Relaxing weekend in Nairobi

I haven't updated in a few days, because there hasn't been much going on for the last few days, which is a good thing :)  After the flight from Kisumu, we got into the Fairview Hotel in Nairobi around 10 on Friday morning, and then I took a nap (because I hadn't gotten much sleep the night before). Then it was lunch at the hotel before a whirlwind weekend of going out and meeting people. Well, not exactly whirlwind weekend... It was mostly just in the evenings. The rest of the time was my time, which I spent running on the treadmill, sitting by the pool, and reading fun books.

The people that we were meeting (well, I was meeting, COL Coldren was seeing again) were some of the officers at the lab here in Nairobi, including the executive officer and a logistics/safety/IT/jack-of-all-trades officer. We went out with them on Friday night to one of COL Coldren's favorite bars while he was living in Nairobi, and it just so happened we were there for karaoke night, so everyone had to get up and sing. Then back to the relaxation on Saturday morning, and last night we went to the XO's apartment and had dinner there, then went out to a club across the street.

The apartments are ridiculously nice, and I think going there was part of the "let's sell the idea of stationing her out here" plan. It was a three bedroom, 2.5 bath apartment with lots of floor space, inside a gated compound with their own security guards, gym, swimming pools, shops, etc. In other words, a nice place. And they call this a hardship tour (no, really--they do. Extra pay for it and everything). So I think I wouldn't mind getting stationed out here someday, but a lot of that depends on what else is going on in my life and what else the Army is offering. We shall see. There's still another two years before the Army is going to be stationing me anywhere anyway.

That was about it for the weekend. There was more lounging around today, a really nice lunch at an Italian restaurant followed by some souvenir shopping, and that's it. My flight tomorrow isn't until the afternoon, so I'll have the morning to do some more running and get all my stuff packed up again, and then it's back to Malindi.

So far, so good, and less than three weeks left.

Kisumu

As promised, here's a picture of the room when the bednet is down and tucked in:

I'm actually writing this early on Friday morning, because I didn't get in until late last night and had to get up early this morning anyway (7:30 flight means 6:30 taxi), so I figured there was no point in waiting. Yesterday we had the whirlwind tour of what the Walter Reed Project is doing in Kisumu. We started here:

It's not a Walter Reed Project hospital, but this is where their pediatricians work. It's called Obama Children's, for all intents and purposes. Unfortunately, some American names are a bit hard for Kenyans to get right:

Yeah. Anyway, we started at the WRP's headquarters in Kisumu and got the brief run-down of what they do. Most of their stuff is centered around malaria, because there's so much of it. This includes training microscopists around the world on diagnosing malaria from blood smears, the development of an automated blood smear machine (which was seriously cool to watch; I would have taken a video, but then the others would have laughed at me), malaria vaccine trials for both HIV-infected and non-HIV-infected children, drug resistance testing, surveillance, and some I'm probably forgetting. It's quite the enterprise they have there.

We also visited the entomologists (bug people) and saw what they were working on (more malaria, also some sandflies for leishmaniasis studies), and then went to the clinical site where they are doing the malaria vaccine trials, among other things. One of those other things is the development of a demographics survey of the district, which is literally a bunch of people going around with PDAs and GPSs, mapping the district and asking people basic demographic questions, such as how many people live there, how old they are, what they do, level of education, etc. They're almost done with the mapping, and while this doesn't sound like much, it's providing the starting point for endless future studies. This can be tied into visits to the hospital, to figure out if there's any geographic commonalities in where people with disease x live or who gives birth at home vs at the hospital; surveys can be given to ask why people do or don't seek care; water points can be determined to figure out who has clean water and who doesn't; serosurveys (looking at people's blood) can be done on, say, 1% of the population easily, because you know how many people that is and you know how to chose houses randomly for the study. There really is no limit to what can be done with this database, which is why the colonel in charge was so eager to show it to us. He's very interested in setting up rotations--real rotations, not my meet and greet--in Kisumu for MPH students and preventive medicine residents, and is very eager to show what they have to get the ball rolling.

The whirlwind tour ended at about three (without lunch), and then it was back to the hotel, where COL Coldren and I met for a beer (or three) before heading out with the people at the labs for dinner and another beer (or three). We did a lot of career discussing (mine, not his; as a colonel, he pretty much has his career figured out), and then, like I said, it was a late night getting in. And then I got up early to get ready (and talk to Brad on Skype), and now I'm here. And now leaving so I can get breakfast before the taxi comes to take us to the airport.

All aboard to Kisumu... except my camera

Today started as a fairly unremarkable day (other than having to write a blog entry for yesterday, of course). I got to talk to Brad over Skype, and that was pretty exciting, and then I ran for a little more than an hour (the original plan was an hour and a half, but I wimped out) on the treadmill at the hotel. Then after breakfast, I did a whole lot of vegging around until it was time to be picked up to head to the airport.

And, apparently, during my vegging and repacking of my stuff, I managed to leave my camera (well, the whole camera bag, but the camera was the important thing) in the hotel room. I realized this when I was on the plane to Kisumu and decided that I would take a picture of the airport when I landed, and despite checking everywhere (multiple times) in my backpack, it was nowhere to be found. Fortunately, when I gave the hotel a call, they informed that they found my camera, and I requested that they give it to COL Coldren when he checks in, so he could bring it to me tomorrow. If all goes according to plan (and COL Coldren doesn't also forget it in his hotel room), I will be reunited with my camera in the morning.

In the meantime, I still have my iPhone camera, so I did get that picture of the Kisumu airport.

Yes, it's that white building in the middle. That's the entire airport. Pretty exciting, huh?

My hotel in Kisumu isn't quite as nice as the resorts in Nairobi or Malindi, but it works. Here's a pretty poor picture of the room:

What you can't really see in the picture is the mosquito net folded up behind the headboard, which is now out and draped over my bed (I'll get a picture tomorrow night, if I remember). Even though I have air-conditioning and the windows are closed, they take their mosquito nets seriously, as well they should: everyone has malaria. That's not an exaggeration. The Walter Reed Project has a lab in Kisumu just to study malaria. They're doing malaria drug trials and vaccine trials here, which is pretty exciting. I'm hoping to hear about that tomorrow during my tour of the lab. During one of their surveillance projects, however, they went and tested about 200 people for malaria by blood smear, and all 200 had malaria parasites. They're so used to being infected with malaria that it doesn't really affect them.

