Coming full circle

After 2 flights, 1 layover (Schiphol Airport is A-mazing!), 17 hours of flying complicated by 4 intermittently shrieking toddlers,  and countless dutch meals courtesy of KLM these two sniffle ridden travelers are HOME!

 

It’s strange to be back in the land of plenty.  Just the paved over sidewalks and lack of ambient dust in the air is throwing me for a loop, to say nothing of the weather. It feels freezing even though I know this is just normal SF “summer”. Eventually my internal thermometer will reset I suppose.

 

Thanks to all who commented and read this blog and thanks to Ray who made it prettier than I could have ever imagined. Its been a great experience putting thoughts into words and essays and I hope its been fun, or at least interesting to read. Further travels and adventures will be coming soon, I’m sure.

 

Rachel

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Hello Nairobi…

Nothing like spending the last month in a village cum-town to make you appreciate the big city. Last time we were in Nairobi it seemed a little terrifying: big, bad and known for violent crime I was eager to get out and on to Kisumu. How the times have changed! Though the bad traffic is still the same (it took us twice as long to get from the airport to the hotel than our flight from Kisumu to Nairobi) it is quite nice to be back in a big city. Finally,  food variety, shopping (my credit card took a few hits today), and certainly a fair amount of anonymity as compared to Kisumu – there are just many more tourists around here.

 

Tomorrow we’re hiring a car to do Nairobi in a day and see all the sites that we didn’t get to the first time around. On our hit list is the Nairobi National Museum, a music festival, and hopefully some amazing food!

 

Rachel

Goodbye Kisumu!

Tomorrow morning we fly out of Kisumu and back to Nairobi, the first leg of our return home. In honor of leaving our home for 2 months, Kisumu, I’ve compiled a list of things I’ll miss dearly. And those I wont.

Top 5 things I’ll miss:

1. Sunsets, clouds and the sky in general

2. The awesome staff and patients at Lumumba

3. Warm evenings without a sweater

4.The shack store that sells and plays CDs that we pass each day on the way to work – always makes me want to break out into a dance.

5. Our amazing 3 bedroom flat and the ambassadors.

Top 5 things I won’t miss at all!

1. Burning garbage smell

2. Giant dudus (Swahili for bugs)

3. Our neighbor’s barking dogs

4. Our tiny bed and mosquito net

5. Did I mention the bats?

Ciao Kisumu, hello Nairobi!

You don’t go to church?

Something I think would surprise people to know about Kenya is that it is quite religious. The vast majority of people are Christian – Protestant/Catholics make up almost 80% of the population. About 10% are Muslim and then a smattering of “other”.  This varies widely by region with the coast being more heavily Muslim and the western area (where we are) being mostly Christian.

What I find interesting though is the complete integration of religion, in this case Christianity, into all aspects of life. Our first staff meeting started with a hymn. A little religious I thought, amused to think how that would never fly in San Francisco. Then there was a prayer. Not the kind of generic prayer where “god” is mentioned and it could be any god. No, this one was all about Jesus.  If I was surprised then I can only describe it as being shocked when the next three staff meetings began with straight up preaching for the greater part of 20 minutes. Today was a verse from Exodus, finally I thought the  Old Testament. At least I knew what they were talking about!

Similar to the way I described race being something that is fair game in greeting and conversation in a previous post, it seems that religion, a notoriously touchy subject in the US, is also up for discussion at all times. I knew at some point I was going to get asked about my religion. It happened in Uganda so I knew to expect it. And I almost made it to the end of my stay but today while I was talking to the administrator of the clinic about a completely different subject he interrupted me by asking whether or not I had been to church this weekend.  Now maybe there are some places in the US  where this is a normal question, but not where I come from.  Wanting to get back to talking about our previous subject I skirted around the issue saying simply No. But eventually I told him I was Jewish.  He seemed genuinely confused and spent the better part of the next 15 minutes trying to convince me that Jews were Christians and could not understand why I disagreed.Then I found out that the receptionist who was sitting with us the entire time is Muslim. And he proceeded to tell me that the administrator always tries to convert him at work.  Between proselytizing at work and preaching during meetings it was a bit like being in the twilight zone.

Despite the lack of division between Church and work I do think there is quite a measure of religious tolerance in Kenya. Every day, even in this most Christian of areas, we hear the five Muslim calls to prayer. No matter where we are I can hear it and its gotten to the point where I know its 1pm when I hear it midday and I associate it with lunch.  Our street is home to a Hari Krishna temple and what looks like a cross between Sikh temple and a cult that worships aliens.  Certainly there is no dearth of places to worship.

