Hakuna Matata

I have now seen the big 5... the majectic Lion, the sexy leopard, the steady water buffalo, the family-oriented elephant and the quiet rhino. (note my personalization of each animal, hehe) How cool! I just got back from a week of safari, which included visits to three main Kenyan national parks: Masai Mara, Nakuru and Samburu. They are vast with beuatiful sceneries and gorgeous animals. My favorite animal was the giraffe, as it exuded elegance and confidence (how I wish I could demonstrate the same on a daily basis). The hyenas surprised me the most -- they are super cute animals!! Since seeing the Lion King (an undisputed cultural reference), I had always assumed that they were ugly animals with nasty atttitudes. Clearly, both Disney and I were wrong!


Jeremy, Christine and I had a great time, chatting with locals, our safari guide/driver John and the campsite managers, who frequently provided me with tips on how to "become one with nature" and live with a Hakuna Matata attitude. Although I can't say that I'll live from here on out without any worries (as they have suggested) I am currently relaxed and enjoying every minute of it! I have at least 1000 pictures from this past week and just as many memories! Enclosed are just a few; a larger selection shall be posted next week on Flicr.


Today, Christine and I were privileged enough to get a guided tour of two coffee plantations around Nairobi. I LOVE coffee and can barely get through a day without at least one cup. Before today, I had no idea what went into the creation of my daily addiction... The process is complex and involves a lot of agricultural engineering, pure biology, safe farming practices and a pact with Mother Nature, just to name a few. I am now a "coffee expert" as the Fairview Coffee Plantation Manager stated, after I had my first "cupping" experience (tasting and discriminating between various green coffee beans and their blends). The process is very similar to wine tasting, just with a more acid taste and a more lovely aroma. I don't think there's a nicer smell than freshly ground (or brewed) coffee. The Manager provided us with some of his highest quality coffee beans to take home with us. I can't wait to share a cup with my fellow addicts (mom and Dad, this include you!! hehe)

Tomorrow, we are off to the Kenyan coast (south of Mombassa for those who like maps) to enjoy the white beaches. I'm looking forward to swimming in the Indian ocean and laying like brocoli with a book in hand. Isn't vacation splendid!

Delphine Akyini

WOW -- what a week. After a calm weekend, I opted for some adventure at the beginning of this week and traveled to the islands of Lake Victoria. What an experience! I spent three wonderful days there, learning how to bathe without running water and cook without electricity. The locals have developed some ingenious ways to deal with mother nature; I"m so impressed with their ability to stay somewhat healthy and promote education and progress within their community with so little technology. The time I had there afforded me the opportunity to chat with many locals about their culture and ways of life. After a lengthy conversation with two mothers and one of the FACES staff, I was re-named Delphine Akyini, which stuck for the remainder of my time in the islands. The second name is a tradidtional Luo name given to someone who was born in the morning. Part of this was in gest, I know, but I like to think it was also in appreciation for my curiosity about their culture. :)

The FACES clinic itself is awesome as well. It's a mobile clinic that visits three different islands within the week. I had the opportunity to work at the large stable clinic in Mfangano and help with the mobile clinic in Ringiti. The mobile clinic, as my good friend Keegan would say, a "suitcase clinic", meaning we bring all of the patient's charts, medications and laboratory necessities to the island on a dinghy little boat, while navigating the waves of Lake Victoria. And on this particular Tuesday, a rainstorm as well! On Ringiti, we set up shop at the local dance hall/bar because that's the largest space available to use. We use the bar tables for registration, medication administration and "blood-letting" as they often say here. Then, there is a separate table for the clinical officer and the patient, separated from teh rest of the room by a curtain. There, we see all of our clients and anyone in need of patient care. FACES goes every Tuesday to Ringiti with another organization named St Luc's. This is the ONLY medical care that Ringiti residents get, so they are always appreciative of our efforts. Plus, they are great patients! I had several patients ask very appropriate questions and most of them actually adhered to their complex medication regimen. I was wowed! I wish I could post pictures of this clinic, but i have no means of doing so at the moment. Perhaps later this week...

Happy Birthday to Me!!

Christine and I traveled back to Kisumu this weekend to indulge ourselves in honor of my 28th birthday. I'm still not quite sure how birthdays are celebrated in East Africa but this year, mine was celebrated with dessert. :) We started off with a lovely dinner on Saturday night at the Imperial Hotel, which the Rough Guide quotes as “the poshest nosh” in the city – doesn’t that sound regal? And today, I treated myself with a bar of scrumptious Cadbury chocolate! Previous to today, my sweet tooth had gone three weeks without chocolate, since it’s no where to be found in Mbita. I think that may actually be a record for me! It was absolutely delicious!!