Here's a shot of my view from my hotel room:

I don't know if you can tell, but there's a sliver of water at the horizon; that's Lake Victoria, which is a large freshwater lake and notorious (at least for those of us who study tropical medicine) breeding site for schistosomiasis, which is a parasitic infection that you don't want to get. Just in case you ever visit, swimming in Lake Victoria is a bad idea.

Overnight in Nairobi

I'm actually writing this on Wednesday morning, because the internet, despite telling me that it had excellent connectivity, was acting up. Such is life.

Yesterday I packed up my belongings (much easier to do when already traveling; you just put everything you own back into the bag. It's much more difficult when packing to leave for travels) and carried my bags (backpack plus duffel) to the hospital, where I met Jeremy, the clinical officer who usually does the scheduling and coordinating with the visiting students and residents. He was at a conference in Switzerland (I know, he has a difficult life, too) for the last two weeks, so that's why he wasn't here. We went through the standard introductions and took a look at the schedule I had and discussed what touristy things I've done and what I still need to do. I'm still hoping to do some scuba diving at some point, so I hope we'll be able to fit that in.

Following that, it was a drive over to the Malindi airport, and when I say "airport", I'm being fairly generous. It wasn't quite the one room shack of the airports in the bush in Papua New Guinea, but it wasn't exactly DCA, either. There were two ticket stands/check in areas, one for each airline that operated out of there (Fly540, which I flew, and another one that I think is mostly for safaris). When the Fly540 agent came up, he weighed my bag and then hand wrote my boarding pass. To go through security, I had an agent go through my bags by hand, because the x-ray machine was broken. Then it was unassigned seating on the airplane, and we were off to Nairobi.

Traffic in Nairobi after being picked up was vaguely reminiscent of traffic in DC. It was about eight miles from the airport to the hotel, and took over an hour and a half to make the trip. Apparently, that's not normal; the lights were out in the traffic circles and the cops had to direct traffic by hand, which always takes longer. I was going to have dinner with the executive officer of the lab while I was here, but because of the traffic, we decided to reschedule for the weekend, when I'm back from Kisumu.

After a run on the treadmill this morning (a real treadmill... I was excited), I had breakfast and am now biding my time until I get picked up to be taken back to the airport for my flight to Kisumu. COL Coldren, my advisor during my MTM&H, was supposed to meet me here last night, but flight delays in Baltimore bumped his schedule back a full day. So I'm on my own for my first evening and morning in Kisumu, and then we'll meet up tomorrow morning when he flies in.

I don't know what my internet situation will be in Kisumu, but I'll probably be writing entries anyway. It'll just be a question of if they get posted as I write them or after I return to Nairobi.

Another case of neonatal tetanus

Lightening struck Malindi District Hospital twice in less than a week: despite the fact that the WHO counted only seven cases of neonatal tetanus in all of Kenya in 2010, there have been two cases at MDH since Friday (the one on Friday and one this morning). Either there are a lot of Clostridium tetani bacteria hanging out in the soil in Malindi District, or the seven from last year was a gross undercount. I'm betting on the former, and so does the WHO: despite the fact that they have counts, they end up estimating that only 10-20% of all cases go to a hospital and are counted, so they inflate their numbers (overall numbers, not each country's numbers) to reflect that. So the two cases in less than a week is probably not so much a statistical anomaly as more women bringing their sick babies to the hospital.

Here's a picture of the case that came in this morning:

So when I came in, I immediately went to the pediatric ward to check on the infant who came in on Friday, and was told that that baby died overnight. And then they told me that they had a second infant with neonatal tetanus in the same "isolation" room. I put that in quotation marks because it's not isolated, it's not quiet, and it's not dark. When I went in to see the baby, the phenobarbital (anticonvulsant) was already being given, but the baby was still having small spasms. I tried to get a video, but it was too dark in the room for video. The story was pretty much the same as the last one: the mother had no prenatal care and no tetanus vaccine, gave birth at home, the cord was cut with a razor, ash was placed on the umbilical stump (not cow dung this time; I guess that's an improvement?), and for the first four days of life, the baby was fine and breastfeeding well. Then on day five, baby stopped feeding, and on day six, started spasming and mom brought the baby in. Unfortunately, the lack of proper medications (namely TIG, or tetanus immunoglobulin) led to the baby dying this afternoon.

I talked to Katana about what the response to this cases is, and he said that the local communities reevaluate their current community health networks (such as community health workers and traditional birth attendants; see the entry about Marafa if you missed that), and train more, if necessary. The community health workers provide education about the importance of prenatal care, tetanus vaccines, and attended births, either in the hospital or under the care of a traditional birth attendant, and the importance of taking the baby to the hospital if it stops feeding and starts spasming. They then vaccinate all women of childbearing age (and probably all kids who need it, while they're at it), a five-shot series over the course of several years. The most important thing is to get all pregnant women at least two shots by the time they deliver (well, and making sure they don't use anything that came from the ground to stop bleeding after they cut the cord).

After all that excitement, I went to the medicine wards, and was joined by a second-year medical student from Georgetown and a pre-med student from Alaska, who I chatted with for several minutes after rounds. I asked her what she got out of the experience and what she was hoping to get out of it, part out of curiosity (because I have no idea what good any of this would be to someone who doesn't know the vocabulary that is taught in medical school) and part out of frustration from interviewing prospective medical students who had similar experiences in their essays. As someone who is going into tropical medicine, there are few things that annoy me more than someone who uses something I do for work as a tool to get into medical school. If you write about crying yourself to sleep every night after the two weeks you spent taking care of babies dying of AIDS in Africa, the next line out of your mouth better be how you're planning on specializing in preventive medicine or infectious disease because you want to help other babies so they don't die of AIDS. If you tell me that you want to do emergency medicine or some such thing, then why did you bother writing about the dying babies in Africa? If it had no impact in your life, it shouldn't make it into your medical school application essay.