What it comes down to is that I think religion and faith are such a large part of life here because when it comes right down to it –  life is effing hard here.  And a little faith in something bigger than yourself makes it easier to deal with the daily difficulties that people have to face. I’m glad I don’t live in a place where religion is so ingrained in the workplace but I understand a little better why it is the way it is.

Rachel

On the benefits of anonymity

As our time in Kenya draws to a close I wonder what it would be like if I lived here. What if there was no end date, could I do it? And surprisingly when I think of the reasons why it would be hard to live here the usual suspects don’t really make the list. It’s not the lack of familiar (i.e. good food) that makes it hard or the concerns about exotic infectious diseases and sub-standard medical care.  It’s the lack of anonymity that I’m not sure I could stand month after month.

No matter where I go in Kenya I don’t blend in.  I stand out like a sore thumb. And Kenyans, like the Senegalese and Ugandans that I met in my travels, are not about to let me go by unnoticed. Here they call white people mzungus, in West Africa it was toubab. Children, adults, everyone uses it and it seems to be, as far as I can tell, not really meant to be offensive.  Coming from a country where any discussion of race or color is highly charged and draped with subtext – being in a place where people mostly associate me with my skin color is particularly strange.

Most of the time being “mzungu” is not problem per se.  Most people just use it as a way to describe us that is fast and easy. But what it represents, our differentness, can be troublesome.  Because in the end being mzungu in Kenya seems to mean a lack of anonymity, a constant gaze from those around you that can be a bit onerous. Children who see us yell out from matatu windows, bicycle seats and behind school fences “Mzungu*! How are you?” Drivers of bicycle taxis and tuk tuks assume we want a ride and slow down to talk to us. Prices for goods and services are increased 50%-100% for me.

Now it’s not that I don’t understand the place of privilege that I come from. As a white person in Kenya I  likely do have the money to pay the increased prices and I recognize the attention of children has more to do with fascination than mischief. But at the end of the day it starts to wear you down a little bit. It feels like an invisible barrier has been erected between you and the people who live here and you’ll never quite fit in.  Perhaps if I lived here it would fade day by day into the back ground of a busy life. But I doubt it.

* a Swahili word that means “aimless wanderer” but used now to denote any white person, sometimes any foreigner at all.

Foodstuffs

I’ll preface this post with a summary of my meals today:

Breakfast: coffee with crackers and cheese (from Kenya! very good!)

Mid morning snack: chapatti and milk tea

Lunch: vegetarian samosas, deep fried

Afternoon snack: Amigo’s salted chips

Notice a trend here? Besides the intense Indian-British influence on the food ? I’ve been getting my fill of fried goods and quite a dearth of vegetables since we arrived in Kenya. Most of this is due to the strict verboten-ness of fresh vegetables and non-peeled fruits. So no salads, no fresh tomato garnish or slaw. No one here wants a repeat of Mali 2004 . And following my no fresh veggies/unpeeled fruit rules I have been healthy and hale since we got here. But I’m becoming more than a bit concerned that my coronaries won’t recover from the 5.5 week fried food binge I’m finishing up. But I digress, what I wanted to talk about was food in Kenya.

Satter’s hierarchy of food needs is a sociological look at human requirements for food in a stepwise manner.

At the bottom is “enough food”, nevermind if its fresh, good tasting, not rotten. You will see that “good tasting food”, or what one would usually expect to hear discussed in a blog post on food, doesn’t even come in until the fourth rung of the pyramid. In case you were wondering, “instrumental food” refers to “choosing food for instrumental reasons: to achieve a desired physical, cognitive, or spiritual outcome.” My desire to eat vegetables to protect my future cardiac health is an example of seeking out instrumental food.

You may be wondering what this has to do with Kenyan cuisine. I’ve been thinking of this food pyramid a lot since we’ve been here because for most Kenyans food ranks somewhere in the last three rungs of the pyramid. There is real food insecurity in this country due to poverty, drought, and rising food prices. Ray and I have seen the child malnutrition ward in the district hospital – it ain’t no joke.  But the national cuisine, or at least what I know of it, is essentially food that clocks in around rung three of Satter’s pyramid, the kind of food that fills you up and doesn’t let you down. It’s not particularly amazing tasting,  but it will certainly fulfill the basic needs of food.