Now fully satisfied and armed with enough chocolate for my last week in Mbita, I am ready to confront the true Kenyan wilderness. Tomorrow morning, I’m headed to the islands of Suba district… Sadly, I will only be there for two days, but I hope that I will be able to appreciate the fishing-village traditions and how the community works together to survive such isolation. Also, it will be interesting to see how medicine is practiced in an even more remote site than Sindo!

One of the best things about working in the Suba district is the view of Lake Victoria. No matter where I am in the area, the Lake and its islands are always beautiful. I've tried to capture the beauty during the day and as well as sunset, but really nothing does it justice. The water looks dazzling from afar, which contrasts well with the lush greenery of the countryside and the nearby mountains. Up close, however, Lake Victoria does not seem to be the cleanest body of water around. Mostly, this is because of its daily use. It's water serves as a bathing spot for many families, an area to wash clothing and dinnerware and a source of hydration (for both people and animals!). Also, in many respects, it serves as the sewage system for the local villages. In addition, it does wonders for Suba's economy. The fisherman count on the lake's Talapia for their daily wages. The lake is huge, shared by several countries, of which Kenya has the smallest territory. However, this "small" volume of water harbors the most fish. Apparently, the fish LOVE the Kenyan coastline. This makes for many jealous Ugandan fisherman...

In addition to this coastal beauty, there is a preserved national park right next door to our residence. On Wednesdays and Thursdays, we travel through the park in order to reach some of our satellite clinics. Last week, I had the opportunity to see some giraffes wandering about aimlessly in the park. Our driver was kind enough to stop to allow me to take pictures. The locals are used to sharing their space with such exotic animals, but not I. The giraffe even cooperated so nicely -- she stopped eating and stood nice and tall for her five minutes of fame! Unfortunately, I can't figure out how to upload her beautiful image appropriately, but hopefully I'll figure out this technology before my safari in 9 days!!

Outpatient Medicine

Practicing medicine on the inpatient wards is quite frustrating; working in the outpatient FACES clinic, on the other hand, is pleasurable and extremely rewarding. FACES is an organization created in 2005 by several collaborating universities in order to provide comprehensive and quality HIV care in Kenya. They are currently located in Kisumu, Migori and the Suba district, where I am currently stationed. The first Suba district clinic opened in May 2006; since that time, the organization has grown and de-centralized in order to reach as many locals as possible. They have done an amazing job in the process. As of this morning's report, Sindo (the largest clinic in the district) was providing health care to over 2000 HIV+ patients; at least 700 of them are on ARV or triple cocktail therapy for their illness. And this is only one of 13 centers! Enclosed is a picture of Mbita, one of these centers.

This means that on average, clinicians see 25-40 patients in one day! (If only I were that efficient in my own primary care clinic!!) Many of the patients come from quite far, walking several miles in order to make their appointments and get refills on their life-saving medications. I've met so many who initially presented with essentially non-functioning immune systems, emaciated and too weak to work. Many of these people now have CD4 counts above 250, are able to work, provide for their families and contribute to their community. One gentleman in particular comes to mind, who I saw last week in the little clinic of Kitare. He was diagnosed with HIV and TB at the same time 6 months ago, when he weighed 42kg, had a CD4 count of 4. He was carried to the clinic by his brother at that time. Now, he weighs a hefty 50kg and looks great -- he was the energetic lead singer in an impromptu Swahilli folk song concert that took place in the waiting room. It's always a pleasure to see such patients in my little exam room, pictured here, taking care of their monthly and often not-entirely-benign medical issues but seeing a positive trend in their overall health. :)

The transformation of Suba district HIV care has occurred with minimal resources. There is only basic infrastructure here and an ability to perform few, but essential lab tests. Before the clinic's permanent dwellings were built, most health care was provided in a massive tent! This tent is still quite useful today, providing some extra clinical rooms and a larger waiting room where patients get daily education seminars. The education provided here is phenomenal and necessary to provide comprehensive care. We have excellent community health workers and outreach teams who teach every patient about HIV, sexually transmitted diseases, TB, medication side effects, worrisome signs and symptoms, etc... They are truly the backbone of this clinic, in my opinion. A similar system could certainly be implemented in resource-poor settings in developed countries. I can definitely think of ways in which the vulnerable population of San Francisco could benefit from similar education services....