Fortunately, this pre-med student understood what I was saying, and she did express her frustrations at the rotation, saying that she thought it was more of a money-making scheme on behalf of the organization than anything having to do with medicine. She said it wasn't the experience that the brochures/website/whatever made it out to be, and after spending around $5000 in total (fees, airfare, etc), that that was pretty upsetting. I would be upset, too, but then again, I didn't go to Africa to check a box when I was a pre-med. I went to Haiti, and after I went to Haiti, I wanted to go in preventive medicine, because it's absolutely ridiculous to hand out chloroquine to treat people's malaria without giving them bednets to sleep under, and that's what I wrote about in my medical school application essay.

Okay, I'll get off my soapbox now. Bottom line: if what you're writing about didn't impact you enough to change your career goals/trajectory/whatever, then there's no point in writing about it.

Tomorrow: flight to Nairobi in the afternoon.

Church today

Today Alex, my driver, took me to his church in Mijomboni, which is just outside Malindi. Here's a picture of the church:

Apparently, bringing students to his church is something that he often does. Nothing too terribly exciting, as far as the service, but they did have English and Swahili translators, so whatever language a person was speaking in, they would translate it into the other. They have a few projects going on, including finishing the structure of the church, building latrines out back, and buying an amplifier for the microphones and guitars, so I gave some money for those projects.

And here's a random shot of the Sunday School kids singing:

The rest of the day wasn't terribly exciting. I ate lunch at the hotel bar (pasta, nothing exciting, but can't argue with the price), then went for a walk with the secondary goal of getting money out of the ATM. I stopped by a supermarket on the way back and bought some basic provisions (Nutella, crackers, conditioner, coffee for Mom...) and then back to the hotel for swimming, lounging by the pool, and working on my presentation, which is about anemia (since the hospital sees so much of it) on August 3. Then I went out for dinner and headed to a nearby Indian restaurant (which is good and really cheap). There weren't any available tables, so the waitress put me with a couple of Dutch teachers on their summer break ("holiday", as they say). It was nice to have dinner company, since I don't often have it (my iPad doesn't count), and interesting to see what people do who are just visiting Africa to visit. Apparently, a lot of the things I've been doing on the weekends, but spread out more. So I'm not missing out on any of the Africa experience by working, I guess.

I don't really know what I'm doing tomorrow, other than I think rounding in the medicine wards. There still needs to be a follow-up on the neonatal tetanus patient, and I thought there was going to be follow up to the village where the jiggers patient resides, but I haven't heard anything further about that. I have been talking to an entomologist who was in a lot of my classes at USUHS (entomology Ph.D. classes and MTM&H classes overlap somewhat) and had been stationed in Kenya about what follow-up is needed, so that's been pretty helpful. If nothing else, it'll allow me to compare the recommended follow-up with what is actually done, which is educational in its own right.

Being a Tourist Again

This morning, I slept in and then continued my touring of Malindi and surrounding areas. Fortunately, I didn't have to go far from my hotel to do it.

This is the Vasco de Gama pillar. It's actually the second pillar he built. He built the first one the first time he landed in Malindi, which I believe was 1597. He then sailed from Malindi to Calcutta in 23 days, established business partnerships, shook hands, etc, and then sailed the reverse journey home to Portugal. When he arrived back in Malindi, he discovered that they had torn down his pillar. So, he built another. I don't know what kept the people who tore down the first from going after the second, but it's still standing today. The point that it's on has been reinforced with concrete and breakers have been put in the water to slow erosion in hopes that it will stay there. This is apparently quite a popular place for school groups to visit; while eating lunch yesterday, we saw three buses of primary school children head out toward the pillar.

Here's a picture of de Gama's route, taken at the Malindi museum. It's too bad the Suez canal wasn't in place back then. It would have saved the Portuguese traders a lot of time and the lives of a lot of men (scurvy was a big problem back in those days).

Also at the museum was this ugly little creature. Okay, it's not exactly little, and it's not exactly real. It's a replica of a Coelacanth, the fish that they thought had been extinct for 20 million years prior to catching one off the coast of South Africa in 1938. Since then, they've found several others up and down the eastern coast of Africa, including one just off Malindi, in 2001 (that's the purpose of the exhibit at the museum). They really don't have a purpose to us, since their meat is supposedly really oily and foul, and nobody intentionally catches them. They just get find them in nets every once in a while when deep sea trawling.

After a lunch at the hotel, I headed out to the Malindi Marine Park. I don't know what I was expecting and why I didn't think this through, but nobody told me that the point was to go snorkeling with the fishes, so I didn't have my swimming suit on. I did still get to see them from the boat, though, including from the glass bottom of the boat, as below.

The hand holding the bread belongs to our boat captain, who, obviously, had his suit and was snorkeling. There were so many fish and it was fun to watch them all attack the pieces of bread we threw in the water, but as anyone who has tried taking pictures of fish knows, it doesn't really project well.

Random update of the neonatal case from yesterday: as per Metsanze's update, the baby is still convulsing, but is still alive. More random updates to follow, I'm sure.

All in all, a pretty low-key day of being a tourist.

Marafa and Neonatal Tetanus

Today started with a trip to Marafa, about an hour and a half west of Malindi (everything's west of Malindi, seeing as it's on the coast and all). It's a rural area, so the goal was to show me a rural health center to compare it to the hospital in Malindi. Here's a picture of the clinic:

One interesting thing I learned about the healthcare system in Kenya is that there are two ministry that are involved in it. One is the Ministry of Public Health and Sanitation (as above), and they are responsible for small clinics (called dispensaries) and health centers, such as this one. The Ministry of Health (or Ministry of Medicine, I don't remember) is responsible for the district hospitals, such as Malindi, the provincial hospitals, and the national hospital, in Nairobi. Two different ministries means that there's a big divide between what happens at the local level and at the district level.

Since I've been working on the waste disposal issue for Malindi, we swung by the waste incinerator at Marafa, used to burn the infectious waste and sharps. It's pretty small, but the clinic is pretty small, so they only incinerate once a week. I don't know about the temperatures it reaches, but the distance from any other building meets the WHO guidelines (50 meters), as does the low volume of incineration.

