Someone asked me this, because I was only talking about my work gardening and pulling weeds on the grounds, learning Dholuo, and sightseeing or fighting with the bureaucracy in Nairobi.
Yes, I am doing a little medicine. I am currently studying malaria, trying to really understand the life cycle, why it is important, how the drugs work and their pharmacology, and the host factors or treatment refinements that may change how the disease responds to treatment. Every time I read the 2015 World Health Organization (WHO) Guidelines for the Treatment of Malaria, I learn something new or see something in more depth. Amazing how motivating it is to have daily reminders of the seriousness and incredible prevalence of this disease!
Then I try to create an engaging, interesting conversation with the staff, who have all seen much more malaria than I, and transmit the current global standards for diagnosis, treatment, and prevention of resistance. That’s the hard part–overcoming months or years of the habits of professionals–and helping them change the way they practice. I have to remind myself regularly that practice changes often take decades to implement fully, and they aren’t going to happen in a year just because some ex-pat describes the ideal a few times!
What a great day today. The day began with a great discussion of a case study I prepared –a conglomerate of many malaria patients I have seen since my arrival in Kenya. We had a lively discussion of the case, and everyone participated: nurses, lab, pharmacy, reception and even the Information Technologist. There were real differences in how people interpreted the facts of the case, and even differences of professional opinion. Everyone was respectful of each other, and everyone with patient contact contributed. I think we aired some very good issues, talked about best practices and how to best implement the guidelines, even down to some discussion of where to best treat the patient, when to ask the lab to come to the patient rather than sending the patient to the lab, and how to prepare tablets that get crushed and administered to children. (During regular hours we can ask the pharmacy to prepare, and when we are on-call, after hours, the nurse can crush and mix with drinking water right in the holding room.)
Next, I saw some patients with one of the nurses, and one was a child with a positive blood smear for malaria. It turns out that she had been to another facility and had been given oral anti-malarials just two weeks ago. The family decided that she had actually been bewitched, and so she did not complete the medications. Instead, they took her to the herbalist who gave her remedies, but of course the child stayed sick. The mom even told us the child had vomited, in an apparent attempt to get an injection. Turns out the child was eating okay and last threw up three days ago. The mom said the child was “afraid” of the oral medicine, so we asked why. Turns out, the whole family had the impression that an injection was better for malaria than oral medication. Since I had just reviewed the treatment of malaria, I was able to describe the actions of the oral medicine, how quickly it entered the blood stream (peaking within 2 hours), and the benefits of using the combination pill rather than the single drug injection.
I was also confident that we were treating recurrent malaria due to inadequate treatment, rather than treatment failure which would require other drugs. Two weeks is too soon for someone to have a positive blood smear (visible parasites in the blood cells) if they have been adequately treated. After the three day treatment is complete there is a period of time, 4 or 5 days, in which one is somewhat protected from re-infection by a new mosquito bite. Then, there is a period of time, 7 to 9 days, after the bite, when the malaria parasites are hiding in the human liver and not causing any problems. During this time they are not visible in the blood smear.
In the end, the mother agreed that the oral medication sounded good, and felt that she could explain it to the father in a way that would also convince him. They left happy even though we did not give her a shot, and I was fairly sure that this time the child would finish her medication and eradicate the parasites in the blood—at least temporarily!
This part of Africa is called “hyperendemic” for malaria, and we are even more prone to get it being in a lakeside area. This means that malaria is always present in the population, is present in high numbers, and is highly transmissible—lots of the mosquitoes are infected. The mosquitoes here prefer human blood, and they live a long time in the mild climate. This corner of Kenya, the lakeside west, near the border of Tanzania, must be the best kind of environment for the mosquitoes that carry the Plasmodium falciparum parasites. P. falciparum is responsible for the most serious and deadly form of malaria, and is the most common cause of malaria here.
I went back to Ochuna and the Craft Cooperative with friends and took some more pictures of the crafters, crafts and the organizers. We had a lovely time and the basket makers even let me try my hand at adding rows of sisal fiber. They do it by threading a needle with one fiber, then binding on the bundle of fibers to the round. Sewing is the same here at the end of the road!
