce in much of the province as buses, matatus, semitrailers, and any vehicle that might have any problems were not driven, and matatus and buses that were carrying passengers well over the legal limit tried to stop well short of the police checkpoints to let off passengers so they could pass through the checkpoints without being hassled. Kind of scary then to realize how many vehicles are not really roadworthy and how many are usually so jampacked with commercial goods or people as drivers are trying to make as much off the rides as possible. Sometimes, it's even comical, as you can see here. At first, I was puzzled why this car would have shoes dangling out the back...until I realized it was stuffed to the gills with people. I remember in college we used to all pile into someone's car to get someplace, but this is pretty ridiculous, not to mention dangerous, especially with the way most drive in this country.

It's been nice to be able to end my time in Kenya by Lake Victoria, near water. Although nothing like the Pacific Ocean, especially with all the hyacinth in so many areas (like by the dock here near Hippo Point), a sunset over water is still beautiful.

And still more to do and see

New sights and experiences seem endless here. That’s probably a good thing as I have to admit that even as I enjoy my time here, I’m starting to really look forward to going home where I can sleep in my own bed, clean my clothes in a laundry machine, make my own food in my own kitchen, not constantly move every few days or sometimes every day to another unknown place, hang out with friends,….. Three months hopping around in the field is exhausting. It might be better if I didn’t have to also write and give reports – not here to sightsee afterall, despite what it may seem like from my blogs.










Only one more week and then it’s back to Nairobi. So for now, I’ve been back in Nyanza where it seems just about everyone has a bicycle, and if you don’t have one, you’re in serious need, and repair stalls with just about anything you could need can be found just about anywhere.....women carry loads on their heads so as to free up their hands, which they can use for other things (amazing how they carry just about anything on their heads!).....and fishing is one of the main industries here.

It’s kind of funny in a way that I end my time in Kenya in Nyanza by Lake Victoria. Some things here remind me of home, although it’s all very different, too. In Suba, I was lucky to be able to stay in a guesthouse of the International Centre for Insect Physiology and Ecology, which is open to any NGO or representative that works for the benefit of the community. Lucky me. The grounds were beautiful and located on one side of the Mbita peninsula so that I could enjoy the sight and sound of the waters of Lake Victoria lapping the shore. I had been missing the water, but I didn’t realize how much until I saw and heard the rhythmic waves of the lake. Yes, waves, small ones, but still waves.

Lake Victoria is huge, or at least large enough that you can’t see the opposite shores in Uganda, and waves are generated. Pretty cool. There probably would be more industry on this lake if it weren’t for the hyacinth that are essentially floating weeds and threaten the lake’s ecosystem and the locals’ fishing industry. It’s amazing how this plant just seems to take over large areas and therefore limit boat traffic and choke out the oxygen from the water. What looks like land or marsh are large green swaths of hyacinth - yes, all the flat green area beyond the trees in the picture is just floating hyacinth. Crazy.

Anyway, it really was nice to stay at the guesthouse in Suba, even short as the stay was. The grounds were large enough to accommodate decent morning runs. I’m sure I provided some curious amusement or head scratching for the groundspeople and security guards, one of whom would clap for me every time I ran by him. The only real negatives here were the swarms of mosquitoes and other insects that came out every evening, throughout the night, and even into the morning. Thank goodness for mosquito nets, Doom, DEET, and mefloquine.

The other day as we drove, we saw a great rainbow, which made me think of the ones we see all the time back home in Hawaii. I mentioned fishing; they’ve got plenty of fish here that gets sent to Nairobi and even, curiously, to Mombasa (which already sits on the coast), and I’ve enjoyed some very yummy fried tilapia – almost like home. Fruits grow very well here (unlike other parts of the country), so I’ve been able to have plenty. In fact, locals will set up at the roadside to sell fresh pineapples (they’re so sweet – even better than at home?...although these days, less and less of those are actually grown in Hawaii), and loads of bananas are transported to Nairobi and elsewhere constantly.