As you can see, there's an American flag on the incinerator building. That's because it was built in May 2010 by the United States Marine Corps African Command (AFRICOM). They built quite a few in a short period of time, covering pretty much all of the health centers and district hospitals up and down the coast, if not further into Kenya. One was built at Malindi, too, but it has since been vandalized and is no longer operational (I think I've said that before).

After the tour of the health center, we went to a depression called Hell's Kitchen, pictured above. It looks a lot like a much smaller version of the Badlands, in South Dakota. According to legend, before there was a depression, there was a rich family that lived on the land, so rich that they bathed in milk, while the population around them didn't even have food to eat. The depression came from being cursed by their opulence and struck from the earth. I think I got that right.

When we got back to Malindi, we were informed that there was a case of neonatal tetanus. The WHO had a world-wide eradication program (well, still does), with the goal of eradication by 2005. Obviously, that didn't happen. Most of the cases annually are in China (the WHO publishes all this stuff on their website), and last year, Kenya had only seven cases. So it's really rare that a case comes in, and I was lucky (in the sense that I got to see a case) that one came to Malindi while I was there. Not so lucky for the kid, unfortunately. The mortality rate with proper medical care is about 50%, and most who survive have long-term physical and mental effects.

This is what neonatal tetanus looks like. Not very pleasant. His entire body was stiff and convulsing. When I took this picture, he was in the admitting area of the pediatrics ward, which is bright and loud. Lights and sounds trigger muscle contractions, so he was pretty much convulsing the whole time. They got him some anticonvulsants and have since transferred him to "isolation" (it's not that isolated) of the pediatrics ward, where it's darker and somewhat quieter. Since I've had a lecture on tetanus for my master's, and I keep my lectures on my iPad (which I have with me), I was able to bring up the proper treatment plan. Unfortunately, the hospital doesn't have tetanus immunoglobulin, which is the key point in treatment, but they do have the antibiotics and anticonvulsants. I hope everything goes well.

This is really sad, not only because of the poor prognosis, but because of how preventable it is; hence the reason WHO has an eradication campaign. This kid ended up with tetanus because his mother wasn't immunized against tetanus, had no prenatal care in which she could have received a vaccine, delivered at home, the cord was cut with a razor blade, and cow dung was used to stop the bleeding. Not a combination of anything. To follow up this case, the public health office will be going to the mother's village to provide education about prenatal care and sanitary deliveries, and will vaccinate the women of childbearing age. It won't help this baby, but it might mean that that village doesn't have another like him.

I decided I should end on a happier note than that. This is what happens when you don't have a very good grasp of the English language but try anyway:

I miss running

It may be a funny thing to say, but I really do miss running, even on a treadmill. It's been a week and a half since I logged any miles, and it's strange to go that long without it. But more about that later.

The day started in the typical fashion, with my standard unexciting breakfast (except for the fact that I've started drinking tea) and then walk to the hospital, where I headed over to the medicine wards for rounding again. It's quite difficult to manage any of these patients, given the resources available. There were a few women who were very, very anemic (hemoglobin of one was 2.2 g/dL; normal is between 12-16 g/dL), but they're still waiting on the blood to give her to arrive from Mombasa, which is where the regional blood bank is. And even after it does arrive, it can be diverted to an emergency patient, such as a trauma or Cesarean section. There was another patient with diabetes, who was transferred from the surgical service post-operation for diabetes management (at least that's one thing that's consistent across the board--surgeons will always transfer their difficult patients to the medical teams). Her blood sugars are all over the place and just about impossible to control. Before eating this morning, it was 194 (high), so she was given ten units of insulin. Three hours later, she started seizing. The intern didn't want to bother to check the blood sugar, because she knew it would be high (because it was high in the morning). I convinced her to check, since nobody had checked since her insulin was given, and it was 42 (very low). She was having seizures because of the hypoglycemia. If this were back home, she'd be on an insulin drip, titrated to keep her sugars even, which would be checked every hour. But there's no insulin drip, not enough testing strips, and not enough hands to make that happen. So she'll probably continue to have spikes of very high and very low.

After rounds was lunch, then working with Katana and Dr. Buni (the medical superintendent) on the waste incinerator issue. Except it isn't a waste incinerator, it's an autoclave (to sterilize the waste) and grinder (to put it into small pieces). There was previously an incinerator, built by the United States Marine Corps, but it wasn't located in the best place, according to the WHO guidelines; besides, vandals looted it for parts and scrap metal. So no more incinerator, and hopefully soon, and autoclave/grinder, which is a CDC prototype (they demonstrate it and let the hospital keep it). Before this happens, though, there's the standard rigmarole of finding a suitable site on the hospital campus, getting an Environmental Impact Assessment, building the shelter for it, and training people in operation. So this isn't a quick and easy project that'll be done before I leave.

Following all that excitement, I decided to try a gym across the street from the hospital, which is run by one of Metsanze's friends (he, like my driver, seems to have friends all around the city). It's not so much a gym as a place for aerobics. So I did an aerobics class, but like I said at the beginning, I miss running, and I don't want to pay for a month membership at a gym that doesn't let me run. It seems a little silly.

Anyway, that's my fun and exciting life. Tomorrow I'm going with Metsanze to a rural area (I forget the name) to see their clinic. There should be pictures with that one.

Clean laundry!

Okay, not the most exciting thing to happen ever, but my clean laundry just got delivered to my room. It cost me an arm and a leg (hotel laundry is expensive regardless of the country the hotel is in), but it's worth it to have some clothes that don't smell like sweat, dirt, and patients.

If you're wondering what happened to yesterday's post, the answer is, the internet. I really can't complain about the quality of the wireless internet when I'm in a country where most people don't own a computer, so I won't. I'll just say it's not at the standards we're accustomed to.

At any rate, yesterday I had my first day in the medicine wards. In some respects, it was very similar to being on the wards back home--large group of doctors and medicines making their way from way patient to the next, talking about him or her as if the patient wasn't there, discussing treatment plans, attendings belittling interns, etc. That's where the similarities ended. Yesterday's round, in the women's ward, was filled with patients with severe anemia, HIV/AIDS, TB, and hypertension. Hypertension is hard to manage in a resource-poor area; people can't really change their lifestyles (how they eat, exercise, etc), and medications cost money that could be used for food. When you don't know where your next meal is coming from, you can't be concerned about getting to the pharmacy to pick up your blood pressure medications. So they come in with heart failure, kidney failure, stroke, and the like.

