My thoughts are increasingly focused on two months from now, when I leave Kenya after spending a year here. There is so much left to do!
Hire a nurse for the expansion of treatment of HIV at Ochuna, and wherever else we need them.
Make sure all the nurses are licensed in Kenya. Some were hired a year ago and have not yet gotten their Kenya license—I think it is because it costs them money to do so, and no one has put much pressure on them thus far.
Meet with the Kenya Ministry of Health and get them to agree that we can treat all HIV positive clients on site with anti-retroviral drugs (ARVs), TB prevention, and prophylaxis of opportunistic infection. (Currently our mandate from MOH only includes treating pregnant mothers who come to us for antenatal care and are then found to be positive, their children and partners found to be positive at our site.)
Hire a “mentor mother” who will be in the well child clinic so that all our duties to the mother won’t be forgotten as we take care of the babies: moms need Vitamin A, sometimes tetanus or Rhogam, post-natal assessments at defined times after delivery, support in the areas of nutrition and breastfeeding.
Make sure somebody feels comfortable assessing the patients with high viral loads (the virus is HIV, and approximately 12.5% of our clients are infected), making sure they get counseled and re-tested if they are adhering to treatment, and switching them to another regimen if needed.
Familiarize the nurses and clinical officers with the system that exists for clinical consultations for complicated HIV cases. This is something I just became aware of in 2018, quite by chance, and I have not yet succeeded in actually getting an answer from them. I have learned how to contact them, how to submit a clinical summary, and several contact phone numbers and e-mails for the county and the national levels. We will undoubtedly need more assistance on cases beyond the two I have submitted so far.
Finish my contributions to re-writing the clinical guidelines for Kenya—a huge project which the folks back in the states are helping me with, thank goodness.
Keep my trees and flowers alive for another two months, and with any luck, figure out who will take care of them when I am gone. I hope the new Agriculture In-Charge will take them on, but she has quite a full plate with the shamba of vegetables for the children’s home, and the “public” parts of the grounds. My plants are mostly in the expat portion of the compound. I now have a small papaya tree, and lots of papaya seedlings, an avocado tree, a loquat tree, some passion fruit vines, multiple philodendrons, two mango trees (volunteers) and several shade trees, the names of which no one knows the English translations for.
The other really exciting thing is that I am having my first friends come visit me! We are going on safari to the Masaai Mara, and I am so excited.
Rechargeable reading light–this Lumino light is by far the best thing I brought!
Unfortunately I lost the charging cord recently, and it is now too dim to use. I ordered another one and it is coming soon!
In the meantime I found a little lamp here that works well on my bedside table. I have to sort of aim it properly and position my book just right inside the mosquito net, and I can read in bed–one of the joys in life, in my opinion.
Small pen-light torches–brought 12! good job. I always have one clipped to my right front pocket, along with my pen, and I use it multiple times a day–in the clinic, but also in the cookhouse or to see into dark corners or to guide my way when I walk in the dark.
Keen sandals–brought three pairs. Should have brought a few more pairs of SmartWool footie socks–I don’t know what they are really called, but the ones that just fit around the moccasin line of your foot and make plastic sandals more comfortable.
Yubi power adapter and surge protector–mine has two 2 USB ports and a socket for a grounded plug. This is incredibly useful, and I could have used 2 of them here.
Brought my unlocked old i-phone and it works great. I just buy another sim card if I go to another country for more than a day or two.
Goal zero solar charger and storage unit–was a good idea but only worked part of the time, and then I could no longer charge phone from it. Not quite sure what the issue is, but the storage unit is a very good flashlight, so it’s all good.
Dental floss-should have brought more. Bring one package per month. Toothbrushes are available, but they seem to all be hard, or at best medium. No soft ones. I brought my electric toothbrush but it refuses to charge so I could only use it for a few days. Same thing happened in Sierra Leone, so don’t bother.
DEET- containing insect repellent. One needs plenty, and it is not available here in rural Kenya.
Permethrin impregnated shirts. Next time, bring the pants, too. I spray mine periodically, but having the ones that last for 72 washes would have gotten me through the whole year.
Things I should have brought:
Mobile hotspot with sim card, removable. I was given one after arriving, but it really is a lifesaver here.
A fan–paper or plastic, non electric. I don’t know why, but they are not seen here often. I bought one in Sierra Leone from a woman at the craft market. She wasn’t selling it–it was her own!