Yesterday, I got to see and sample fresh fruit and a traditional Kenyan meal at the country home of Nyambok, the provincial disease surveillance coordinator here in Nyanza. He and his family, including his extended family all live on a nice-sized area of land (at least several acres), where they have a modest farm that supplements their food supply and even occasionally income. Nyambok proudly showed me his idyllic homestead, where his children were busy planting maize and beans in a portion of the field, and encouraged me to try guava fresh from the tree – tasty. Then, we enjoyed a meal of stewed chicken, cooked and seasoned kale, and fresh, hot ugale. The last was tastier than what I’ve been served in restaurants, probably because Nyambok’s wife uses whole maize kernels rather than processed maize to make the ugale, although her sister-in-law actually did the honors for us. We finished the meal with fresh, sweet, juicy pineapple Nyambok had picked up earlier at one of the roadside stands we’d passed. Mmm!!

A mellow day

Today, the last day of the long weekend before our last sojourn into the field, we decided to take a short trip out to Karen, just outside Nairobi.

Who can pass up an opportunity to see and even touch a giraffe up close? I’ve been pretty lucky to be able to see so much wildlife, especially giraffes, as I’ve moved around the bush in Kenya just going about my work. Giraffes have always been one of my favorite animals; they seem so graceful. At the African Fund for Endangered Wildlife Giraffe Centre (Giraffe are endangered because of the constant encroachment on their natural habitat.), where one can stand in a “tree house” to get at eye level with the giraffes, Diane and I had the opportunity to very close to these stately animals. They are quiet (in fact, giraffes rarely make any sounds), and their huge eyes appear so gentle, but they can also butt you with their big head if you’re not careful or you’re close to one that’s hungry and you don’t have any food in your hand to satisfy it. Feeding them or watching kids feed them is really amusing. The wardens provide visitors with food pellets, that the giraffes eagerly take from from your palms. It’s a funny feeling as they grab the food using their lips but mostly with their long and slightly rough but definitely slobbery tongue. (The wardens claimed that giraffe saliva has been found to be a natural antiseptic – not sure about that, but something to look up later…) When you’re not actively offering more pellets to them, they’ll use that long tongue to try to reach for more from you. Definitely a cool experience.

Next, we checked out the Karen Blixen house (remember “Out of Africa” with Meryl Streep and Robert Redford?). She really existed, and the movie and book are based on her true life story, and her house and lands around have been preserved. It was nice to see, and, of course, I took a few obligatory idyllic photos, but Diane and I both agreed that paying Ksh 800 (almost $12) just to get a tour of the small house was asking a bit much, so we opted out of that touristy option.
It was nice to get out for a few hours and relax. Now [sigh] back to work.

Happy Easter

I suppose I could have taken off for the coast (like Mombasa or Lamu) or gone to Maasai Mara to see more animals, but after constantly traveling and living out of a suitcase for the past 2-1/2 months and sleeping in so many different places in so many different and sometimes trying conditions, I just wanted to be able to stay put in comfortable, familiar surroundings. Diane agreed. So, we both decided to return from the field to Nairobi for the long weekend (it’s a 4-day weekend here). We both just need some downtime, and staying at the Fairview is perfect for that. Besides, despite the fact that we’ve probably seen and experienced more of Kenya than even many Kenyans, we haven’t really had the opportunity to explore Nairobi. So, we’re back. The best part, for me, is that I can go on my early morning runs again – yeah, I know, I’m a running nut.

Yesterday, we did a little shopping at the Maasai Market. Actually, it’s held on different days in different parts of the city, and it’s the best place to shop for gifts and souvenirs. It’s a scene, and you definitely have to be in the mood to bargain and be firm with sometimes aggressive vendors, usually the male ones. Still, it’s colorful and fun, and Diane and I agreed we probably bought way too many scarves, but we love all our purchases so they’re worth every schilling. Diane’s a pretty shrewd bargainer, and I had just as much fun watching her than actually shopping for anything myself. The trick is that you get them to name a price and then only offer at most half what they ask and work from there. Then, you have to be ready to walk away. The last is easy to do, at least for us; there isn’t anything that we really need or can do without anyway.