Today's ward round was in the men's ward, and many of the cases were similar, with fewer severe anemia cases and more hypertension and complications of HIV. There was one patient who is still a mystery to everyone involved, because the clinical officer intern didn't bother to do her job. The patient (a man in his 20's) came in with altered mental status and left-sided weakness, and she decided that it was cerebral malaria. She got a blood smear, which was negative for malaria, but decided that it was still malaria, and began treating with quinine. Just as an aside--cerebral malaria is a very serious complication of malaria, and only occurs when malaria is severe. When malaria is severe, you're not going to get a false negative on the blood smear. So, she was lazy and ended up giving a drug with some pretty serious side effects. When we came to this patient in rounds today, the consultant (attending) went nuts. He said, "I'm sure everyone here has had malaria, and we can all agree it doesn't look like this." He then proceeded to tell the intern that if she couldn't be bothered to do her job, he didn't want her in his ward or in his hospital and she had no business being in medicine. Harsh, but true.

There were a few Australian med students during rounds, so I introduced myself and chatted with them. When it was time to finish with the jiggers patient (and yes, we finally are finished), I invited them to join me, since none of them had ever heard of jiggers (or chiggers), and they helped out in finishing with the patient. Then we went out to lunch at Old Man and the Sea (the place I went for my first lunch in Malindi) and talked about their elective here, our comparative health care and medical school systems, and the like. Good times.

Katana and I have also begun working on plans for a waste incinerator. My job is to figure out how many operators they need and what kind of training they need, so I got on the WHO website and looked up some stuff. Turns out, they don't like waste incinerators, but they do have some guidelines when they can't be avoided. One of the most valuable lessons I learned getting my MTM&H is that if you have questions about how to do something health-care related in the developing world, the WHO website will have answers.

Tomorrow: more medicine rounds, then working with Katana more on the waste incinerator. Should be a pretty low-key day.

Tsavo East, day 2, and back to Malindi

I woke up today at Voi Wildlife Lodge, ready to continue the safari and see more animals. This is the view I had as the sun was rising:

And here's a picture of the outside of where I was staying. The building closest to the mountain is the one I was sleeping in.

After breakfast, we continued our game driving and I continued my incessant picture-taking. Here are some of the things we saw:

Elephant

Giraffe. This guy was probably less than fifty feet away and seemed quite content posing for pictures for a few minutes. Then he (or she, I don't know) walked away, and I got pictures of that, too, which will be loaded up onto Facebook as soon as the internet decides to cooperate.



And this was what we saw as we left. This picture probably would have been better at the beginning, but I took it at the end, so it goes at the end.

All in all, a pretty good safari, even considering that I didn't speak the same language as my fellow safariers. We chatted a bit, but for the most part they were content talking amongst themselves in Italian, and I was okay with that. I think if I come back to Kenya at some point in my career, I'll probably go on a longer safari, and I'll definitely make sure that I have people with me who speak English.

I got back to my hotel in Malindi a bit after noon and went and grabbed something to eat, then I went to the hospital at two because I was supposed to be meeting with Dr. Katana about the waste incinerator. Someone, somewhere (yes, I know, I'm a fountain of information) is sponsoring an upgrade of their waste incinerator, so he was going to show me the current system and we were going to go over the information the sponsor needs. Well, he (Katana) was busy with something else, so I spent a couple of hours preparing for my presentation on Thursday, and then headed back to the hotel for my afternoon swim. I understand that people are busy and can't always entertain me, but I would have preferred it if he said, "well, I'm busy with x, why don't we just plan on doing this tomorrow?" I could have been just as productive, if not more so, working on my presentation in my hotel room. Oh, well. It's good to show some sort of accountability, I guess.

Tomorrow: ward rounds with the consultant in the medicine ward, then working with Dr. Katana on the waste incinerator and the jiggers patient (who has just been hanging out at the hospital, still infested. Standard of care differences, maybe?)

Tsavo East, day 1

I’m writing this on Sunday night to post when I get back to the land of the internet. Yes, that’s right, I have my computer with me even though I knew the chances of me having internet access while on a safari was slim to none. You would, too, if you were responsible for a government computer and your hotel in Malindi has been known to have things stolen from the rooms. Like government computers.

The day began nice and early with a five am alarm from my phone (thanks, phone), so I could get dressed and be ready to go when the safari people call to say that they’re ready to pick me, any time between 6 and 6:30. It ended up being around 6:15, so kudos to them for punctuality.

I was told yesterday by Alex, my driver, that the group that the safari people are putting me with was an English-speaking group, which I was relieved about. Malindi is primarily an Italian tourist town, so I was kinda expecting to end up with Italian tourists. Well, I found out this morning that either Alex lied to me or the safari people lied to Alex, because I am with a group of Italian tourists. It’s kinda lonely not being able to understand what the other people in the vehicle are saying, but at least the driver speaks English, so he’s able to explain things to me, which as which animal we’re looking at, etc, etc.

After a stop at some overlook that the local children knew we were stopping at—and Italians don’t know better than to give them stuff—we arrived at Tsavo East around 10:30ish, and began our safari through the game park, followed by lunch at the lodge, followed by another game drive. I took many, many pictures (there are 130 or so on my computer right now), so here’s just a random sampling of some of the animals we saw.

This is what happens when you give children stuff. They all want some.

Crocodile

Mom and baby monkeys

Gazelles

Elephants (lots and lots of elephants in this park)

Giraffes

Zebras

The lodge is pretty nice as well, nothing terribly exciting (and lacking internet access), but my view from the room included elephants, so that was kinda cool.

Tomorrow we head out around 7am and begin game drive number 3, which is scheduled to get us to the gates of the park to exit at 10:30. Two day safaris only get 24 hours in the park, so that’s why we have to leave then. Then it’ll be back to the hotel, and depending on what’s going on at the hospital, back to doing what the Army is paying me to do (which, in case you’re wondering, is not going on safari or buying trinkets).

Being all touristy

Today, being a Saturday, meant I didn't have to go to the hospital for rounds (yay!). Instead, I slept in (yay! again) and then was picked up by the driver for some touristy time.