More discreet panties–not thongs. Everyone hear wears long knit shorts (omg they look hot, but at least keep your thighs from sticking together) under their skirts, and of course all clothes are used–matumba!
Solar-recharging lights/torches. But you can buy some here. Batteries are a pain in the neck.
Shampoo-hard to get good quality. I’m keeping my hair short so two bottles should be enough.
Prepare computer ahead of time-load software, movies, books or music. You pay by the minute to download anything here, so all those Amazon Prime or Netflix videos are being paid for twice. Mostly I do without, but it was really painful to fly across the continent with nothing to watch, and only one book.
Bring some thumb drives for work.
Computer should have had Bluetooth, and/or better sound. I bought (later) a nice Bluetooth speaker, but my computer doesn’t connect! Oh, well, I use it with my iPad.
Parmesan cheese, bacon bits, decaffeinated tea and coffee–any little things which keep and that you really like. You cannot get good cheese here, though we have finally found real butter. Don’t bother with bringing crackers unless you are okay with eating them all in the first week or two–I really miss them but they get stale so fast, even if the package is unopened.
I’m sure there are many more things I should note down, but maybe there will be a Part 2 to this blog!
I spent the day attending patients in the remote clinic in Ochuna. It is a much smaller site than Matoso, and is not open for emergencies or deliveries. It is less than 5 km from the border with Tanzania, and many of our patients come to us from very rural areas of Tanzania. Malaria is even more common than it is here for some reason–probably poverty, poor nutrition, and maybe fewer mosquito nets.
It takes 45-60 minutes to get to Ochuna, and today I rode a motorbike with another staff member who helps at Ochuna frequently. He does data gathering, registration of patients, immunizations, dispensing in the pharmacy, –and driving, obviously! On the way, we saw men from the Rural Electrification part of the government installing electric lines in the village of Othoo. Imagine, all of this part of western Migori County (and much of Kenya, I’m sure,) has no electricity, no water system, no trash pick up.We are truly living in the wild, wild west. And just because they were putting in lines does not convince me we will have electricity soon. Poles and wires have been in place in Ochuna for two years, but the transformers all failed, apparently. So they sit.
For the first half of the day hours, from 9:30 until 1 pm, I saw patients with Mary, the nurse. We saw a bad scrotal abscess in a three-year old that probably started with the itchy rash of scabies. (Scabies is also rampant in Ochuna and our patients in Tanzania.) One family of a mother, her 4 girls ranging from 5 to 11, and her one year-old son–all the kids had scabies, and the mother and one of the daughters had malaria, as well. We saw a girl who fell down yesterday and felt a foreign body in her knee. Mary pulled out a splinter 2 cm long! We saw one child, about 2 years old, who had such severe malaria that we immediately referred her to a hospital. (Fever measured 38 degrees C, respiratory rate 60-80/minute, lethargic and dehydrated.) Mary suspected they would not take the child for lack of money, and there is no ambulance in Ochuna, so we also gave the treatment for malaria so the mother can at least try to give at home. I suspect the child will not survive the next 12 hours, but only God knows.
From 2-4:15 I saw patients with one of the medical assistants translating for me. Many of our patients were sick with malaria or just fever, but we saw one child with dysentery (bloody diarrhea). She got zinc tablets, ORS, Bactrim antibiotic, and Whitfield’s ointment for her scalp fungus. Many of the ladies came for their depo-provera shots, and Mary put in some long-term implants. We talked about PReP (pre-exposure prophylaxis of HIV) with one woman, not so much for her but for her husband, who is negative, because the first wife is positive. Mary knows the husband, whom she says will not come to the clinic for testing or treatment, but I was glad we got to discuss it with the second wife. Luo family culture is very complicated sometimes, with its odd blend of acceptance of sexuality as part of life (often resulting in early sexual intercourse–especially for girls–and multiple partners throughout life as far as I can tell), polygamous marriage, and Christianity with its attendant shame and secrecy.
We rode home again on the motorbike, taking about an hour and arriving back in Matoso hot, sticky and dusty. Time for a welcome cold shower!
I am busy, and happily so. The Vice President of Lalmba came to visit for a week so we were busy with meetings and staff interviews to hire a public health specialist and an agriculturist–both new positions.