Food

My daily lunch costs anywhere from 75 cents to $1.15! The Kenyan diet, although somewhat limited, can actually be fairly tasty. The staple is ugali -- a very dense mix of flour and water that essentially replaces any need for a utensil (if you don't mind getting your hands dirty, that is). A chunk is separated form the larger bloc and formed into a spoon with one's hands. Then, it gets dipped into a stew that consists of fish or beef, or intestines (a delicacy here that I have no intention to try) next to a pile of sukuma wiki (greens). The ugali itself is fairly tasteless, I'm told, but it serves as the backbone for the rest of the dish, pictured here.

As for myself, I prefer using chipatti as my utensil, which is not surprising, considering how much I love Indian food. Usually, I order beef stew or fried beef, which comes with sukuma wiki and a side of Chipatti. The greens are surprisingly good -- a great thing, considering that this is my only vegetable of the month! Today, however, I opted for the fried fish. Tilapia is abundant in Mbita, as we are on the banks of Lake Victoria. As much as I enjoy the current meals, I am looking forward to a brief stop in Kisumu this upcoming weekend for some good Indian food. My taste buds lost miserably in "the battle of the spices" two weekends ago, but I look forward to the re-challenge. :)

For dinner, Christine and I attempt to cook. This week, our gourmet meals will likely be very carb-heavy, as we did not head back to Kisumu over the past weekend to visit a real grocery store. We did find the sole "supermarket" of Mbita yesterday, however -- there were four isles, consisting of many beauty products, rice, pasta, bread and peanut butter, porridge and beef flavoring. Needless to say, we can't go very far with this assortment! Thankfully, the open air market had an abundance of tomatoes, potatoes, sukuma wiki and fruits, which I was quite pleased about. The pineapple here is really good; I have a feeling that it will become my daily dessert. If only it weren't so difficult to prepare (i'm a lazy bum at heart).

I am in my third year of residency and by most standards I feel fairly well prepared to pursue a career as an internist or a subspecialist in the US. As I've realized over these past two weeks, this does not mean that I am well-equipped to practice in Kenya. The medicine here is very different, in all senses of the word. Because of the lack of resources, diagnoses are based on history, physical exam and clinical gestalt. In many ways, this is the way medicine was supposed to be; taking a precise history and performing a thorough and exacting physical exam have always been considered the art of practicing medicine. There is no question about this. The physicians I revere most in the States are those who can generate a short differential diagnosis just based on those skills. But not having the ability to confirm your suspicions with specific tests is quite challenging, sometimes frightening, and very frustrating!

For example, last week, a 27 year old gentleman was admitted to the ward with seizures. He was too altered to give us any history, but his brother told us that he had seized three times that morning and was supposed to be taking anti-TB and anti-HIV meds (but wasn't that compliant). His CD4 count was 22. On physical exam, he was unarousable but breathing on his own with a decent pulse. Temperature was 39, neck was as stiff as a board, pupils were reactive and he extremities were completely flaccid. The possiblities here were several: bacterial meningitis, toxoplasmosis, TB meningitis or cryptococcal meningitis. History and physical could not truly differentiate these and there were no reagents in the lab to perform any blood or CSF analyses. There was no way to image the head or spinal column. What to do? I was at a loss. The physician here, however, had been through this so many times before... the answer: treat them all to the best of our ability and hope that something works. So, we put him on anti-TB meds with steroids, high dose medication for the possibility of toxo and some IV antibiotics for the possible bacterial meningitis. The pharmacy had run out of medicine to treat cryptococcal meningitis, so we couldn't bother with that. As of Friday, the patient had stopped seizing and no longer ran a fever, but wasn't waking up very much. We'll see how he is tomorrow....

The conditions under which physicians practice are extremely challenging. The wards here (pictured above) consist of concrete rectangular rooms with about 25 beds. There are often two patients per bed, each with his or her own communicable disease. The dirty walls, overpowering smells and abundance of flies and mosquitos is also disconcerting. Lab reagents and imaging studies aren't available currently (except for HIV test, CD4 count, hemoglobin, malaria smear and a chest x-ray) and sometimes the pharmacy doesn't have the appropriate medicine. These conditions make me worry that we are encouraging disease propagation rather then healing. Thankfully, many patients do improve, thanks to the very limited resources that clinicians here are able to use and provide. What is amazing to me, is that the conditions now are much better than what they used to be! Despite the lack of resources, patients with HIV/AIDS today are getting medical care, which is a HUGE step in the right direction. This has helped curb the prevalence rate in the Suba district from 45% in the late 1990s to about 20% now (stats are per one of the clinical officers here; I still have to look up the official rates myself).