Our first stop was Midi Creek, which is a salt marsh / mangrove forest / bird habitat. My guide explained all about mangroves as we walked around, and then we had this:



He called it their Indiana Jones bridge, and it was. It was shaky and unsturdy and went on for 200 meters and was all sorts of fun. Then we began walking around the salt marshes and saw a couple of different species of birds, including a sacred ibis and yellow-billed storks, which are shown below.

After Midi Creek, we went on to Gede, which is an ancient city with sections dating back to the 8th century. It has a long and complicated history, beginning when the first Muslims came to Kenya and ending with the excavation of the site in the 1950's. In the middle was a war that Vaso de Gama started with the people of Mombasa (to the south), aligning himself with the people of Malindi (to the north). The people in Gede got caught in the middle and ended up leaving their city. It wasn't found again until the 1920's.

Here's what the palace of the city looks like from above (they have a very rickety treehouse which I climbed up to to take pictures). There was also a section for the other "nobles", the middle class, and where they theorize the poor lived. Excavation is still in process, but they estimate around 3000 people lived there when they abandoned the city. Among the artifacts that have been found are bowls and coins from China, scissors from Spain, and lamps from India. The world may be smaller now than it was in the 16th century, but not by much.

And this was the original mosque, which they estimate to have been built in the 8th or 9th century. They found graves under the mosque, which was highly unusual--Muslims don't bury anyone in mosques--and they think this mosque was built on top of an old Bantu burial ground (Bantus were the people who were there when the first Muslims came). I don't know if anyone's done any forensics on them to test that hypothesis or not.

After wandering around the ruins, my guide and I fed the monkeys bananas:

If I look terrified, there's a reason for that: I was. And I have scratches on both arms to prove that when it comes to bananas, monkeys aren't afraid to use their claws to climb people like trees.

Although we tried to get through this in time for me to finish with the jiggers with Dr. Katana, by the time I returned to the hospital, he was nowhere to be seen. I didn't miss him, because the patient hadn't been completely de-jiggered yet. I don't know if he's planning on finishing tomorrow or Monday, but either way, I'll be out on Safari :)



Jiggers!

I started out the day with really not wanting to get out of bed, and I think I took it out on Brad as we were chatting online. Time zones are tough--he stays up late and I get up early, because those are the only times neither of us is at work.

But I eventually did get out of bed, and even managed to make it to breakfast on time, which isn't hard, since they always start serving food ten minutes later. Breakfast is supposed to open at 8, but they usually open the doors around 8:10, which gives me just enough time to shovel food into my mouth before I have to get out of there by 8:20 to make it to the hospital in time for rounds. The fact that they arbitrarily assign room numbers to tables every morning doesn't help my situation much, since I have to spend a few minutes figuring out where I'm supposed to sit that day.

I digress. The day started out in the pediatrics ward for consultant rounds. 'Consultant' seems to be the word in British English for 'attending'. At Malindi District Hospital, the wards are managed on a daily basis by the clinical officer interns I talked about yesterday, and the consultants come through twice a week to make sure the plans make sense. Unfortunately, it turns into your typical rounding situation, with the senior guy pontificating about something while everyone else just wants to keep moving. I'm not a fan of rounds at baseline (I could never do internal medicine, where they round multiple times a day, for fun), and rounds when the docs are speaking to the parents in Swahili really aren't any more fun.

After ward rounds, I followed the consultant to the NBU (newborn unit), where I got to see where they take care of sick babies. This is an incubator, and I don't know if you can tell, but there are two babies in there--twins born at 32 weeks, their birth weights 1.8 and 1.4 kilos. So, small babies.

I had just finished NBU rounds when Metsanze, the clinical officer who's arranging my schedule, called to say that the public health office got word of a patient with jiggers in the men's ward. 'Jiggers' are what we call 'chiggers', and it's a huge public health problem in Kenya, and preventable (by wearing shoes and washing your feet every once in a while). Actually, Miss World (from the US), Miss Venezuela, Miss Kenya, and Miss Botswana were recently in Kenya to do some good-willing about it. It was even in the news: http://www.nation.co.ke/News/Top+beauty+queens+in+Kenya+to+fight+jiggers+/-/1056/1199814/-/xru5g8z/-/index.html

My jiggers patient was not cute little children, though, but an old man who apparently does nothing but lie in bed. Jiggers are small bugs that crawl into the skin, usually on the feet, and burrow pretty deep into the skin there. They have a hole to the surface where they lay eggs, and from those eggs come more little jiggers which do the same thing. Since this man never got out of bed and no one was washing his feet, the jiggers he had kept laying eggs and producing more jiggers that burrowed and laid eggs, etc, etc.

Not a great picture, but I think it gives the general idea, once you realize that each of those black dots is a jigger. It was actually worse on his heels, which makes sense (that's the part that would be on the mattress if he was laying on his back).

So we got to work. The first step is to soak the feet in 3% hydrogen peroxide. Unfortunately, they only had one bottle of 6%, which was cut in half with water, so there wasn't much liquid there.

This is Dr. Katana, the public health officer, explaining something to me as we worked on the soaking step. Just a side note here, 'Doctor' is a title, not a degree. Dr. Katana has a bachelor's in public health, so he's had the same amount of formal schooling as the clinical officers. He has a few years' experience in the field, though, and is working on his MPH.

Anyway, this is when we were really getting into it. After soaking the feet, each jigger has to be pulled out with forceps. We spent two hours and finished one foot, and I'm not sure we got them all out. And this is without an operating room or anesthesia. At this point, he doesn't have much skin left on his feet (and I was getting down to the Achilles' tendon on his heel). I don't know if he'll ever be able to walk again, not that he was doing any walking when we started with him.

So that was my workday, finishing around 2:30, when we took a break for lunch. We had biriani, which is a Kenyan dish of some sort of meat, stewed in a spicy sauce and served with rice (I asked Metsanze if I wanted to know what it was, and he just laughed... not really that reassured). I know it's something small and four-legged, because I had a section with vertebrae and ribs. Maybe something around the size of a rabbit? I'm not sure. Anyway, aside from the mystery-meat aspect of it, it was pretty good and gave me the fuel I needed to return to the office and get some work done on my presentation before calling it a day and heading back to the hotel for a swim.