The VP complimented the work I have done so far to beautify some parts of the compound. I have shrubs growing in clay pots, philodendron under a tree where formerly grew only weeds and spiderwebs, and several fruit and shade trees started. (Avocado, loquot, mango and shade trees I do not know the names of.)
And that’s just my after-work work!
I feel like I am finally getting in the rhythm of being an ex-pat Medical Director. Here is my week, which I feel is fairly representative:
Sunday: walked with the Public Health Director to neighboring farm belonging to a local community organization. Her goal was to view the shamba and advise the group members in how to get the water pump they would like. We met one of the organization members on his personal shamba, which was lush with oranges, papaya and other crops. I talked with him about my problems with growing trees, and he presented me with a beautiful papaya fruit and we arranged for him to come and plant a papaya tree at Lalmba.
Monday: worked on the rewrite of the Medical Guidelines specific to Lalmba in Kenya. These were last written in 2008 and must be updated and harmonized with our current formulary of drugs.
Tuesday: spent too much time completing business related to my health insurance back in the United States. This project involved forms to fill and sign, then e-mail to my partner Jack, who had to print and send with a check to the company. All vastly more complicated than it should be in this day and age, but I am grateful that after my health insurance coverage, which was suspended for many months, it has finally been re-activated. Thanks, Jack! I consulted with a teacher at a nearby vocational school who was concerned that one of the students, a twenty-year old man, seemed to return from each break spent at home with symptoms of a sexually transmitted infection. I assured her that it appeared to have been treated appropriately, and that no, that particular infection did not “stay in his body forever.” I told her that his partner at home likely needs treatment!
Wednesday: Normally I help document immunizations in the Well-Child clinic, but today we had a visitor from Palladium. They are the folks that have developed KenyaEMR, our EMR. While he was here, we did a “regular data quality check.” We got excellent scores for completeness of everything except some scores for tuberculosis. It turns out it was good I was there, because I was able to convince the rest of the team (all non-clinicians) that the EMR did not give us a chance to gather all the information they were looking for. We were recording everything we could, but the tools we were given were faulty. In the end, the guy from Palladium had to go back to his team and tell them they must solve this problem. That felt like a big victory.
Thursday: I went to Ochuna, our remote site, as I try to do every Thursday. As I arrived, Mary told me that she had two patients for me to see. One was a 47 year-old woman who had been brought in by her much older co-wife (the husband died a long time ago) and other relatives because she was confused on Wednesday, and unable to walk and talk Thursday morning. After much conversation they were finally able to make me understand that the woman had actually been sick for at least a year and a half, having to do with a mass in her abdomen, and had been given no long-term medications or diagnosis at the time she was seen at the referral hospital. Of course, they had left any medical documents they might have had (one is normally given some kind of referral letter from your local clinic to the referral hospital, and a letter from the referral hospital back to your subsequent care-givers) at home. Sure enough, she had a firm mass in the abdomen which was NOT her spleen, and which was quite obvious to even the untrained eye. Our conclusion was that she had some kind of neoplasm. She seemed to feel a little more normal after we gave her a liter of fluids intravenously, and got up and walked, and talked with her family. We recommended that she go back to the referral hospital for diagnosis and treatment, but the family took her home. There was no money for a hospital.
The second patient was someone I had seen a month or so before with a swollen left foot and pain in the left groin. It looked like he had an infection in the foot so we gave him antibiotics. He came back because while his foot was less swollen, now his entire left lower limb was swollen from ankle to groin and felt tough and “woody”, and he had bumps and pain in the groin. Mary suspected a dramatic and fairly classic case of very rapid onset Kaposi’s Sarcoma which usually accompanies AIDS, and I agreed. He came from Tanzania where he is living, but his home is in Kenya, so we recommended he go to the county hospital in Homa Bay, our neighboring county. Homa Bay County has the highest incidence of HIV in Kenya, and there are specialists from Medecins Sans Frontieres (MSF, Doctors Without Borders) there. We hope they may be able to offer him some kind of treatment, because we had none to offer.
The rest of the day we saw our usual scabies and malaria, as well as other routine cases. I also saw a nine year old girl with pain in the left chest and ronchi on just that one side. She had recently been hospitalized and was on some unknown medications, but again, they had left all paperwork at home so we really had no way to tell if she just had resolving pneumonia or something more serious. We advised they complete the course of medicine for another week, and return if she was still ill at that time. And this time, bring all the paperwork!
