My first stop on the way home from Kenya was to the city of Bunnick (near Utrecht in the Netherlands) where my friends the Menkes live.  Aswin Menke stayed with me in Indianapolis for a few months while conducting research in Dr. Yoder’s lab.  In his last month, his wife and two children came to Indiana as well and we spent a very nice Christmas together.  We have been friends ever since.  Within minutes of seeing the family, it was like we had never been apart.  The kids, Henk and Roos, have both grown a lot since we last met.  Roos is now doing gymnastics on a regular basis and Henk is big into soccer.  The first thing they had to show me was their new toy in the back yard.  When they moved to their new house in Bunnik, Aswin dug a large pit in the garden and installed an industrial trampoline.  I don’t think a day went by when we didn’t spend a few minutes jumping on it.

While Roos was at a birthday party, the rest of us took a trip to Utrecht to see the sites.  Aswin made a stop at his favorite comic store to stock up on a few series and get something for Henk.  Our big adventure of the day was a climb to the top the cathedral as part of a tour.  The interesting story about Utrecht Cathedral is that the middle is missing.  The Catholics built the top of the cross first.  Shortly thereafter, the bishop arrived and ordered that is tower at the non-existent bottom of the cross be completed next.  When the protestants took over during the reformation, they were appalled at the excessive support pillars and buttresses and built a practical middle section of the church.  A hurricane came a few years later and destroyed only the protestant section which sat in ruins for 150 years.  We spent the evening practicing the kids’ soccer headers in the back garden.

The next day was spent on a fantastic bicycle tour of the Dutch countryside.  We rode past the sprawling farms split by long channels, through old growth forest, and even to a couple of castles along the way.  It was a wonderful ride but we were all exhausted afterwards due to the long distance traveled (52 kilometers!) and our individual burdens; both parents had a kid on the back of their bikes and I was riding a folding bicycle with 12 inch wheels.  Never a dull moment with the Menkes!

From the Netherlands, I will head to the Alsace valley on the French/German border in search of my family’s roots and then to Wildon, Austria to help my cousin with his Archeology project.  I will be returning at the end of my trip for a quick night’s sleep at the Menke’s before my plane trip home to Indiana.

Dave McCabe asked me to join him and his friends on the home server show podcast again this week.  We had a great time recording this one even though it was 3:30 in the morning for me here in France.  This is show number 45 for Dave and the show seems to keep getting better with time.  I gave an update on how I used my server and netbook during my travels as well as how Windows 7 was received in Kenya.  To listen to the show, click the icon to the left.

(Kwaheri = goodbye)

The previous week has been one of transition for me as my time in Kenya came to a close.  My list of loose ends needing to be tied was fairly long and took up most of my time, but Kenya found a few ways to give me pause and say goodbye in it’s own way.

Slamendas - In the last few days, I was asked to help make preparations for the arrival of a group of five first year medical students coming to Eldoret on scholarship as part of the Slamenda program.  Space needed to be found in the dorm for the two women coming and security for my room (which would go to the men) needed to be upgraded a bit.  My main goal was to help orient the students to the dorm, wards, and city.  I wasn’t able to be shown around the dorm before my arrival and this made for a difficult adjustment period.  Dr. Helphinstine and I took the students on the wards the first day they arrived.  Despite a lengthy talk about what they would experience on the wards, two of the students became weak in the knees within minutes and needed to excuse themselves.  Some had never seen a hospital ward even in the US.  This reaction was expected and I have no doubt they will be fine in the weeks to come.

Infusion Grand Rounds – Two months is not enough time to generate any significant change to a health care system.  Members of IU partnership live for years in Kenya to help improve the system and often meet with limited success.  Something I saw on the pediatric wards obliged me to take action, no matter how trivial the result.  While rounding on our patients, the nurses go from bed to bed administering medications.  On our crowded ward rounds, it is often difficult to hear the patient presentation and considerable effort needs to be taken to block out the background noise.  Something I could not tune out were the cries of agony I repeatedly heard from children during the medication delivery.  I snuck away from rounds to find the source.  What I found was fairly shocking.  When the nurses give drugs by IV to the children, they would grip the syringe tightly and use tremendous force to push the plunger as fast as possible.  This practice saves time, but is dangerous in adults let alone small children.  I fought off the instinct to stop the offending nurse and chose rather to think of a more sustainable solution.  As I returned to the ward rounds, we began to discuss a patient who had recently had his arm amputated.  The cause; his IV had leaked medication into his arm which became gangrenous and threatened to kill him.  The next day, we saw an infant who had an IV related chemical burn on the top of his foot near the ankle.  This will likely scar and complicate his ability to walk normally.  We have placed a major stumbling block in front of his first steps. 

I had a discussion with two dedicated 6th year Kenyan students about the problem and we decided to ask for time to make a presentation to the nurses about the issue.  Our faculty advisor suggested that this issue goes beyond a peds nursing issue as several adults have recently undergone amputations for the same reason.  Our small team has been asked to give a hospital wide grand rounds on the topic in early July.  Unfortunately, I will not be able to attend the presentation, but we will be generating the materials over the next month together.  A drop in the bucket, but if it helps one person, it will be worth it.

Sally Test Says Goodbye – As much time as I could spare was spent in the Sally Test Center for Children working on small projects or simply playing with the kids.  My last day, the children surprised me with a goodbye talent show.  The IU carpenters had built a puppet stage and the kids used home made puppets to act out a series of nursery rhymes.  Apparently, they had been preparing for over two weeks!  They sat in a circle in their story area and sang songs they had been practicing and danced for us in their story circle.  One of the children I had become closest to brought me a small basket that had a sheet of cloth in it.  All the kids had made paint hand prints on the cloth and written their name on it.  The title, “For We Are Kenyan Children”.  It was a very touching sendoff from a group of children I had grown quite close to over the last two months.

Karaoke – Tuesdays are Karaoke night at the Spree night club downtown.  I sang there the first week I was in Eldoret and the invitations to return came about every week thereafter.  My last night in Kenya happened to be on a Tuesday and I had heard that the hostess insisted on my being there.  The bar quickly filled up with Kenyan medical students, friends from the IU house and even some people I had met in town.  By the time the night was over, I had been pushed to the mic at least half a dozen times.  It was a great way to unwind before my travels began the next day.

Emily – If you have been following my blog, you are familiar with the patient I have called Emily.  I wish I could say that everything was in order for her when I left.  It was not.  As with all stories, hers was more complicated that it initially seemed.  It would be inappropriate to go into many details, but I will share where I left things and what I hope for the future.  I was able to mobilize a significant team of social workers and a concerned physician to address her case.  They are aware of Emily, but with over 10,000 patients, they have not been able to dedicate a significant amount of time to her.  By the time I left, we had had several meetings about getting her moved to a public boarding school near home.  There were several good options and time will tell which will accept her.  The next session starts in August.  Max and I took one final visit to the IDP camp on a rain soaked afternoon so I could say goodbye.  Emily was alone in her tent so we sat on a bench beside the door.  I told her I had no immediate answers but assured her that many people were working to improve her situation.  I emphasized her role in this process and that she needed to continue to work hard and keep a positive attitude.  I hope we left her with a sense of her potential for success in this world.  She has many impediments to that goal, but I truly believe that with a little luck she may be one of Kenya’s success stories.  She has a stack of self addressed stamped envelopes to reach me.  I will be eagerly awaiting my first letter.