Diane read about a Kenyan traditional dance show at a place called Bomas, so we decided to check it out. Although it was a bit on the touristy side, there were plenty of Kenyans, including families and school groups, that attended the show, which was actually pretty entertaining. The troupe performed a number of dances and songs that are performed for various celebrations and/or events (e.g., weddings or ritual male circumcisions) by different tribes across Kenya. According to our driver, the performances were actually true to real life. He himself is a Kikuyu, and I think he got a kick out of watching the dance and music representing his tribe. Turns out he’s perfomed that dance himself at one time. Interestingly, some of the dance movements of some of the tribes especially seemed similar to the Hawaiian hula and other Polynesian/Micronesian dances. Also, in many ways, Bomas is very similar to a less done-up version of the Polynesian Cultural Center on Oahu; there are even examples of various tribal villages through which you can walk and visit. I took a picture of Diane by one of the “first wife’s” huts of one of the tribes.

This morning, we enjoyed a nice walk in the area of the city around our hotel. Given that it’s Easter Sunday, thankfully, there wasn’t the usual crowd of people on the streets and sidewalks, and traffic was infrequent, although there were still plenty of matatus and buses letting out there ugly spurts of blue-black clouds of smog – blegh. We explored the nearby Panafric Hotel, which would have been our alternative if the Fairview had been booked. Nice place, but we prefer the tranquility and environs of the Fairview. We saw people walking and driving to churches and could hear the blasts of some exuberant sermons through open windows as we passed by a couple of the very large churches. We made our way to Uhuru Park and enjoyed watching all the families enjoying the day, just like they might in the U.S. or Canada.

Happy Easter everyone!

Dusting off my clinical skills

(OK, this blog is especially for those of you who are doctors or in the health profession.)

One of the things I’ve really enjoyed about my time here is the opportunity for interaction with children and their parents and specifically, the opportunity to use my clinical skills, which I had put on hold while I pursued my public health career. Working with the kids and assisting with some clinical evaluations has made me realize how much I do miss practicing clinical medicine – not enough that I’d go back full time, but enough that a part-time gig would be pretty cool.

At the same time that I enjoy the little actual clinical practice, it can also be frustrating here. On the one hand, I see how relief agencies, NGOs, and other sources have provided a number of resources like antibiotics, antimalarials, and clinic and laboratory equipment, or even just electrical power. On the other hand, there are no doctors in many of the dispensaries and health centers, and very few in the subhospitals, if any, and hospitals. Usually, there might be a nurse and/or a clinical officer, and I often wonder about their level of training and knowledge – of course, I’ve wondered that about some nurses and physicans assistants, and even some doctors, back in the U.S. All the same, it seems like there’s often only the most basic understanding of the how’s or why’s of using whatever resources are available.

For example, they’re so concerned about malaria here that it’s often clinically diagnosed in any child with fever, and antimalarial treatment is begun empirically. At the same time, the child might be treated with an antibiotic. All these meds given in the face of a presentation, for example, that is clearly chicken pox (i.e., viral etiology). OK, here’s where my infectious disease training balks and shudders as I consider how much potential antibiotic and antimalarial resistance may be bred by this kind of practice. The countries here on this continent have enough problems just dealing with the diseases and other challenges here; how much worse would it be with the addition of resistance issues, although one could argue that they already have them here. At any rate, it’s hard to argue against the constant empiric treatment (i.e., giving out meds like water) when they often can’t even do a basic bacterial culture or get a simple complete blood cell count (i.e., CBC or blood cell indices), and likelihood of patient follow-up is often sketchy given the often tough, rural conditions (i.e., lack of transport, lack of money for transport, long distances to travel to clinical facilities, etc.).

All these things make me more aware of how fortunate we are in industrialized countries. While here you often have only your clinical exam to aid you in the management of your patient, in the U.S. and similar places, we’ve grown used to being able to order all sorts of blood tests, imaging studies, and other diagnostics to aid us in getting and even more complete picture of our patients’ problems. Having little else but one’s clinical skills can be very daunting and frustrating.