Friday I was back in Matoso and was called to help counsel the family of an HIV positive eleven-year old girl. She is one of our approximately 30 clients who are failing in the treatment of HIV and therefore have a “high viral load.” She usually comes to the clinic alone, but on this day she came with her mother. (Everyone in the clinic and our area seems to agree that the mother is “not mentally fit” but cannot tell me what makes her so.) We talked with them, but I noticed that the baby the mother was carrying on her back looked pretty tiny and wizened. I unwrapped him, weighed and measured him, and found that he was severely malnourished: 10 months old, 3.7 kg, 47 cm tall, with an upper arm circumference (MUAC) of 9 cm. (normal for child under 1 is >12.5cm, if I remember correctly.) He had thrush, and mom admitted he was breastfeeding but not getting much. Much of the morning was spent getting him treated and referring the family to relief, our program in Matoso for children or elders who need extra nutritional supplementation. It is likely that the mother of these children is not taking medication for her HIV. As the children are not orphans, and the mother declines or is unable to accept treatment, it seems there is nothing we can do for this desperately sad situation.
Highs and lows, and sometimes pushing rocks uphill. That’s my life in Kenya!
Banded groundling dragonflies flutter their short lives away with barely-there percussion in my shadow as I gather the valuable leavings of the cows. Why don’t we call it scat, as in the leavings of raccoons? Is it too boring to earn the jazz name, composed as it is of grass and leaves, barely touched in the journey through mouths, stomachs, mouths again and gut? It may not have variety of content, but it is a gallery of different forms: rosettes of flat and lacy fiber, soft, glossy stacks teeming with larvae and their attendants, or dried pucks of shellacked and hollow rind? And don’t forget the mounds of half-termite-hill, half scorned and uneaten dung—left perhaps from day-before-yesterday?—that will add ready-made soil to the concert of compost.
Today started like any other Saturday: I woke up at seven and puttered around making banana pancakes and eating them for breakfast. Then I wandered up to take an armful of books that the current ex-pats have either already read, or don’t want to read, to the library. The clinic is open only for emergencies and maternity on the weekend, so it is usually quiet. One nurse is on call for the entire weekend, and handles everything. Only occasionally do they call another nurse to help them. Today, there were 25-30 people standing around inside and outside the clinic, and the project director was in the crowd. He explained that the nurse on call was in the procedure room with a patient. They had had to latch the door to the procedure room, from the inside, to keep all these people from walking in and out of the room as they were working. The project director said I should go in, so I knocked and the folks inside let me in.
The patient was a man who was bleeding profusely from multiple lacerations of one thigh and leg. His friend was holding the injured leg in the air as the two medical folks were attending to the patient. There was a puddle of blood on the floor, and the nurse was struggling to suture the first laceration on the top and back of the thigh, about 6 inches long. The skin was torn loose off of the front of the thigh, leaving a triangular area of muscle exposed that was probably 6 inches long and three inches wide, with a large flap of skin hanging down. There were three other lacerations on the back of the thigh and behind the knee that were somewhat shorter, but deeper.
Later, I found out that he was a fisherman who had been swimming out to his boat. On the way, when he was in deep water, he met a hippopotamus, and that is what tore up his leg! I was told that it was very good that the water was so deep, because that meant that even the hippo could not get his feet on the bottom of the lake. The thirty or so people at the clinic were friends and family, waiting for him to be treated and wanting to take him home.
We dressed his wound with some new bandaging materials donated to us from Kenya Relief. I don’t know what we would have done without the long gauze strips and the Coban we used to wrap the leg, because the only alternative would have been 4 x 4 gauze with yards of tape. Partnering with Kenya Relief was great for us, and for our patient. You can look them up here to see the kind of work they do: https://kenyarelief.org/
Like everything else in Kenya, I expect 2018 to be a very similar, patched and mended 2017. The work goes on, slowly by slowly, both clearing the fence line and mentoring the nurses.
I spotted this guy in Matoso Center (we are not big enough to be a village) on Wednesday, market day. He had his fire and tools set up in the shade of a tree and was mending plastic basins and buckets. My bet is he charged only 30-50 shillings (about 30-50 cents) to repair each item. He heats up the fire with a bellows made from a grain-sack.