Early in my time in Kenya, it was apparent that at many levels, the country is dysfunctional.  Two months is certainly insufficient time to become an expert on the topic, but I feel it’s important to record my impressions as I continue to process them.  Like much of Africa, Kenya was once part of the vast British Empire.  England and other colonial powers sought to bring order and civilization to what they deemed chaotic savagery.  Tribal lands were fragmented by geographical and political lines.  Indigenous leaders were supplanted by British diplomats who retained those willing to serve as puppets of the empire.  Western culture, commerce, and politics were introduced in place of tribal rule.  It was all seen as progress.  That was until the empire failed.  The economic and political will of England faltered and member countries seized the opportunity to expel the foreign invaders.  During my time in Kenya, the country celebrated it’s 46th year of independence.  Celebrated, however, is the wrong word; they acknowledged the occasion.  There is little to celebrate.

Politics – When the empire was expelled from the colonies, an inevitable power grab ensued.  The new Kenyan democracy was cobbled together from Kenyans who had held titles under British rule.  Cabinet positions, the court system, the senate, even the corporate world was populated by Kenyans replacing their English counterparts.  The new leaders lacked the knowledge and training to function in their new roles.  This was by design.  Empires maintain control by denying citizens of their colonies access to the inner workings of their government and businesses.  46 years is not nearly enough time to establish the knowledgebase and experience necessary to maintain a functional Western society.  The result is political corruption, a crumbling infrastructure and a collapsing economy.  Without appropriate leadership, the police force is more interested in shaking down citizens for bribes than enforcing law and order.  Even the public hospital administration turns a blind eye to faculty who accept a staff salary and spend their days in private hospitals never entering the public facilities. 

Tribalism – I have a sense that Kenya is a country torn between the Western promises of economic prosperity and a deeply rooted instinct to return to a pre-colonial tribalism.  America is idolized in Kenya.  Popular culture is almost entirely imported from the US.  Clothing styles have shifted from tribal garments and beaded jewelry to jeans and branded shirts.  While local music from various cultures can be found, most people blast R&B radio stations from their car stereos.  Barack Obama is more of a celebrity in Kenya that he is in the states.  Many Kenyans I spoke with expressed a desire to one day live in America.  Kenyans seem unified in a goal to become as much like us as possible.  The other face of Kenya was exposed during the clashes a year and a half ago.  Tribal gangs roamed the streets murdering those who did not speak their dialect with the appropriate accent.  Families were forced from their land as tribal homogeneity was re-established.  This went largely uncorrected by the government.  Intertribal marriage is still poorly accepted by many.  The artificial unification of these tribes under imperial rule continues to cause strife to this day.

Racism – The creation of a colony presumes the superiority of the colonizing power.  The British Empire considered people of darker skin color to be inferior to themselves as did most European cultures.  This flawed logic was employed to justify colonization and slavery.  In my time in Kenya, I witnessed first hand the lasting effects of social status being determined by race.  One of my first experiences was going to a local golf course with an American and a Kenyan friend.  We didn’t have the appropriate clothing or even clubs, but the business was welcomed.  As we were being checked in, the attendant assumed there were two of us playing and our Kenyan friend was our caddy.  As I left Kenya, I visited a businessman in Nairobi I had met at a wedding in Eldoret.  He was dressed in a suit and polished shoes.  I was in a t-shirt and jeans.  As we passed people he knew, they asked if I was his new boss!  We stopped for lunch and the waiters approached me before asking him what he wanted.  I understand that this treatment was more based on economics than race, but it is unacceptable that in a country of well over 90% dark skinned people, they should be made to feel inferior.   

Religion – A final theme I wish to address is that of missionary work and religious conversion.  One of the changes brought by colonization was the introduction of Christianity.  In the name of evangelism, African colonials were taught to abandon their tribal beliefs and accept Christian theology.  Those who were ‘saved’ and proclaimed their acceptance of church doctrine could advance in society.  Failure to accept the teachings would mark one as a heathen unfit for the benefits of Western culture.  Today, the churches remain, but appear to also be subject to the power struggle gripping the rest of the country.  I attended a Catholic church service and noticed an interesting practice during the collection.  Rather than sending baskets down the pews for anonymous donations, the entire congregation was ushered forward to rows of children holding large padlocked crates.  Money is collected with the eyes of the entire church on you.  I am also bothered when I witness Kenyans stating that “God will provide” and failing to take any initiative to improve their own lot in life.  The promises of a foreign religion are too often being used in the place of personal responsibility and ambition.

Final Thought - I realize that the tone of this post is relatively negative, but the content is based on my experience of the darker side of Kenya.  There are many fantastic and positive experiences chronicled in my previous posts.  My thoughts here seem to temper that a bit and are an attempt to help add more depth to the description of the trip.  I welcome any thoughts or debate on the subject.

Sunday, May 17th, 2009
A Church In West Eldoret

After discussing how I missed riding my bicycle in Kenya, Taxi Max and I came up with a plan to buy a bike together.  I would keep it for the remainder of my stay and he would get it once I left.  After purchasing the bike at Ukwala, we took it to a local bike shop to get it tuned up for 100 KSH.  While the bike was being prepared, we walked through the market to get something to drink.  “Hey,” Max yelled, “there’s my Dad!!”  Sitting in on a high wooden stool in the middle of the square was an imposing old man wearing a brown vested suit and blue turban.  A street vendor was busily shining his black leather shoes.  The man warmly embraced his son who introduced me as his friend the doctor.  “Chris, this is my father Waweru.”  With a high pitched belly laugh, Waweru abandoned his shoe shine and stepped forward to embrace me.  He stared at me for a long while with his one good eye then yelled something to Max in Swahili.  With a surprised smile, Max turned to me and translated that Waweru wanted me to attend his daughter’s wedding this Sunday.  The offer was too good to pass up.

Sunday morning found me working in the hospital and I didn’t get away until noon, several hours after the wedding had started.  I was picked up by a car carrying Max’s girlfriend and children.  “Max isn’t coming,” she said.  “He got a job driving some Dutch tourists to Boringo.”  There went my safety net.  I was going to be the only Mizungu at the wedding and not know anyone but Waweru who I had just met.  We arrived at the church to find services still going on.  The final hour of the 5 hour service was clearly taking it’s toll on the bride and groom who looked about ready to pass out.  With an eruption of drums and loud singing, the wedding was over and the celebration began.  Everyone, young and old, leapt to their feet and danced and jumped around the new couple.  They hoisted them up on their shoulders and carried them to the party tent that had been erected just outside the church.  Waweru found me and nearly squeezed the life out of me as he laughed and jumped.  “You came!” he exclaimed in rough English.  He assigned a man named Timothy to introduce me to the family and guests.

Timothy found me a plate of food (rice and beans) and a Fanta and told me to stand by a flower arrangement.  After eating a bit, I looked up and realized that he had made me stand directly in front of the head table!  “Timothy, can I sit somewhere out of the way?”.  He took me by the elbow and sat me behind the bride and groom in the middle of the groomsmen and bridesmaids the oldest of which was at most 12 years old.  30 little eyes were fixed on me trying to figure out who this guy was sitting with them.  One boy sitting next to me was particularly fascinated with my camera.  I showed him how to use it and after a few practice shots, sent him around the wedding to take some candid shots for me.  He did a wonderful job! (The bottom row of pictures are his.) 