So what kind of food are we talking about? The first and most ubiquitous staple of Kenyan food is ugali, a starch that accompanies almost every meal in Kenya. It’s made out of maize flour that is boiled into a porridge until it sets and then is served in large slabs. The consistency is fluffy play-do.  Kenyan’s say “a man hasn’t eaten until he’s had ugali” but  it’s certainly not going to win any culinary awards anytime soon. The most common vegetable served is chopped up and stewed kale or spinach called sukuma wiki. The word translates in Kiswahili to “stretch the week”, a nod to food insecurity even today.  When  Kenyan’s can afford meat they prefer it barbecued, referred to as nyama choma. It’s not exactly melt  in your mouth –  these animals are as free-range and lean as they come – but it’s one of the tastier sides of Kenyan food nonetheless.

This isn’t to say that all the food in Kenya is utilitarian.  Ray and I ate at Carnivore, a high end Nairobi homage to nyama choma specializing in strange game meats (we tried ostrich, alligator and camel).  The fish in Kisumu, even at the most bare bones corrugated tin roof “restaurant” by the lake, is excellent, fresh and tasty.  But generally higher end restaurants that cater to tourists and expats serve non-Kenyan food. They do it well but I’m not sure its a stretch for pizza to be pretty darn tasty.  Then there is the influx of Indian-British food influences. Chapattis, samosas, and curry are all staples of most restaurants here due to the large Southeast Asian population.  Heavy sometimes, but a large source of  vegetables cooked into acceptable antisepsis. Thankfully the British influence on food is minimal (no shepherds pie or creamy peas) but they left a long legacy of milky, sugary tea that is alive and well 40+ years post colonialism.

Most days we end up eating a mix of familiar/western food and Kenyan food. The clinic has a few  women  who come and cook food for the doctors and clients.  This is where the majority of our ugali and sukuma wiki intake happens. You can’t get a better deal than 40KSH (less than 50 cents) for a plate of goods there. We are also lucky to have the ability to cook at our flat and have produced, with our one gas burner, pasta, fried rice, stir fry and guacamole. In the end its been quite a learning experience to live in a place where food is a limited resource, both in quality and quantity. But there’s an element of voyeurism to it as we have the money and ability to opt out of the nutritional reality that exists for many Kenyans.

Rachel

Disclosure

One of the big issues at Lumumba clinic is disclosure. Disclosure here refers to a person informing others of their HIV positive status. It’s deeply intertwined in the philosophy of FACES as a whole and  with what they call “positive living”. As best as I can describe it “positive living” is the idea that by reducing self stigma (or shame as we would call it), disclosing one’s status to others, and keeping oneself healthy (eating well, using condoms etc) is the best way to ensure that you will continue to adhere to your antiretroviral therapy (or ART).

When I first heard about the ideas of positive living and disclosure after attending some of the patient education sessions, I’ll admit I was a little skeptical. I’m all for letting sexual contacts know your status – but neighbors? Co-workers? That runs against the deeply ingrained ideals of privacy we hold so dear in Western medicine. As for “positive living”, I thought, well there’s nothing wrong with eating well and feeling better about oneself but could that really improve taking your pills? In the US we think of adherence is being primarily about individual’s  commitment to taking a drug, not predicated on these other issues.

I’ll admit after the last two and half weeks of clinic – I’m coming around to the FACES disclosure bandwagon.  After listening to stories and interviewing patients I began to see how inextricably intertwined issues of disclosure and adherence were. I met a seven-year old girl who was congenitally infected with HIV. As disclosure to children is not done until the age of 10 usually, this child wasn’t privy to why she was taking medications. Her mother, who was also HIV positive, was in charge of dosing the medications. But her mother works, every day. So the child spends lots of time with their neighbor, including time when she is supposed to be taking her HIV drugs. We saw the child because she was failing her medication regimen, meaning her immune system was breaking down. Her mother, after much questioning, revealed that her daughter hadn’t been taking her medications at the neighbor’s house because the neighbor wasn’t aware of the child’s status. Now to us this reticence to disclose the child’s HIV status likely seems understandable. What business is it of the neighbor to know this child’s private health information? Part of me agrees but as I am learning, it ends up being very important indeed. In fact it ends up being the reason this child had to be switched to the second line HIV drugs. That means that barring the Kenyan Ministry of Health striking a deal for 3rd line drugs, this child has no safety net, no next step if these drugs don’t work out.

