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

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Published in: on May 19, 2011 at 9:47 pm  Comments (3)  

jackal enjoys lunch

any guesses about what he ate?

Published in: on May 18, 2011 at 6:00 am  Comments (2)  

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

Published in: on May 17, 2011 at 9:57 pm  Comments (1)  

flying in east africa

A special dedication to Howie-

I (Ray) generally enjoy flying, and at one point in my life I wanted to be a pilot. The same could not be said for Rachel, who does love to travel, but would prefer if it didn’t involve rocketing 30,000 feet in the air in a wobbly metal can full of explosive jet fuel. To her credit, this has never stopped her from going anywhere in the world!

Our first flight out of SFO was on a pretty nice plane…

oh wait, that was Air Force One. I believe Obama was visiting Facebook, where he probably asked “want to bet how many likes I’ll get if I kill Bin Laden?”. The result was all our flights were delayed about 20 min for extra security steps.

our first leg was a much more conventional KLM 777 direct to Amsterdam.  Even though it’s a grueling 12 hour flight, they get points for their frequent and above average food, and solid personal entertainment system.

Once in Amsterdam, we only had about 2 hours to connect to our flight to Nairobi, not even enough time to acquire euros and purchase a Heineken.

After another 6 hour flight, we arrived in Nairobi, Kenya. We only stayed for about 10 hours before we hopped on another flight to Zanzibar, Tanzania! We booked this airline called Precision Air before we left. I’ll admit we were a bit skeptical of booking a regional East African airline (my experience mostly being with regional Asian airlines, which are either great or very sketchy…. I’m thinking of you Asia Spirit!), but the plane turned out to be a pretty new-looking ATR-72. I was very distracted by the tasty organic yogurt with granola they served on a 40 minute flight!

Our preferred mode of transport.

After our awesome time in Zanzibar (see past posts for pics), we flewback to Nairobi for a day, then we were off to the Maasai Mara for Safari! Our Safari company booked the tickets as part of the deal, so we went to the regional airport to check in to Air Kenya. When we asked what kind of plane we’ll be taking, they said it depends on how many people are flying that day. Apparently they book tickets and assign their fleet of small prop planes later.

When we collected our boarding passes, the Air Kenya employee said “you will be the fourth stop today”. Fourth stop you say? No, we’re flying to the park, not taking a bus. Oh, this is a plane? Oh so we stop at 4 different dirt air strips in the park, each 7 minutes apart. Do we land or do we parachute out? Eleven seater? Sweet. Why does Rachel look so green…

The best part was when we were the last passengers on the twin otter (see above), and the pilot was clearly letting the 23 year old co-pilot practice taking off and landing. I suppose it’s similar to what we do when we let medical students and interns stick large needles in people in the hospital… “watch one, do one, teach one”

Well, the view when flying 2000 feet above the Maasai Mara is breath-taking. I tried taking a few shots but they didn’t do it justice. We buzzed a few elephants and giraffes! After our 4th landing, we were greeted by this amazing 20 year old Land Rover that was tough as nails, but desperately in need of a new clutch.

After 3 days of watching animals and bouncing around the park in the Land Rover, we were sitting on the dirt runway again. I remember watching the guards chase zebras off the runway, awaiting our twin otter to take us back to Nairobi, when this relatively huge 50-seat Dash-7 drops in.

After a very quick and smooth ride, and another couple days in Nairobi, we were off once again, this time Kisumu, our current base. The plane was a small Kenya Airways Embraer, and the flight was most memorable for the slick maneuvering the pilot did to avoid the usual afternoon thunderclouds that roll through this part of Kenya. A choppy but well-flown flight by the pilot.

Thankfully, the only flights left are the ones that will take us home in 2 weeks! More posts on daily life in Kenya soon.

-Ray

Published in: on May 17, 2011 at 6:00 am  Comments (2)  

the ambassadors

As Rachel mentioned in a previous post, there’s a group of kids who live in our apartment building we call “the ambassadors”, because whenever we walk through the gate, they will suddenly stop all shrieking, running, and other horseplay, walk up to us, and with a straight face, shake our hands in turn and say “hello, how are you”. When Rachel brought the camera out to take some pics of the building, the ambassadors insisted on being the stars of the show.