It came time for me to present my gift to the couple so I joined the line of guests with presents.  The MC spotted me and called me forward.  “Our mizungu doctor friend has joined us from…?”  “Indiana,” I said.  “Ingreeamdah!” he exclaimed.  Close enough.  As I handed my gift over to the bride (who had no clue who I was) a microphone was pushed in front of me.  “I want to congratulate you on a beautiful wedding and wish you a bright future together!”  They clearly wanted me to say more but leaving well enough alone, I handed back the mic and slipped into the crowd.  Max’s girlfriend found me and said it was time to go.  We climbed in the car and headed back to Eldoret.  Weddings in Kenya can last well into the early hours of the morning.  I’ll have to imagine what went on.

(Note: ‘Emily’ and her grandmother have granted me permission to share their story on this site)

In two previous posts (“Sometimes, when there’s nothing to do…” and “Rounding With The Pediatrics Team”) I described my interactions with a young patient who I have referred to as Emily.  This week, she returned to the hospital for follow-up of her seizure disorder.  Medically, she is improving dramatically.  Her medications have reduced the frequency of her seizures and with additional adjustments to her dosing, we hope to eliminate them completely.  She again was accompanied by her grandmother who is her sole caretaker since the death of her parents.  Now that Emily’s medical condition was coming under control, my conversations with the grandmother turned to other aspects of her life.  I was surprised to learn that they are currently living in an internally displaced persons (IDP) camp.  These camps were constructed by international aid groups following the political violence referred to here as ‘the clashes’.  Around new years 2008, the current president Mwai Kibaki, announced that he had won an election that he was strongly predicted to lose.  People from his tribe became targets of brutal street violence that lasted over 2 months resulting in the killing of hundreds of people.  The fighting shut down the IU/Kenya partnership for a time.  It also displaced thousands of people from their land including Emily and her grandmother.

The camps include row upon row of tightly packed tents where food and water are distributed.  Attempts are made to place these people back in their native lands or resettle them to new parts of the country.  Unfortunately, many people are still living in these camps over a year after the clashes.  From what I have learned, some people are there due to an inability to find or afford a new place to live.  Others have become accustomed to the convenience of clean water and food delivered by trucks and have chosen not to leave.  Aid organizations are beginning to cut off supplies to these camps in an effort to discourage the latter group.  Emily’s grandmother is in her 80’s and does not seem thrilled by the notion of starting a new life for herself.  She is, however, intensely interested in seeing her young granddaughter gain access to a stable life.  Emily currently attends a school in the IDP camp that functions more as a day care than a true school.  Before the clashes, she was one of the top students in her class.

I have begun discussions with Emily’s social worker to try and find solutions to some of the many obstacles facing her.  We will travel to the IDP camp soon to access her current situation and discuss the available alternatives.  It may not be possible to solve any major issues for her before I have to leave, but at least we can start the gears in motion.  I will continue this story as additional progress is made.

May 4-10, 2009

AMPATH (Academic Model Providing Access to Healthcare) is a division of the IU Kenya Partnership dedicated to battling the HIV epidemic.  It is arguably the most successful and impactful aspect of the partnership and certainly receives the most international recognition.  AMPATH functions to both treat existing cases of HIV/AIDS as well as to prevent it’s spread both between adults and from mother to child.  The program has bases in over 19 regions of western Kenya.  These sites provide HIV testing, clinical evaluation, anti-retrovirial drugs, food, and psychological counseling.  The numbers of patients treated in the AMPATH centers is constantly growing and will soon pass the 100,000 mark.  Each site is staffed by clinicians, medical officers, pharmacists, and various support staff.  Program directors, including Dr. Mamlin, travel daily to these sites to see patients and ensure quality control.  AMPATH also maintains a series of farms to provide food security for the ever growing population of patients.  Students who work in the IU/Kenya partnership are given a week to experience the AMPATH program in the community first hand.  My experience occurred the week of May 4, 2009.

AMPATH Farms – Eldoret

Two days working on the AMPATH Farm in Eldoret gave us a significant change from our normal routine in Moi Hospital.  There are several farms throughout Kenya that all produce food solely for the patients of the AMPATH program.  Justina and I were assigned to the farm in Eldoret located directly behind the new Mother Baby Hospital at Moi Hospital.  The farm is a beautifully maintained piece of land that is worked entirely by hand by a dedicated staff, many whom are patients of the program.  Row upon row of carrots, onions, sukuma wiki, managu, and cabbage stretch for several hundred meters.  Each plot is manned by a team of two workers which creates a friendly air of competition.  There are no power tools so all of the work is done by hand.  Justina and I helped with weeding, planting, tilling, harvesting and plot maintenance.  Lunch was a cup of sour uji warmed in a pot in the fire.  The farm currently produces 1,800 kg of vegetables a day and their goal is to soon reach 2,000 kg per day.  The harvested crops are loaded on large trucks for distant distribution and on bicycles for local dispersal.  The vegetables are supplemented at the AMPATH clinics by bags of grains and rice from America provided by USAID.  We came to learn later that this food in no way can support all 100,000 patients but is instead dedicated to those patients who are just starting their drug therapy or who are deteriorating medically.  Working in the sun warmed fields with the AMPATH staff was a welcome change of pace and a highlight of my time in Kenya.

AMPATH Clinics   

I had the opportunity to travel to several AMPATH clinics in the towns of Amukura, Chulaimbo, and Mosoriot.  Many of these sites are accessible only by traveling on some of the worst roads in Kenya.  We often would drive for over 4 hours round trip to work at the clinic for less than 2.  We were exhausted doing this for one week.  The AMPATH program directors sign on for 2 year contracts.  The clinics consist of cinder block buildings with corrugated steel roofs and wooden benches in the waiting areas.  Buildings range from food storage to pharmacy and clinical buildings.  We arrived at each clinic to find close to 100 patients waiting in long lines in the shade to be seen.  Many have traveled for long distances on the same terrible roads we arrived on.  Some patients come to refill their medications which are given in 1 to 2 month supplies both due to availability and also as a means of ensuring compliance.  Many HIV+ pregnant mothers come to the clinics in an attempt to prevent transmission of the virus to their unborn infants.  With proper drug therapy, most will be successful.  In stark contrast to the west, infected mothers in Kenya are encouraged to exclusively breast feed their infants for 6 months.  The risk of dying from malnutrition exceeds that of contracting HIV from the virus laden breast milk.  Adults and children alike come to the clinic to learn the results of their HIV testing.  The patients are often stoic in their reaction, but the results clearly impact them deeply. 

The AMPATH clinics have experienced such a high volume of patients that they have the diagnosis and treatment of HIV down to a science.  The vast majority of the patients we see in the clinics have no visible signs of being ill.  Herein lies a bit of a paradox that exists in the success of the clinics.  They are not curing anyone of their disease.  Every person that is treated by the AMPATH centers becomes another carrier of the virus and can live a relatively normal life.  There are a number of reasons why the HIV/AIDS epidemic has hit Kenya particularly hard.  First of all, researchers believe the disease began infecting humans roughly in this part of the world.  The virus has been spreading here longer than anywhere else and the treatment has reached Africa relatively late.  Culture also has a major impact on the dissemination of the virus.  Kenyans are very accepting of a loosely structured polygamy.  The tradition of wife inheritance, where a man is expected to take the wife of his deceased brother into his bed, also creates a problem.  Men traveling for work visit roadside prostitutes (90% of whom are infected) on a regular basis.  These cultural practices fuel an already raging fire that is devastating Africa.  A vaccine (which has been a painfully elusive holy grail of HIV research) or a viable cure are badly needed to stem the tide.