I also met a man who was HIV positive and worked for a security firm, one of the many be-uniformed guards that stand outside of the nice houses in town. He was at clinic in the middle of the day on a weekday. He was wearing his uniform and proudly told us that his boss and co-workers knew his HIV status. He said he told them because he didn’t want to hide it. He wanted them to understand why he had to go to clinic on a weekday and to understand that he was taking his health seriously. I was pretty shocked that he had disclosed to his work, but also pretty impressed with his openness and refusal to be ashamed about his predicament.  I realized how easy it would be for him to skip clinic on busy work days if his boss and co-workers didn’t know his status.

In Helen Epstein’s book The Invisible Cure she discusses how the tragedy of HIV in Africa is magnified by the export of US stigma based around the disease. Because we view it as  a “gay” illness and the product of promiscuous sex we have exported our view of the illness to Africans despite the fact that the demographics and transmission here are deeply different.  I think about that sometimes when I hear about disclosure at the Lumumba clinic.  By departing from Western ideals about privacy and encouraging disclosure perhaps people here are finally combating the stigma and shame that coats this illness unlike any other.
Rachel

Lumumba

I realized that we’re halfway through our time in Kisumu (!) and we’ve yet to write about our work. UCSF has a relationship with the Kenya Medical Research Institute (KEMRI) and together they run a cluster of clinics in western Kenya  under the aegis of the Family AIDS Care and Education (FACES) program. Visitors like us are often clinical, either medical students, residents, or fellows, or doing research here. You may have heard about this large HIV study which has been in the news recently. One of the study sites was our clinic in Kisumu.

The FACES clinics  serve HIV positive people and their families  in the Nyanza province of Kenya. This province has the highest rate of HIV positive people in the country, some clock it as high as 25%. The clinic we are working at is called the Lumumba Health Center and serves 9-10,000 patients, including a large number of children who were congenitally infected. The clinic is a busy, busy place.

The majority of the work at Lumumba is done by non-physicians: clinical officers and nurses. The clinical officers do 3 years of training after high school and a one year clinical rotation in the hospital. The closest approximation in the US would be a physician’s assistant. Medical doctors in Kenya do 5 years of training post high school and a year of internship to be a general practitioner. The only time we see the medical officers, as they are known here, is during multi-disciplinary rounds where the CO’s and nurses bring difficult cases that they need help with. Then there are a cadre of CCHA’s, or clinical assistants, that take vital signs, do counseling, home visits and other miscellanea.

The clinic doesn’t necessarily run smoothly or speedily. Patients don’t have an appointment time, just an appointment day, so the wait is long.  Patients start lining up at the clinic entrance at 4 or 5 in the morning. But its a pretty amazing example of HIV care in a resource limited setting.  The vast majority of patients know their drug names and follow their CD4 counts (a measure of the immune system in HIV) avidly. These are people who often have just a primary school education. Its pretty amazing. They also do a lot to reduce the stigma around HIV through counseling and HIV education classes. The issues they deal with are tough, in some ways tougher than those we see in the US. At what age do you disclose HIV status to a child who was infected at birth? How do you protect co-wives in a polygamous relationship? What do you do with HIV positive teenagers who won’t come to clinic?  There really aren’t any easy answers to those questions.

HIV mortality is still high here. There are only 2 lines of antiretroviral therapy (ART)  and after that patients have to pay out of pocket which is basically impossible (the first two lines of drugs are paid for by PEPFAR). However, we’ve seen ways in which the patients get better care through their association with FACES and thus their HIV positive status. Whenever a FACES patient goes to the hospital, which is inevitably the public hospital, they are visited every few days by a FACES staff member. This person looks over the chart, sees the patient, discusses the case with a medical officer if necessary and generally tries to make sure the patient is getting what they need. If the patient can’t afford a test that is available at the clinic, they do the test free of charge. Given the public hospitals in Kenya, and much of the developing world, are overcrowded, understaffed, and care is only given if you can pay, this is huge.
It’s obviously not all rosy and rainbows, there are some deep systems issues and problems which I’m sure will come out in later posts, but by and large it’s an example of how to give solid, quality care at low-cost.