Today, I saw a 7-year-old Ugandan girl who presented with refusal to bear weight on her legs. I won’t go into detail here, but from her presentation, I doubt we have to worry about polio – the “weakness” in her legs seemed to be more due to pain and some process referred from her distended abdomen. However, I’m stumped as to the real cause of her problems (although a differential diagnoses list springs to mind), and I admit to feeling blind without even a CBC and a few other basic labs or X-ray. Well, I made what recommendations I could given the limitations and urged them to transfer her to the district hospital at least where there would be more resources, especially if her condition progressed and given that her very pregnant mother is about ready to pop with her next child – no one will be able to care properly for the child once her mother delivers (in the health facilities, your family is responsible for taking care of you, including feeding and washing you, your clothes, and your bedsheets, not the very few nurses). However, her mother is very reluctant/resistant to let her child be moved so far away. This is just one of many, I’m sure, similarly tough situations here. I’ll probably check on this girl through my public health/health care contacts in the next few weeks while I’m still here in Kenya. I would really like to know what’s going on with her. Hopefully, her mother won’t decide to just take her home and/or even take her to some traditional healer and then they all disappear into the bush somewhere.

Home stretch

OK. The home stretch now. I’m out in the field one last time. This time, I’ve been sent west to Nyanza province. Kisumu is the province seat, where I’ll be calling home base most of the time. It’s amazing how opposite it is from Northeastern province in so many ways. It’s much more developed and even a little touristy here – plenty of game parks and, of course, Victoria Lake. The conditions are much easier – much greener. Although it’s still warm, it’s not hot enough to make you feel completely wrung dry like in Wajir. Instead it’s a little on the humid side. Actually, the climate kind of reminds me of home. Much of the major road is even tarmacked and in decent condition. The unpaved roads are in much better condition, for the most part, compared to Wajir and even parts of Tharaka and Mwingi (the areas I worked during my first month in Kenya). After experiencing some of the more challenging parts of the Kenya bush, it’s really amusing when the locals tell me that the distance to a health facility is quite long and the road is very bad. The first time they told me that, I thought maybe we’d have a two hour drive over rough roads. Instead, it was more like maybe 40 minutes, of which maybe 10-15 minutes was over uneven, rocky, dirt road, but otherwise the rest was tarmacked or packed even dirt. Perspectives are always relative to experience.

For the most part, the people here are farmers (tea, sugar cane, and even rice – amazing vast green fields) or fishermen – lots of tilapia from Victoria Lake – rather than pastoralists (i.e., livestock herders). There’s also a lot of freight or lorry traffic along the roads. Apparently, the road between Nairobi and Kisumu is a major commercial throughway for transporting goods all the way to Uganda, Rwanda, and other African countries. This means that we often ran into more conventional traffic on the road than what I’d seen in Wajir. I think I prefer the camels, goats, and sheep. They were at least more interesting and picturesque and didn’t emit big clouds of black smog.

In contrast, aside from the big lorries and the occasional semi-trailer, here in western Kenya, you also have to watch out for the boda-bodas (bicycle taxis) and other cyclists. It sometimes seems like there are bikes everywhere, and they often dart in and out of car traffic and among other bicycle traffic. Some of them are aggressive to the point of maybe crazy the way they ride into your way or into other bikes. We saw a near potentially fatal accident when one boda-boda careened into another and knocked the passenger and “driver” off their bike into the path of an oncoming matatu (shuttle bus) that barely swerved in time to miss them. A definite close call.

It’s nice to wind up my time in Kenya in Kisumu and Nyanza province. I’ve been able to go running in the small park across the street from my hotel once and drew some very curious looks, but it was a good run. Unfortunately, the rest of my time here has required long days with very early starts, so running was not an option on other days since it’s too dark. Instead, I’ve been running the stairs of the hotel – and drawing the rare odd stare when any of the few people who are up happen to see me through their windows (the stairs are outdoors, sort of). Oh well. It’s something to keep me in semi-decent shape.

The other reason I’m glad to be in Kisumu is that I have some friends from my CDC days who are now stationed here. I had a chance to catch up with my friend Wairimu, who is working in HIV/AIDS research here for CDC and whose family is in Nairobi. It was really great to see her; the last time I saw her was almost three years ago back in Atlanta. We had a really tasty Indian dinner at a nearby hotel as we chatted and caught each other up on our lives post-Atlanta. Hopefully, I’ll also get a chance to catch up with some other friends (Danny and Mary), who, as it turns out, are neighbors of Wairimu. Anyway, it’s nice to have friends in an unfamiliar place.