May 11, 2009  10:00 PM
Student Hostel, Eldoret, Kenya

The thunder started during dinner and the heavy rains quickly followed.  The rains were much needed as farmers were beginning to dig up their recently planted corn in search of food.  The rains continued into the night.  The rainy season had finally arrived in earnest.  I sat at my desk in the dorm reading and listening to the rain when a winged termite landed on the page in front of me.  Then I heard the buzzing sound.  I looked up and saw over 100 termites crawling on my ceiling and thousands more climbing my windows up to the open vent window I hadn’t noticed was open.  After quickly shutting the small window, I grabbed a grocery bag and began scraping as many of the invaders off my walls and into the bag as possible.  When I was satisfied that I had most of them, I took the bag out into the hall to release them outside.  That’s when I realized that the entire dorm had been over run by hundreds of thousands of the winged insects.  The water from the rains drives them from their underground homes.  Then, they fly towards the lights of the dorms and congregate in vast swarms.  Quickly after landing, their wings fall off and the now wingless insects begin to crawl looking for food.  It was an amazing sight, but there was one thing left to do to make this a truly Kenyan experience.  My friend Benson had showed me these termites before and told me that the Kenyans like to eat them as a delicacy.  To demonstrate, he popped one in his mouth and ate it.  I was standing alone in a giant swarm of termites.  As one flew by, I plucked it from the air by it’s wings and in a quick bite, I ate the live termite.  It crunched.  It was salty.  It wasn’t all that good.  I have heard they are good fried and even cooked into an omelet.  I may have to try that someday, but at least now I am one step closer to knowing what it’s like to be Kenyan.  

May 8-10, 2009

Travel to Fig Tree Camp

The Masai Mara is a large wildlife sanctuary at the southern border of Kenya.  Inhabited by the Masai people, the mara is the northern aspect of the massive Serengeti that extends deep into Tanzania.  Joining me on this trip were Chelsea, Marcie, Justina, Ester, Mandy.  Our drivers were named Erick and Victor.  The drive to the Masai Mara is a brutal 7 hour trek over some of the worst roads in Kenya.  We eventually reached the Fig Tree Camp which turned out to be well worth the trip.  Fig Tree is a beautiful compound in the heart of the mara.  The rooms are a mixture of a cabin and a canvas tent with western bathrooms and covered porches.  The canopied beds were hung with mosquito nets and looked out over the river where we could see crocodiles and hippos.  Small monkeys played around the tents and pool and watched to see if we would drop anything for them.  Meals were served in a large open dining room by our wonderful waiter Paul.  A troop of Masai would enter the hall nightly to demonstrate their guttural chanting song and display their jumping prowess which is used to determine the quality of wives they will be granted.  Nights at Fig Tree were peaceful and quiet apart from the grunting of a hippopotamus, the bark of a hyena, and the occasional anti-malarial induced psychotic nightmare (Marcie had a rough night).  Before sunrise each morning, we were awoken by a guard rapping on our tent door so we could explore the mara at first light.

The Cats of the Masai Mara

Soon after entering the park on the first day, we came upon a cheetah and her cubs feasting on a freshly killed impala.  While we did not see the kill, we were told that the parents will often wound the animal and slow it down enough to allow the young to practice their hunting skills.  The animals took turns eating pieces of their prey while the others stood guard on the perimeter.  They, like many animals in the park, were accustomed to large trucks and were not frightened despite our close approach.  The young cheetahs had a mane of fluffy fur making them look harmless, but their bloody snouts suggested otherwise.

On several occasions, we visited a pride of lions that had taken down a Cape (water) buffalo.  There were several males (brothers of the alpha male), females and cubs gathered around the carcass.  In the matter of two days, the buffalo was reduced to bones and the lions rested lazily in the shade digesting their enormous meal.  The lions were extremely watchful and often had scouts hidden in the bush many meters from their gathering place.  At one point, we turned a corner in the road and passed within 2 meters of a female that none of us had seen until we were right on top of her.  Without the protection of our vehicle, we would have been an easy kill.  100 meters from the group of cats, we found several Masai men crouched in the grass cutting bundles of straw for their roofs.  We warned them of the nearby lions, but they were not in the least bit worried and continued on with their work.  The Masai and the lion share a balance of power on the mara and both seem to have a healthy respect for each other.  Recent poisonings of the lions by the Masai have been harshly condemned and the practice has been largely abandoned.

The most elusive cats in the Masai Mara are leopards.  Many groups travel through the park for a week without seeing one of these secretive animals.  On our last night in the park, Justina spotted a dark shadow in the trees far in the distance that she thought she saw move.  We drove slowly into the wooded grove and saw the female leopard high in a tree protecting a warthog that she had killed.  She seemed skittish and we soon learned why.  A large male leopard bolted up the tree and with teeth bared and claws exposed, challenging the female for her meal.  Before we could take any pictures, our driver slammed the vehicle in reverse and ordered us to close the roof.  “Battling leopards are VERY unpredictable and we can’t be near them when they’re fighting!”  The roar of the engine scared off the large male who slunk into the trees and out of site.  We occasionally saw movement in the distance, but for the time being, he had left the female to her prey.  We cautiously moved back towards the tree and tried to catch another glimpse of the cat.  We briefly opened the roof and by leaning out on the roof of the car, I was able to see her through a break in the leaves.  We counted ourselves fortunate to have seen a leopard and left the grove to explore other parts of the park.

The African Elephants

Elephants in the mara travel in troops led by the eldest female.  The Masai Mara was once home to thousands of these massive animals, but their numbers have dwindled to the point where it is a rare site to see more than 10 of them at a time.  After crossing a small river and barely making it up the bank in our vehicle, we came across a small troop of six elephants including a small baby lazily grazing on dried grass.  We stood admiring the peaceful animals for a good while.  The matriarch would frequently blow trunk-fulls of dust onto her back to cool off and brush away flies.  The baby stayed close to its mother occasionally taking drinks of milk to wash down the dry grass.  When our driver changed positions and moved too close for their comfort, the elephants reacted quickly forming a tight ring around the baby.  The largest male moved forward and began to grunt loudly.  The agitated male appeared to be ready to charge and we urged our driver to leave before things got out of hand.  We left the elephants to enjoy their grass lunch in peace.

      

Mara Wildlife

While the cats and elephants are certainly the highlight of a trip to the Masai Mara, there are many other fantastic things to see.  Giraffes are in abundance and were often seen far in the distance walking in a line on the horizon.  Flocks of impalas are composed of a harem of females led by a single male who, according to our guide Victor, “has to take care of all that.”  Hippos seem clumsy and harmless wading in the rivers or lumbering across the plains, but kill more humans than any other animal in the mara.  Several varieties of vultures sit in dead tree branches waiting for the cats to leave them scraps of meat.   Hot air balloons leave at sunrise every morning taking tourists who can afford the trip on a quiet flight over the mara.  Zebras and exotic birds cover the plains watching for predators.  Throughout the territory, the Masai men and boys walk their territory draped in red or orange cloth.  Sadly, these proud warriors are often reduced to begging for money or rushing towards cars to sell trinkets.  The poor Kenyan economy does not spare even the Masai people.

