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.