I got my panga sharpened, both edges, and it only cost 30 shillings. A handle for my new jembe, the heavy hoe-like chopping tool, cost only 50 shillings but still must be fitted to the blade. My friend Maxwell, a young man trying to get enough school fees together to go to school for engineering, made a handle for my new rake from a branch lying in the compound. The most expensive item in my collection is my new full-length (120 feet) ¾ inch hose-pipe. It cost 3000 Ksh, or $30.00 in Migori, and like all hose-pipes I have seen here has no threads or fittings on either end. I am learning how to tie things together with strips of inner-tube! Never throw those useful things away. I am collecting my own tools so I no longer have to borrow from the groundsmen. I will leave most of them here when I leave, but I may take the panga and jembe with me.
Several people have asked if they can send me something for Christmas. Really, it is crazy to send gifts here! It costs me money to pay the customs, and someone has to go to Migori during the work day to pick up packages from the posta.
If you are truly motivated to give this holiday season, I would be most grateful if you would donate to Lalmba. Mention my name if you like. I promise, this is the best gift for me.
Or send a check to Lalmba Association, 1000 Corey St. Longmont, CO 80501
To give you an idea how your donation can help, here are some of the medical projects (actually a very small sample) that Lalmba is working on, and I am involved in, in Kenya:
Receiving blankets and soft towels for the newborn babies in Maternity. It is considered bad luck to prepare much and bring things to the hospital, so some women arrive with nothing. I am buying these in Matoso Center, used, at 50 shillings each (about 50 cents.)
Expansion of services to adolescents, those young people ages 15-24 who are most at risk for new HIV infection, unwanted pregnancy, sexual assault, and trading sex for food. We hope to create a welcoming corner in the compound where youth can gather, talk with trained peers and each other, and have easy access to a nurse for accurate health information and confidential services like sexually transmitted infection screening.
Digital thermometers and blood pressure cuffs so that each nurse can have their own.
Proper scales and height measurement for infants, children, and adults.
Possible in the future: adding care for HIV patients in Ochuna. Currently they have to travel quite far for care. (We provide primary care and anti-retroviral drugs to about 500 children, adolescents and adults living with HIV in the big clinic in Matoso.)
Lalmba does good work. See the website for more information.
Friday, during a funeral that most of our staff attended, a mama arrived late in the afternoon carrying her sick child, about 5 years old.
She told me the child had been sick in the morning with fever and malaise, but then seemed to get better.
By the time the nurse was called and arrived from the funeral 5 minutes away, he had time to try to start an intravenous line, but as he was putting it in the child took her last breath. He was able to get a little more history: apparently the mama left the child at home feeling okay, but when she arrived back home the child was unconscious and appeared short of breath. (In retrospect, she was having Cheyne-Stokes respirations, the deep sighs that signal death is imminent.)
I found the mom, keening alone on the floor, with the body of her dead child on the bed beside her. All I had to offer were murmurs of sympathy and a shoulder to cry on, so that is what I gave.
We suppose she had severe malaria, which kills so many of the children here. We will never know for sure. All I know is that another funeral will be held. One of too many funerals.
So, I live right on the shore of Lake Victoria. We hear the waves at night. Unfortunately, we also live very close to the people of the small center of Matoso. When people here have a funeral they always seem to hire loudspeakers, microphones, and music, and the speeches, music and sermons go on all night long. This week there have been two nights where we were not able to get much sleep due to noise from a funeral on an adjoining property.
After Thursday night’s festivities, I decided that I needed to get away for at least one night.
I am staying at a friend’s compound even closer to the water, and about 30 minutes walk from Matoso. It is so gorgeous here, and so very quiet.
This morning I woke up and enjoyed the antics of the vervet monkeys that live here.
They climbed on the cookhouse roof, looked in the windows, played peekaboo with Tamara, and sprang wildly from treetops to the ground to the roof and back.
One of the monkeys playing on the solar panels atop the power house.
We fed them our banana peels. There’s a baby with its mother and the baby is about the same size as the kitten born a few weeks ago to the feral cat in our compound.
This property is more rural and next to some very rocky hills called Got Kachola. I’ve always known that the monkeys hung out on the hill but I didn’t know they came down to the compound here. The compound is very lush and there are so many Bougainvillea plants of different colors that the owners have had planted here.
I hope my pictures can partially do it justice. Of course I can’t show the wonderful expanse of rocky shoreline beach and property that they have but I can show you glimpses.