On our last drive out of the park, we drove through a herd of Cape buffalo lazily grazing in the open fields.  They kept a watchful eye for predators and many of them eyed us intently as we drove through their ranks.  Small birds referred to as ‘buffalo peckers’ jumped from animal to animal cleaning off small insects.  Cape buffalo can also be extremely dangerous to a person walking on the mara and must be approached with caution.

All in all, the trip to the Masai Mara was the trip of a lifetime.  The land is beautiful, seeming to stretch forever in all directions.  Despite being almost flat, there are rolling hills that offer the animals plenty of places to hide and hunt.  This place is home to some of the most fascinating animals in the world.  Hopefully the Kenyan and Tanzanian people will continue to keep it safe for generations to come.

Before leaving for Kenya, my mother Donata Lux gave me a children’s book by Kelly Cunnane entitled “For you are a Kenyan Child”.  She thought I might find someone in Kenya who would like to have it.  I flipped through the story and while it was a nice book, I didn’t put much thought into it at the time.  I decided to slide it into my luggage at the last minute.

One of the first places I visited in Moi Hospital was the Sally Test Center for Children.  The center is run by Sarah Ellen Mamlin and is made possible by financial support from a close friend of Sarah Ellen’s named Sally Test.  The center is a wonderful oasis of happiness in the otherwise dreary pediatric wards.  Children who are well enough to join in group activities come to the center every day for teaching sessions, games, songs, food, and an escape from their treatments for a short while.  The staff of the Sally Test Center also help care for children who are orphaned or abandoned by their parents by searching for long term placement.  Even children who cannot leave their beds benefit from the center.  The staff pushes a toy cart down the halls of the wards daily loaning toys and books to the sick children.  I realized that while my mother had never heard of the Sally Test Center, she had sent the book for them.

I spoke with Sarah Ellen and her assistants Patricia and Helen about a possible project to help bring the book to life for the children.  The book, “For you are a Kenyan Child”, repeats the title phrase after describing a typical activity in the life of a Kenyan child.  There are few books specifically about Kenyans and seeing a story about their lives can be empowering for these sick children.  Many of the children we see in the hospital have little or no concept of the world outside of their town or village.  None of them had heard of Indiana (one child thought it was in Japan) although they had all heard of the United States.  I sent a message to my elementary school art teacher and family friend Ruth Simmons who eagerly accepted the challenge to start a collaboration between her children at Mary Castle Elementary School and the Children of Sally Test.  All of the pieces were in place.

Blank pieces of paper were prepared with short phrases written on them leaving room for the children to add something specific to their lives.  A favorite food.  A game they play with their friends.  A family chore.  The children would then color an illustration for their page that could now be added to their books.  Each child was photographed with their work of art and the images were sent electronically between the two groups of children.  The tag lines read either, “For you are a Kenyan Child” or “For you are a Hoosier Child”.     

   

Children in both Indiana and Eldoret learned a great deal about each other that made them unique but also much that they had in common.  Hoosiers had never heard of uji for breakfast or washed cows to help their families.  Kenyans did not know what a pop tart was or how to play baseball.  Both liked pancakes, although Kenyans call them chapati.  Both liked soccer and swing sets.  Both now had a connection to children half way around the world and knew a bit more about them then they did before.  The pages in Kenya were collected and added to the back of their copy of the book.  The hope is that this project will be repeated in the future as new children enter the Sally Test Center and Ruth Simmons’ art class.

The activities in the Sally Test Center are more than just distractions from time on the wards.  The center is more than day care.  On many occasions on rounds, a child that was struggling with their illness and seemingly losing hope would come join in the play or singing and a new strength would be rekindled in them.  You can see it in their eyes.  This is as much a treatment as anything we prescribe in their charts.

Saturday, May 3, 2007
Kakamenga Rainforest, Kenya

Friday was labor day in Kenya giving us a nice long weekend to recover our energy and set out on another quick adventure.  It was agreed that a group of us would take the relatively short journey to the Kakamenga Rainforest for an afternoon hike in the old growth forest.  We were accompanied by our favorite driver, Taxi Max.  After a fairly short drive, we arrived at the gates of the forest, hired a park guide, and set out on our hike.

Kakamenga Rainforest is a small remnant of what was once a mighty expanse of trees ranging as far as the Atlantic Ocean and covering hundreds of thousands of square kilometers.  Now, the remaining forest is a mere 240 sq km.  Unfenced, it is under constant assault from local cattle farmers and villagers in search of free firewood.  Still, what remains is a beautiful example of the diverse life that exists in an old growth rainforest.

Quickly after entering the park, an alarm was sounded by red tailed monkeys alerting the forest of our intrusion.  Blue monkeys seemed less disturbed, but let out loud hooting grunts to mark their territory. 

Continuing into the forest, we followed signs that lead us to the muddy waters of the Isiukhu Falls.  Legend has it that visitors of the falls hear a woman crying upstream and none that have searched have found her.  We didn’t hear any crying on our visit.  We did find a small opening in the forest where a pool of water fed by the brown rapids of the falls was churning in circles before continuing into the forest.  The rapids served as the fishing grounds for a small crane called a hammercock that searched for a meal in a small eddy current.  Anita and Kalpana clambered out to a rock in the middle of the pool to enjoy the sun while Angeli and I searched the shores for good subjects to photograph.

Many of us were surprised to learn that within rainforests exist natural grassy clearings that are home to a variety of animals, birds and insects.  The final category, insects, was by far the best represented on our walk.  Butterflies and moths danced around the grassy fields and through the tree branches of the forest.  Angeli and I stumbled upon a nest of ants that produced a loud rattling sound by vibrating in unison as we stood watching them.  Justina had the unfortunate experience of stepping in a nest of fighting ants wearing her ill-chosen sandals.  She was able to brush them off quickly with no real harm done.  Giant termite mounds the size of many Kenyan houses could be found throughout the forest.  Silk worms hung precariously from a thin strand gleaming in the sun.  Dragon flies landed on any warm rock surface especially those near water.

Deep in the forest, we came across an enormous fichus tree.  Kalpana could not resist practicing her climbing skills on the tangled structure and quickly made her way high into twisted branches.  The acrobatics did not stop there as we shortly came upon a massive labyrinth of vines that had long outlived their host trees and served as a perfect natural jungle gym for our group.

   
            
The final portion of our hike again presented us with a new surprising terrain.  Rather than the dense broad leaved trees and vines we had become accustomed to, we were now climbing across bare rock and gravel covered slopes studded with tall cedar trees.  The rock slope was split with gaping chasms and scattered boulders.  The thin trees offered little protection from the afternoon sun.  Thankfully, we had all been living in Kenya long enough that the altitude and heat had little effect on our stamina.  Our guide commented later that we didn’t seem to tire out like typical mizungus.  A final climb put us back in the edge of the forest where we found a winding staircase leading to a watch tower.  We climbed the tower and found it offered a wonderful view across the entire rainforest to the hills on the opposite side which concealed the town of Eldoret to which we would soon return.  While we saw few birds or animals, we all left satisfied with a day spent hiking through the Kakamenga Rainforest.

Friday, May 1, 2009
Tuyambe Village, Ziwa, Kenya

During my time in the NICU, the team was lead by Dr. Melly, a young doctor recently graduated from medical school.  Dr. Melly is a pleasant and engaging physician who, more than many of his older colleagues, values the contributions of his foreign guests on the wards.  He has a warm sense of humor and is passionate about the practice of medicine.  May 1st was a holiday in Kenya (labor day) and those people who turned up for rounds did so in casual clothes ready to enjoy a long weekend.  When rounds were completed, Dr. Melly asked Justa (a medical student from Brown University) and me if we would like to join him for dinner at his grandmother’s home.  Neither of us could turn down the offer.  We were joined by Anita and Kalpana who worked closely with Dr. Melly on the OB ward as well as our hired driver Francis.