Published in: on May 16, 2011 at 7:09 am  Comments (3)  

zebras, wildebeest, gazelle’s…

the “cud chewers” or grass grazers are plentiful in the Maasai Mara, to the point that you wonder if it’s overcrowded… literally these animals are everywhere you look. And when they see you, they’ll either stare, or turn their rear in your direction.

kinda rude, i know

-ray

Published in: on May 15, 2011 at 6:00 am  Comments (1)  

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

Published in: on May 14, 2011 at 9:43 pm  Comments (1)  

hyenas vs baby giraffe (R-rated)

Warning: these pics are not for the faint of heart.

We spotted a couple hyenas in the distance and followed them to this: a mother giraffe standing over the mutilated body of her young.

Over the next hour, we watched a back and forth standoff between a dozen hyenas and the mother giraffe, who was out to either protect her dead baby’s body or extract revenge on the hyenas. She would chase them around and around, but in the end the hyenas won, and in a melee of barking, yelping, and bone crunching, they dismembered the body within 10 minutes.

I’ll post the videos I took of the drama upon my return home. If you’re feeling sad and disturbed like we were, just look at the cute pictures of baby elephants and baby lions I posted last week!

-ray

Published in: on May 14, 2011 at 11:49 am  Comments (1)  

Maasai village

We took a break from our game drives to visit a Maasai village in the Maasai Mara park. The Maasai are known to be the most isolated and traditional tribes in East Africa. Not surprisingly, most Maasai villages are known to be cautious around strangers, but this particular village caters to tourists by letting people come by and observe their customs for a fee. The chief, who I found to be very business savvy, spoke fluent English and led us on a guided tour.

He explained that they use these tourists fees to send their children to local boarding schools (commuting is not an option when lions roam the plains). His children attend a school partially funded by American donations, and he thanked our people for our generosity. In return I thanked the Kenyan people for our president.

The tour began with the men demonstrating a traditional dance. They stood and shifted in a semi-circle, with most of the men singing harmonies and one leader singing the main melody. They then took turns coming to the middle of the circle and jumping. High. Very high. Being Filipino and therefore a tragic basketball fan (tragic because its the national sport and obsession of a people who’s average male height is 5’4″), I was in awe of their tall frames (this first guy was about 6’5″) and the way they repeatedly bounced into the sky.

Inside one of the mud houses, the chief explained that their tribe continues the traditional lifestyle, where men herd their cattle through the plains (they often graze alongside zebras and wildebeest) and defend them from predators. The women maintain the village and build the mud houses.

Their traditional food staple is cow’s blood mixed with cow’s milk. I asked him how many cows they have to kill to do this, and he explained that they don’t kill cows daily. Instead, several men hold one cow still, and they lance the jugular vein and let a few liters of blood pour out before patching it up.

Now that most their children attend boarding schools (which are a mix of different tribes) they are exposed to other children with more westernized habits. At one point one of his sons came home and asked his dad to trade a goat for some hamburgers and fries.

The children looked extremely happy to be back on their break from classes, and were running around the village, laughing and saying “hello mizungu (white person) how are you!!!”. The chief said he was a little sad they would be going back to boarding school by the end of the week. The only kid staying behind is his newborn son, for whom they threw a celebratory feast the other day complete with barbecued goat!

Overall, it was a fascinating experience. I enjoyed seeing the dance, and they enjoyed it when they insisted I join them. This was not a window into a socially isolated people. Many of the villagers spoke excellent British English, a few had cell phones, and they were very active in trade with other neighboring tribes (whom often dressed in western clothes and drove Chinese-made motorcycles around). Yes it was somewhat artificial, a show for tourists, but together with our discussions it was an honest window into how very old traditions meet a continuously changing world.

-ray

Published in: on May 12, 2011 at 6:21 pm  Comments (1)  

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.

Published in: on May 11, 2011 at 6:25 pm  Comments (2)