Tomorrow: Dr. Katana and I tackle the man's other foot and his hands (which are also jigger infested). I might do something touristy as well, but I'm leaving for safari on Sunday and I still have five weeks in Kenya to see touristy things, so I'm not in a hurry.

Pediatric Mortality Meeting

It's pretty much as gruesome and disturbing as it sounds.

Today was my first day of pretending to be a doctor again (yay?) and using my stethoscope and otoscope for the first time in over a year. Apparently, using a stethoscope is just like riding a bike, but using an otoscope requires a little bit more thought to figure out. It's kinda sad how much better at this stuff I was as a second-year medical student than I am now as a third-year preventive medicine resident.

Anyway, I was in the pediatric ward today, and after the initial "so what year of medical school are you in?" and "let me tell you what pneumonia is", I got back in the groove of doing things. The woman I was with is a clinical officer intern, which is pretty much the same amount of training as an entry-level PA (physician assistant). She had three years of post-high school school, and now needs to complete her internship before she'll be certified to practice independently. For the most part, she was pretty good at what she does, but there are some things she did that were just blatantly wrong, like trying to count the respiratory rate of a crying toddler and attributing upper respiratory noises as lung noises (when the patient is breathing through his/her nose and you listen to the chest with a stethoscope, you can hear the sounds from the nose), which she interpreted as pneumonia. The most common diagnoses in the pediatric ward, at least based on what I saw today, were "pneumonia" (blanket term for any respiratory tract infection, it seemed), dehydration from diarrhea, and malnutrition. There was usually an overlap with two or all three of those.

I caught one of the clinical officers sneaking out of the ward (he wasn't really sneaking and in fact announced where he was going) on his way to the mortality meeting, so I decided to join him, because it sounds fun and cheery, right? Mortality meeting here is what we call Morbidity and Mortality in the States; it's a chance to look at things that didn't have the outcome we were looking for (I think we can all agree that death in a kid is not the ideal outcome), examine them closely, and figure out if there's a way that the system could be changed to prevent a similar death from happening in the future.

This mortality meeting was specially for the newborn unit, which is the closest thing Malindi District Hospital has to a NICU. There were 97 admissions to the NBU in June and nine deaths, each of which was discussed (the deaths, not the admissions, or we'd still be in the meeting). One was very clearly not anyone's fault; it was a baby with a laundry list of congenital abnormalities, including a small head, small ears, abdominal distention, and polydactyly (extra fingers), which I'm guessing was Trisomy 13 (three copies of the 13th chromosome), which is fatal within the first month of life in most cases in any country. There was also a case of hydrocephalus (swelling of the brain) which requires neurosurgical intervention to place a shunt. Three babies were premature at less than 30 weeks of gestation and would be NICU babies if they were born here. The other four were neonatal sepsis and the only four that I would consider to be preventable deaths in this setting. By that I mean that if everyone was on top of things--the parents brought the kid in early enough, the diagnosis was caught right away, the right antibiotics were given right away--the kids might have pulled through. Those are the cases these mortality meetings are made for, because it let them see where things went wrong and how they can fix it in the future to keep it from happening again.

Mortality meeting ended up going through the usual lunch hour, so I had a late lunch of Kenyan food (it seems to be Kenyan food for lunch, European food for dinner), which was much better than yesterday's Kenyan food. Nothing terribly exciting--fried chicken with rice. I think every culture has some sort of fried chicken as a dish.

Since there's not much happening in the afternoons, I swung by the safari office and shelled out the money for a two-day safari (either this weekend or next, depending on availability). I'm still suffering from sticker shock, and I'm still pretty sure the combination of the safari coordinator and my driver overcharged me. For some reason, I had to pay an extra $56 because I paid in Kenyan shillings instead of American dollars. Does that make sense to anyone else? I'm sure I'll have a great time on the safari and forget about the money, but until then, I need to get to my bank's website to move some money around.

Tomorrow: more pediatrics wards (but not more mortality meetings).

And still no doctoring

 As promised, here's a picture of my room at the Scorpio Villas resort (and yes, that is mosquito netting):

Despite my belief that I would begin doctoring today, nothing of the sort happened. After a very European breakfast of crepes, a chocolate croissant, and tepid milk (which is seriously gross, but I'll tolerate because that's the best way for Malarone, my anti-malarial, to be absorbed), I walked the long and strenuous walk of about three city blocks to the hospital, to do a meet and greet of pretty much everyone who works there. Do I remember their names? No. Let's be serious. There were about fifty of them. Maybe not that many, but it was quite a few.

There was one patient I observed (not cared for or even examined), a kid who was being diagnosed with malaria. They diagnosed using a rapid test (kinda like a urine pregnancy test, but with blood). There's an ongoing study being run out of USAMRU-K to evaluate malaria drug resistance patterns, so they consented the mother for the kid to participate in the study--and by participate in the study, I mean they took a little more blood than usual so they could culture the malaria parasites and test it against ten different drugs. Then they took a few drops for blood smears (which is the gold standard of diagnosis for malaria) and gave the girl CoArtem, which is the WHO first-line drug of choice for anyone with malaria who is not so sick that they can't swallow pills. Nowhere in the world has their been a case of resistance to CoArtem reported, so it's a good drug. Then they'll check the kid's blood again in a week to make sure she cleared the infection.

Following a lunch of real Kenyan food--some sort of stiff corn mush, which is used as the base for a soup and really salty fish; I'm not a fan--it was back to the hospital to do some admin stuff (Metsanze, the clinical officer I've been following, do some admin stuff, that is) while I checked my email. I don't know what I did while traveling to Kenya, but my calf has been killing me since I arrived, and I didn't pack any ibuprofen (there's a method to my madness, which I'll explain if you care to know). Despite me asking several times where I could go to get some, regardless of cost, it wasn't until late afternoon that they took me to a chemist (pharmasist) to get some. And they weren't done with me yet. It was on to two different craft markets, which was kinda cool, because you can see the whole process, from them chipping a block of wood, to something like this:



Yes, that says "Hakuna Matata". It's not a Disney phrase; it's Swahili for "no worries". I thought it was cool that it was a real thing. The craft markets had all sorts of other things, including entire sections of elephants and giraffes from the very small to the "seriously, there's no way anyone can get that out of here and to their house."