Ziwa is a town populated by the Nandi people.  It is a lush green region bordered by the Nandi Hills 50 kilometers from Eldoret.  The closer we came to Ziwa, the more the roads deteriorated.  Pavement became bumpy and pitted with pot holes then finally the road became red clay with stones mixed in.  Often, we drove in what appeared to be creek beds.  We stopped by the home of Dr. Melly’s parents to pick up his brother and nephew who also wished to visit their grandmother and descended into the valley where she lived.

Dr. Melly is one of 70 or so grandchildren that can be claimed by his 84 year old grandmother who comes from the village of Tuyambe.  She lives in a mud house with a corrugated steel roof built for her by her sons.  The house sits on a flat clearing half way up the side of the valley.  Cows and sheep graze in the fields nearby.  Chickens and cats wander in and out of the open windows and doors of the small house.  Other houses and mud huts surround the central house and are the homes of family members and neighbors.  As we approached the home, people began to emerge from the fields, faces looked out of windows, and grandmother emerged on her porch to greet her visitors.  We were ushered into the small house where water was poured over our hands and we were served a meal of chicken, rice, chepati, broth, and tea.  Fresh milk sweetened with charcoal was served.  Grandmother stayed in the kitchen and did not eat with us as is their tradition. 

When the meal was over, we emerged from the house to find that many more people from the village had come to meet us.  It is customary for the Nandi to share their visitors with their neighbors.  We photographed the families and children, and the villagers laughed with excitement to see their pictures on the digital screens of our cameras.  Dr. Melly asked us to join him at the front yard where a small hole had been dug in the earth by the front gate.  “Our family has a tradition of planting a tree to remember those who visit us.”  As we gathered around the hole, a small blue gum sapling was brought to us.  We each helped lower the tree into place and used our hands to fill the hole with red earth.  Water was again brought and poured over our hands onto the tree.  As we stood, the villagers began to sing a cheerful song of welcome.  A series of decorated gourds were brought and grandmother gave one to each of us in turn.  Next, a large potted plant was given to the group so that we could take something growing back to Eldoret from Ziwa.  We brought from the car gifts that we had purchased in town; a bolt of cloth, flour, sugar, soap, rice.  We wrapped grandmother in the cloth as is the tradition here.  As the singing came to a close, it marked the end of our visit.

Before leaving the house, we climbed up to the ridge of the valley to see the whole of the village.  As we walked, children from all over the village rushed to join us.  They were shy, but loved to have their pictures taken and play with their foreign visitors.  As dusk approached, we loaded back in the car to go visit Dr. Melly’s parents.  As in the valley, we were warmly received.  Here, a series of five holes had been dug for each of us (including Francis) to plant trees.  Mine was a guava tree.  We entered the house and were offered chepati and tea.  Dr. Melly’s sisters and several neighbors joined us. 

As the light faded, lanterns were lit.  A gentle rain beat on the steel roof.  Father and mother sat at a table by the kitchen and welcomed us with blessings spoken in Swahili several times during the visit.  All of us were enveloped in the warmth and serenity of the evening.

A calm announcement quickly changed the mood of the room.  Word came that a child from the valley was sick and was being rushed to see the visiting doctors.  Dr. Melly is the first doctor from his village and news of his arrival had spread quickly.  It was now a dark moonless night and while the rain had subsided, the roads now more closely resembled creek beds.  We heard the whine of an engine in the distance.  With flashlights in hand, we walked to the road to find three adults and one infant crowded onto a motorcycle.  We ushered the mother into the house.  The baby was one year old and had started crying in pain several hours ago.  The mother took her baby to a local medicine man who told her her boy’s testicles had reentered his body and he was very sick.  After taking a thorough history, we took the mother and child into the entranceway of the house with a lantern and examined the sleeping infant.  Not only were the testicles both normally descended, there were no signs of illness at all.  Our diagnosis; a first time mother with a perfectly healthy child scared by a local medicine man.  We took the relieved mother back inside where she was given tea and chepati in preparation for the journey home.  Our group insisted on driving her back to the valley unwilling to let her get back on the motorcycle with her infant.  We said goodbye to our hosts and headed into the night with our patient to return him home. 

Waving goodbye to the family, we drove out of the valley towards the road to Eldoret.  All of us agreed that we had seen the heart of Kenya that evening.  We have all experienced the poverty of the cities, the sorrows of the wards, and the struggles of this country.  Our evening in Ziwa is the Kenya we all want to remember.

April 30, 2009
12:45 AM
Moi Hostel

Wednesday evening had been spent relaxing at a local club called Caesar's which was packed to the walls with people watching the Manchester United vs. Arsenal champion’s league soccer match.  It was a fairly uninteresting game and we were all ready for sleep when the taxi dropped us off at the hostel at about 12:30 AM.  The rest of the group continued on to IU House.  I was about to climb into bed when my phone rang.  It was Manika.  “Something’s wrong in the NICU Chris.  I don’t have any details but the hospital sent word to the guards that they need help right away.  Can you go and call if you need help?”  “Of course.” 

I threw on my shoes and white coat and bolted out the door of the hostel, crossed the street and passed the hospital guards.  As I reached the NICU, nothing immediately presented itself as wrong.  There was a nurse calmly searching through drawers in one of the rooms.  “Did you call for help?” I asked.  “Yes doctari, I want to start CPAP on a baby but I can’t find all of the parts.”  CPAP or continuous positive airway pressure is essentially a canister of water attached to an air hose that helps keep oxygen flowing into the lungs.  As we searched for the parts, I asked what baby this was for and she indicated it was a new admission in the incubator room.

The tiny room was stifling, filled with mothers tending to their babies, some breastfeeding.  A single warming bed was left unattended at the back of the room.  As I stepped forward, I saw the tiny lifeless grey body lying uncovered on the gel mattress.  Its hands and feet were blue.  There was no movement.  A sudden gasp for air showed signs of life, but was an agonal breath which is a sign of the brainstem trying to save itself, not of functional breathing.  The oxygen saturation which is supposed to be no lower than 90% was 31%.  This baby was on death’s door.  As I assessed the situation, I quickly called Manika to tell her I would need help and we agreed that I would start delivering oxygen by ambu-bag and order labs while she found her way to the NICU. 

As I began to breathe for the baby, the nursing mothers filed out of the room, none of them particularly interested in what I was doing.  I ordered the nurse to get labs started and find the on-call registrar (resident).  The nurse left the room.  It was 1:00 in the morning, I was alone in the NICU, sweat pouring from my forehead, pumping air into a dying baby.  Was I helping?  Was the air getting in?  Was I forgetting anything?  A million questions ran through my mind.  The pulse oximeter chimed and showed that the oxygen level was rising above 50.  The baby twitched.  65.  Color began to come back to the skin.  80.  Was there a cry?  90.  The tiny black eyes open, not seeing, but alive.  It was working.