Rachel

Learn more about FACES here

On language

The official languages in Kenya are Swahili and English. But that is an oversimplification of the situation. Most people learn English in secondary school, which only some of the population attends (education here is ostensibly free but most people you ask will say that the price of uniforms, books etc can make it prohibitive). Nevertheless all government proceedings (as far as I can tell), most countrywide newspapers, and all medical charts/medical meetings are held in English. In the face of the upcoming elections next year it has got me thinking about the ability of the average Kenyan to be an active participant in their government, their health care, or even understand what is going on when watching, as we have been, the selection of the next Chief Justice on TV, when it’s all carried out in English. How can we expect a population, already saddled by poverty, corruption, and tribal tension, to have a representative democracy or to take ownership over their health care when it is carried out in a language that they may or may not speak?

It gets more complicated when you realize that the language that people use when they are talking to each other in informal settings is sometimes Swahili, but more often than not a tribal/indigenous language such as Dholuo, the language spoken by the Luo tribe here in Kisumu. Most Kenyan’s refer to this as their mother tongue, and it is the language that they grew up speaking, more often than not, in their home. For some living on the coast this is Swahili, but most of the time it is neither Swahili nor English. This results in a large portion of the population that speaks neither official language well. We’ve run into this problem in clinic when a staff member does not speak Dholuo well, which is the most common language spoke in this area, and the client speaks neither Swahili nor English. Even our safari guide Simon could not tell us the Swahili word for rainbow, he only knew it in Gikuyu (another local language) – and he went to university.

All of the above makes it that much more amazing when in clinic I hear the patients faithfully recite their anti-retroviral medications from memory. I’m always amazed when I hear them eeking out complicated, multi-syllabic, scientific words like zidovudine or efavirenz. Some of my US clinic patients don’t know their drugs and can’t pronounce those words either.  But these issues  I’ve encountered do make me wonder how much of what we deem progress in a developing country, like Kenya, is held back by issues of language and just simply understanding each other.

Around the neighborhood…

The neighborhood our apartment (or flat as it’s called in this former British colony) is in is called Milimani. As far as I can tell its populated mostly by immigrants from the Indian subcontinent all of whom have gated complexes with semi-private security guards guarding whatever valuables lay inside.  Our set of flats has a gate, which is always open, and a watchman/babu* who kind of guards our valuables but mostly a) plays with the neighborhood children, b) waits outside for the electrician (we’ve had power problems), or c) hangs out with the night watchman who seems to arrive at half past 4. But hey, they were kind enough to remove that bat I injured, so I appreciate their presence.

Most of the time we don’t really see our neighbors except on our way to work in the morning when I see their exceptionally cute children waiting in their ridiculously cute uniforms for the matatu (shared van ride – Kenya’s version of public transportation, seats 11!) ride to school. However! If you are outside at just the right time, when the sun has faded and its gotten a bit cooler, but before sunset you will see them. Them? The power walking sari ladies! Usually is 3-5 women who wear full on beautiful saris accompanied by brand-spanking new tennis shoes and they are on a mission. They power walk around the block and don’t even break a sweat! Seriously, it inspired Ray and I to go running yesterday and those ladies didn’t bat an eye at us.

The other thing I’ve noticed about our neighborhood is the dogs. Everyone has guard dogs. Guard dogs that bark. All the time. You would think, as Ray pointed out, that they would get used to the passing motor bikes, bicycles, tuk tuks, and matatus. But perhaps they are bred that way, to always be alert.  For a while Ray and I had never actually seen any of the dogs that made the racket, certainly they sounded like the meanest Dobermann or German Shepherds you could imagine. But the other day we saw one! Attached to the chain link leash and being walked by a very serious looking, be-uniformed security man was a white miniature Pomeranian.  I’ll never know how those owners keep that coat so white in this land of dirt and dust, nor how one trains a Pomeranian to be guard dog, but we’ve nicknamed it “Killer” and try to stay away from it!

The best part of apartment, though, are the kids; they are little but many. At least 5-8 of them under the age of 8  live in this complex of flats (approximately 6 apartments). From the hours of noon-sunset the stairwell, ground floor and garage are their turf. When we come home from work at 5pm through the gate that is never locked they can be seen, like clockwork, riding bikes, running around and generally messing with each other. This usually ends in tears; 4-5pm is generally the crying hour. But the funniest thing is whenever Ray and I walk in they stare at us intently and then offer to shake our hands! I’m telling you I have shaken the hand of a two year old multiple times now. Its quite soft. So I’ve taken to calling them “the ambassadors” for their formal handshakes and general welcome to the neighborhood.

*Swahili for grandfather