I'm very happy that Metsanze is interested in showing me around, but there's really no need to do all of it in the first week. I'm exhausted, and I still have more than five weeks in Kenya. Not only that, but I need my down time.

I did finally get down time once it started raining, thus ending the sight-seeing of the day, and I decided to go for a swim in this pool, which is pretty close to 25 yards long:

Following my swim (of approximately 1500 yards; weak, I know, but I haven't been swimming in forever), it was out to dinner, to a restaurant that is really called "I Love Pizza". I didn't order the pizza, because I had that last night, but the four cheese gnocchi wasn't all that bad :)

Welcome to Malindi

Okay, this is going to be a pictureless post, because this computer/internet connection is being stubborn and doesn't want to load them, and I don't have the patience (or the insanity) to keep trying. So use your imaginations.

This morning I made the journey from Nairobi to Malindi, which was about two and a half hours waiting at the airport, followed by an hour flight to Malindi. Here's where your imagination (or your use of some sort of map on the internet) comes in: Nairobi is near the middle of the country, Malindi's on the coast.

I was picked up at the airport (I am loving this being picked up at the airport thing, by the way) and taken to my hotel, Scorpio Villas (there would be a picture here, so if you want to see it, Google would probably be your friend. Or waiting until tomorrow when I can try again to post a picture). It's a nice little resort on the beach, which I am told not to visit. It is apparently not safe. The resort is, don't worry (Mother). Then it was into the city of Malindi, which is pretty much stereotypical for a mid-sized city in the developing world (I'm beginning to notice trends in my world travels). A good portion of this time was spent trying to find an ATM that accepts MasterCard debit cards, instead of just VISA. I had to resort to giving up, using the MasterCard ATM locator online, and giving it a second try (which was successful). Since nowhere accepts credit cards, the cash is a must. And I wasn't thinking straight about conversion rates back when I was in Nairobi, where there are ATMs everywhere.

After that debacle (and before I actually got a decent amount of cash), it was out to lunch at a restaurant called Old Man and the Sea, which is (wait for it...) seafood. It was pretty good and seemed pretty well cooked, so I might not get a parasitic infection from this whole adventure. Then it was onto Malindi District Hospital, where I'll be working most of the next six weeks. They really only see patients in the morning, so there wasn't much for me to do other than meet some of the staff and get a judge of the distance between my hotel and the hospital (about the distance of three city blocks, and it's safe to walk it).

I headed back to the hotel after that and did some exploring, seeing all three of the pools on the resort (again, there would be pictures...) and the lack of a gym/fitness center, which means I'm going to have to get creative when it comes to getting some running in. There's a gym in town, so I might be doing that. And I did bring a few swimsuits (and goggles), so I'll be spending a lot of time in the pool, too.

Dinner with one of the doctors at the hospital rounded out my day and gave me a few directions to start looking when it comes to topics to present to the staff and projects to work on, and then that brings us back to here, where I'm lounging on my bed (again, I do have pictures) and typing this blog entry. Tomorrow should be time for some doctorish stuff... We'll see how that goes.

Jet lag, a trip to USAMRU-K, and the hotel

I started my day with a Skype conversation with Brad, which was two hours later on his end than I thought it would be, on account of me not being able to tell time. Well, not so much not being able to tell time as thinking that Kenya was nine hours ahead of DC, not seven. Oops.

I was feeling awake enough to hit the treadmill this morning (I've been told no fewer than ten times that I can't do PT outside the hotel). I took it easy on myself, on account of the hours traveled and the hours I am off, and I really hate running on a treadmill, but I'm going to have to get over that if I hope to train to prepare myself for the Marine Corps Marathon in October.

After a hotel breakfast, I decided that my life was far too strenuous, so I took a late-morning nap (I'm blaming the jet lag, not my general laziness, but draw whatever conclusions you want from that), and then got ready for my trip to USAMRU-K. I got to see a little more of Nairobi during the drive to the lab, which isn't saying much. It's pretty much the same as any large city in any developing country; the only difference is what language the signs are in (in Kenya, English) and which side of the road they drive on (left). The driving itself is the same (absolutely insane, with "might is right" as far as right of way) and there aren't many differences in the people (mostly dressed in Western clothes with some more colorful outfits, walking or driving to work, and kids in uniforms walking or taking the bus to school).

At USAMRU-K, I got the introduction to the lab and the GEIS (Global Emerging Infection Surveillance) system. It's not too different as far as the mission from the Peru lab. They do research and surveillance on respiratory illnesses (flu is a big one), gastrointestinal illness, STIs, malaria, and a smattering of other things. The lab here was actually founded in 1969 by request of the Kenyan government to help them study African trypanosomiasis, or African Sleeping Sickness (which is not, despite its depiction on House, sexually transmitted). It's branched out since then, but what's remained constant is the cooperation between the United States government (both the Army and CDC have offices at the lab) and the Kenyan government. Without that cooperation, you get a situation like there was in Indonesia, which led to the Indonesian government requesting that we close the lab (that was a Navy lab; it closed last year).

After my trip to the lab, I came back to the hotel and decided to wander around. It's a pretty nice place:

Above is the hotel from the outside (this picture was actually taken from their website).

This is the view from my room. It's very green and tropical, despite the fact that July is Kenya's "winter". It is actually cooler and less humid here than it is in DC right now, but less of that has to do with the season (Nairobi is at 1 degree south latitude; you don't have seasons when you sit on the equator) and more to do with the fact that we're over 5400 feet in elevation. That's high enough that malaria mosquitoes aren't found, and have never been found, in Nairobi.

This sign is also on the hotel grounds, and I had to take a picture :) The spiral staircase in the picture leads down to a wine cave, and this sidewalk is the route from the wine cave to the hotel's restaurant. I thought it was funny :)

Tomorrow will probably be another day of playing tourist before I get to work. My flight to Malindi is at 10:40 and lands around noon, and I'm supposed to be getting a tour around Malindi after that; according to the coordinator at USAMRU-K, there isn't much that goes on at the hospital in Malindi in the afternoons. Then, Wednesday morning, it'll be time for me to pretend to be a doctor again :)