Manika burst into the room and I updated her with the little I knew about the baby.  In her hands were tools for intubating the infant.  I recalled stories about how infants at this hospital are almost never intubated because there are no ventilators available to breath for them once the tube is inserted.  We agreed to try and start CPAP as a last resort.  The nurse brought in the device from an infant who no longer needed it and I began to set it up for our patient.  The setup took less than a minute and the oxygen had already dropped to 50% telling us how fragile this infant was.  We watched as the pressure began to fill the tiny lungs and the pulse oximeter assured us that the CPAP was working.  We bundled the baby and sat on the nearby bench to watch for signs of distress.  Thankfully, there were none.  The baby was stable.

As we both sighed with relief, we noticed that nearly every monitor in the large NICU room across the hall was alarming.  Manika held down the fort with our patient and I went to investigate.  It was 2:30 AM.  Three children on CPAP were not properly set up and were not getting the oxygen they needed.  Several babies had EKG leads that had fallen off.  The warming beds were alarming because the temperature sensors were not attached and the bed couldn’t gauge the temperature of the patient.  There was no nurse in sight.  I moved quickly from bed to bed correcting the problems and silencing the alarms one by one.  Manika joined me.  Our patient was stable and sleeping.  We finished tending to the more than 20 infants in the room.  Still no nurses.  An hour passed.  No sign of the people responsible for the wellbeing of these children.  Children with the greatest need of attention in the entire hospital.  Children in intensive care. 

Finally, a door at the end of the hall opened and the nurses re-entered the unit.  “Excuse me, but where have you been for the last hour?”.  I was responded to with blank stares then, “It has not been an hour.  We have been here the whole time.  We had to prepare formula for some of the babies.”  I wanted to yell, to tell them how unacceptable their behavior was, how lives were in their hands and they were hiding in a back room.  “Is that your phone ringing?” Manika asked.  She saw my anger growing and rightly defused the situation.  Chastising the nurses was not going to change anything tonight.  “One of you needs to watch these babies the rest of the night.”  I was done, I had to leave them alone.  The resident had returned and assured us she would check on our patient throughout the night.  A hospital pickup truck picked up Manika and I and dropped me at the hostel.  It was after 4:00 AM

Thursday Morning, April 30 
8:30 AM

I reported to the NICU for rounds.  “Dactari,” said one of the night nurses, “your baby is doing so fine this morning.  We knew she would make it.”  I walked quickly to the incubator room passing several smiling nurses.  There she was, still on her CPAP, pink instead of grey.  She had made it through the night.  I don’t know what future she has.  Her weight is at a point where few infants survive in Kenya.  We have no way of knowing how long she went without breathing properly.  There may be underlying conditions that caused her to crash in the first place.  Regardless, she has the chance now to try and survive another day.  Against all odds.

Friday Morning, April 31
4:00AM

The fight was lost during the night.  She never had a name.

Wednesday, April 29, 2009
Eldoret Kenya

Located just a few kilometers from downtown Eldoret sits a small warehouse.  Inside, dozens of people are at work producing pieces of artwork for sale both in Kenya and abroad.  These people may never have met each other if not for a shared trait; they are all infected with HIV.  This is the IMANI Workshop.

The IMANI workshop was formed for the purpose of giving hope to local patients with HIV.  Despite the virus affecting a large percentage of the population here, a stigma still exists that makes it difficult for infected individuals to find gainful employment.  This is important not only from the standpoint of basic living expenses, but also for the added expenses incurred from living with HIV.  The workers are able to make a comfortable living wage that allows them to live healthy productive lives. 

An array of crafts are produced at IMANI including pottery and clay sculpture, papyrus journals, clay and paper beads, clothing items, and carvings.  Products are sold both in Kenya and abroad through the IU Partnership.  One of the fascinating stories of the workshop is the creative way that raw materials are selected and procured. 

The clay for the ceramics shop is largely generated from discarded chunks of clay collected from local manufacturers that is reclaimed and processed back into workable material over the span of five weeks.  The clay is molded into animals, figurines, and even grotesque shapes meant to represent the effects of untreated HIV.

Colorful paper beads are made by cutting strips of old magazines, coating them with glue and rolling them into to various shapes.  The resulting beads are a mix of colors as diverse as the pages from which they were rolled.  The beads are strung into elaborate necklaces and other jewelry or used to decorate the cloth work made by other craftsmen. 

All of the profits from the IMANI Workshop go directly to the workers who greet visitors with open arms seeming more excited to show you their craft than to try and sell you their products.  They do not hide the fact that they are HIV+, but rather are proud to share their success despite their affliction.  It is a remarkable endeavor that is enriching lives and truly giving hope people who sorely need it.  If my schedule permits, I may have the chance to spend a little more time at the workshop before I have to leave.

This week, Dave McCabe (host of the Home Server Show podcast) and I caught up a bit by Skype to discuss some of the latest home server news.  We did a little recording and you can hear our conversation on show number 41 by clicking below.  I’m not sure how many podcasts have been recorded from Kenya, but it can’t be many. 

Moi Teaching and Referral Hospital Neonatal Intensive Care Unit

Impressions and Thoughts

When a baby is born that is in need of special medical attention, they are admitted to the NICU.  In the states, the sick neonate is placed in a crib or incubator and attached to series of tubes and wires.  Temperature, respiratory rate, fluid balance, heart monitoring, and weight are analyzed on a constant basis.  A fleet of doctors, nurses, technicians and students pore over the data and assess the wellbeing of the child.  It is an intense environment that must seem as alien to the new parents as the world appears to the newborn.

The NICU I walked into in Eldoret this week bore little resemblance to what was just described.  After changing into hospital scrubs and donning communal slippers we entered the first of several rooms.  We were greeted with a wall of heat.  The babies were placed nude in a row of plastic bassinettes on wireframe stands lined with a black mattress covered with a hospital sheet.  There were no wires, no monitors, no tubes.  Some of the babies had a fine plastic oxygen line fixed to their nose at one end and spliced together with other lines leading to a lone O2 tank.  The heat was produced by a series of rusted electric coil heaters haphazardly placed on the floor.  Metal bowls of water were placed in front of the heaters to provide humidity.  Why heat a room in a cinderblock building just miles from the equator?  It dawns on us that the room itself is functioning as a giant incubator.  Body temperature; 98.6 degrees.  Necessity breeds innovation.

There is no relief from the heat in the next room.  This room harbors some of the sickest babies in the hospital.  Some are awaiting surgery they may never get.  Some lay blindfolded under the hum of a fluorescent bili-light to combat their jaundice.  One baby was born with externalized intestines with little chance of survival.  There is a single nurse assigned to each of these intensive rooms.  There are no monitors.  The nurses’ charting consists primarily of paper cards where weight and temperature are listed and little else.  Inevitably, the power fails leaving us temporarily in the dark until the large diesel generator belches to life outside the NICU window.

The final room is larger and houses the healthiest newborns still requiring some degree of medical attention.  The plastic bassinettes line the walls, each one containing a naked baby.  In the center of the room is a pair of rough hewn wooden benches where the mothers congregate.  The women are clothed in hospital gowns tied at the waist.  Most sit with their breasts exposed.  (Breast feeding is by far better accepted in Kenya than the states and it is not uncommon to see a woman breastfeed in a restaurant.)  The hospital has some interesting rules about when a baby should be allowed to breastfeed.  Before starting breastfeeding, many mothers are told to cup feed their infants.  These women sit on the benches and use their hands to massage milk into small containers.  They then hold their babies at arm's length in blankets pouring the milk from the containers into the babies' mouths.  It is shocking that more of them do not aspirate milk into their lungs.