Joyce makes us lunch Monday through Friday. Tamara is vegetarian when possible, and I told Joyce I prefer not to eat meat, but we both will eat fish. She makes us lentils, beans, rice, and sukuma wiki, the local kale. We sometimes get pasta with a tomato sauce, and even pizza. (You have not lived adventurously until you have had Joyce’s pizza with Nile Perch and vegetables on top.) Tamara scored some mozzarella cheese at the supermarket, which we keep frozen. That can be used for pizza and pasta. Parmesan cheese does not seem available anywhere in Kenya, but we have a tiny stash that Jack sent (thanks, Jack!) that greatly improves the pasta. Usually when she gets a perch, Joyce cuts it into chunks, fries it, and then makes a stew with vegetables. It is quite yummy. She made potato salad one day, which was very good, and she also makes a nice potato soup. The vegetables we have plenty of are cabbage, kale, red onions which are incredibly sweet, firm plum tomatoes, green bell peppers and potatoes. Sometimes we have some green onions, but not as commonly. When I first got here we had carrots, but I have not seen any lately. For fruit we have green oranges that are orange inside, pineapple, and bananas. Papayas grow here but I never see them in the market. Watermelon grows for people with irrigation, but the season is short here and we haven’t had it for a while. Just got one in the supermarket in Migori, imported from heaven only knows where. Mangoes seem quite seasonal, and July and August are not the season! Joyce bakes cookies and cakes, but we have to store the cookies in the freezer to keep them from the ants. I think we have given up on cake for a while—we didn’t get to eat any of the last one she made because the ants found it first. I don’t really enjoy ugali, the corn flour staple, so Joyce makes chapatti or really good corn bread.
For dinner we usually eat leftovers, unless one of us is inspired to make pasta, rice, eggs, potatoes or lentils, or some combination thereof. Joyce will make popcorn for us, and that is nice to snack on.
As you can see, we are quite spoiled and none of us is losing any weight–no danger of undernourishment for us. The poor people are always at risk–more on that tomorrow.
My darling step-father, who gave me his Tilley hat for my journey to Africa, asked for this topic. Stefan, this one is for you!
First I will tell you how we mzungus eat in the cookhouse with the luxury of Joyce’s experience, years of cooking for visitors from all over the world, and the specialized tools here: gas burners, a stove-top asbestos baking set-up, and the solar oven. (The freezer comes in handy, too, but the refrigerator has apparently outlived its rubber seal and no longer keeps things cold OR free of ants.)
We prepare our own breakfast for the most part. We have oatmeal, homemade granola (thanks to the solar oven), scrambled eggs with vegetables, or cold cereal. The Kenyan cold cereal is called Wheatabix and Tam likes it but I do not. It is soggy, which makes sense after I learned that it is used to make porridge—hot cereal. I found some corn flakes that taste breakfast pretty good and stay crispy long enough to make me happy. We have whole milk, so of course that tastes delicious. We have a good brand of Kenyan instant coffee and black tea. I occasionally stop somewhere for mendazi and chai. Mendazi are fried dough, and are often served with a weak, very milky and sweet tea called chai. I’m sure it is the unhealthiest breakfast ever, but I actually enjoy it a lot. We miss toast, but occasionally we buy the terrible white bread and “toast” it over the gas stove or fry it with margarine. I have also found some natural peanut butter and will eat peanut butter and banana, sometimes with bread. The rest of the peanut butter in the stores is full of sugar and tastes terrible to me. Macadamia nuts are grown here, so sometimes we put them in cereal. They are expensive, but available in the bigger towns.
This week we had french toast! We had it for lunch, but still, it is a good breakfast food to keep in mind. There is no maple syrup here, but honey works, and I like it plain, anyway.
I feel so bad that I posted the last post about fishermen being at high risk of infectious disease, and that I had not heard of them drowning. The very next day, a young man drowned here in Matoso. He was out fishing with another man, and the waves were higher than usual. I guess the boat tipped, and they both went into the water. One survived, and one was not found. He was apparently quite young–not yet married–and from a family in this area.
I have been told that the family must stay in the village center, near the small fishing dock, for at least three days, or until the body is retrieved. So please forgive my insensitivity. Fisherman die here, in the same ways as they do all over the world.
Matoso is a fishing village. Because of the way things work here, being involved in the fishing industry is very high risk. Not of drowning, or having fingers and limbs cut off, but of contracting HIV. I mean, maybe fishermen drown and lose fingers and other parts here like they do in the rest of the world, but here, they are also at very high risk of contracting HIV.
It didn’t make sense to me at first, and I confess I still don’t completely understand, but here is what has been explained to me. The fishermen go out in their boats and spread their nets, and pull them in to the beach in the morning. Then they have fish to sell, and the fishmonger women come to buy them. It turns out, the women compete for the privilege of buying the fish, and the competition involves sex. So they won’t get to select from the best fish unless they are willing to have sex with the fisherman. Then, maybe he lets them buy fish from him. Anyone who is not in on the game gets only the tiniest or poorest fish, if anything.
So maybe the fisherman has a couple of “fish wives”, as well as one or more wives back tending the farm. And I suppose the fish-monger women may have to barter with more than one fisherman in any given week. Anyone making their living fishing here is in a very hand-to-mouth existence. There is not a lot of money in fishing with nets, in wooden boats that are not even watertight. I suspect there is even less margin in buying and selling fish in the market. The desperation is evident, and the price is the high rate of infection in fishing communities.
I have been welcomed everywhere I go in Kenya–and people love to take their picture with the white lady! The pictures are just snapshots of daily life here, with friendly Kenyans, both familiar and brief acquaintances.
I need a lighthearted topic today, as we await the outcome of the election.