Dr. Lemons, director of neonatal medicine at Riley Hospital in Indianapolis, arrived at the hospital this week.  He has been instrumental in arranging the funding to make the MTRH NICU a reality and continue to improve the conditions here.  The hospital administration elected to post a framed picture of Dr. Lemons in each NICU room whereas the rest of the rooms in the hospital display a portrait of Kenyan president Mwai Kibaki.  The morning Dr. Lemons arrived, the unit was swarming with doctors (called consultants and usually hard to find on the wards).  A blue ribbon was hung from the NICU doors for Dr. Lemons to cut.  As he entered the ward, he noticed his portraits.  He was obviously uncomfortable with the celebrity attention he was receiving.  With him were two Riley NICU nurses here for their first visit; both trying to conceal their surprise at the state of the ward.  Their job will be to assess the conditions in the MTRH NICU and determine areas in need of improvement.  They have one week.

   Sunday, April 12, 2009
River House, Eldoret, Kenya

Word had gotten around the IU House that two of our friends (Colin and Francesca) had birthdays coming up, so a party was planned for Sunday, April 12.  I enlisted the help of Simon and Benson to help plan an event down at River House.  They informed me that there are two birthday traditions here in Kenya; 1) Pour as much water and/or beer on the birthday boy/girl and 2) Prepare a goat or sheep for the celebration.  After clearing the birthday animal sacrifice with Colin and Francesca, I gave Benson the go ahead to start searching the local villages for a good candidate for dinner.

In the meantime, Bethany and I decided it would be fun to make a piñata for a little entertainment during the party.  Neither of us having made a piñata before, we googled the directions and modified them to fit our resources in Kenya.  We tied a balloon and a surgical glove together and realized that we were going to be making a rooster.  Our plaster consisted of flour and water which was remarkably similar to the ugali mentioned in a previous post.  After several rounds of plaster and yarn for structural support, we hung our creation out to dry in the back of house 5.

Next, we went on a bit of a nature walk to find local plants and flowers to decorate our creation.  We found a cluster of spiral seed pods for the tail, pink and orange flower petals for the crest and beak, palm fronds for the feathers, and yellow bush tomatoes for the eyes.  We even fashioned an official whacking stick from a bamboo pole.  The final decoration happened while I was in Nakuru.  With the help of Allison and Greg, the results were fairly spectacular.

The day of the party came and Benson and I went to pick up the goat he had purchased for 3,500 shillings (about $40).  Naomi, a long term resident of the IU house, volunteered to drive us to the village where our dinner was waiting.  Our purchase was tied to a bush on the side of the hill.  I noticed that the ‘goat’ looked awfully wooly.  “Benson”, I said, “is that goat a goat or a sheep?”.  “A ram”, he replied.  Apparently, for birthday celebrations, either will do.  You can’t be too choosy during the rainy season because farmers need to breed the next generation.  We drove back to the IU House with the ram quietly sleeping in the back.

CAUTION: Continue reading only if you are comfortable reading and seeing the ram being prepared for dinner.

At around 2:30, we gathered at the River House to start preparing the ram for dinner.  Colin, as the birthday, boy was offered the job of killing the ram, but he asked me to do the job for him.  I had never slaughtered a large animal before (just lots of lab mice), but felt comfortable giving it a try.  Benson held the ram with feet tied and head laid over a metal basin and I was handed a newly sharpened blade.  I took hold of the ram’s head and with a quick series of forceful cuts, the job was done.  Some people in the crowd could not watch.  One person became momentarily angry at the site of dying animal.  Most just watched and seemed glad not to be me.  Benson and his friend Nicholas continued to prepare the ram for cooking.  The muscle, we would keep for our dinner.  The head and limbs went to the guards to make soup.  The viscera went to the cooks who cook them for their families as a delicacy.  There was little or no waste.  I think it was a good experience for us to see where our food comes from.

While the meat was being prepared, we gathered to break the piñata.  It was stronger than we anticipated and it took seven people hitting it to finally break it open.  The contents of our rooster were all local items; packets of roasted peanuts from Mary (a woman who sells them on the side of the road on the way to the hospital), some local candies called ‘happy sweets’, several Safaricom top-up cards (cell phone minutes), and a hand full of government issued condoms (maybe you have to be here to find that funny).  We played volleyball, drank tuskers and coke, ate our roasted ram and had a fun birthday party for Colin and Francesca.

Easter was a long weekend here in Kenya.  With things fairly quiet in the clinic, some of us decided to go on a bit of a safari to Lakes Nakuru and Naivasha.  We hired a driver who we all call Taxi Max who would be our guide and he arrived in his beat up land rover early on Friday Morning.  In addition to myself were Manika, Kalpana, Anita, and Justa.  This was my first introduction to the Kenyan highway system.  While there are short stretches of semi intact pavement, the vast majority of the roads are a mixture of large rocks imbedded in red dirt or asphalt in such disrepair that some drivers resort to driving in the dirt to the side of the road.  Even going as slow as 30 KPH, we were still being thrown around the land rover for most of the ride. 

Along the road to Nakuru, we passed over the Equator.

Lake Nakuru is a beautiful nature preserve run by the Kenyan Wildlife Service.  Quickly after paying our admission fees and entering the park, we were stopped by a pair of park rangers.  After a brief discussion with our driver, the rangers demanded our entry cards and receipt.  Then they drove off without returning our cards.  This was likely a scam on their part to illegally sell entry passes from paying customers outside the park and pocket money.  It is a sad truth that you have to be on your guard for this kind of scheme in Kenya.

We saw an amazing array of animals in the park.  The following are just a small sample of the many pictures I took in Lake Nakuru Park.

After a quiet night’s sleep in the Lake Nakuru Lodge, we went for a final morning game drive by the lake and up to Baboon Point.  We had a spectacular view of the lake and park from the point.  As we drove out of the park, we found a tortoise in the middle of the road, so we helped him back into the woods.

From Nakuru, we drove towards Nairobi to Lake Naivasha.  We had a nice lunch at Fisherman’s Camp during an afternoon rainstorm while Colobus monkeys played in the trees.  When the rain cleared, we hired a motor boat to take us out to a small island where you can walk with herds of zebras and wildebeests.  The island is actually now a peninsula since the booming flower industry around the lake has drawn down the level of the lake enough to form a land bridge to the island.  Max decided it would be a good idea to ‘help’ the wildebeests with their daily migration across the island by chasing the herd.  As we walked around the island, the clouds began to break and a series of rainbows appeared on the horizon.  On the boat ride back to the camp, we passed by the region of the lake where hippos like to spend the day.  There were 30-40 hippos including several babies that kept diving out of sight.  We learned that the babies will actually dive under their mothers to nurse.

When we returned to the camp that night, we found that our banda (cabin) had been sold to a group of drunken partiers.  The manager decided to put us in the staff quarters in a triple bunk bed.  I was able to practice my bargaining skills (a must have in Kenya) to drive the price way down the next morning.  Our last adventure was to a gorge known as Hell’s Gate.  The gorge was full of obstacles that we had to climb over and down which made for an exciting walk.  Lining the walls of the gorge are natural hot springs that give the gorge it’s name.  Nearly halfway down the gorge, we started to hear thunder and feel drops of rain.  I suggested that we leave immediately and any resistance from the group vanished when a Masai guide leading another group rounded the corner, pointed to the top of the gorge and simply said “GO!”  We just made it out when sheets of rain began crashing down on us.  I hate to think what it would have been like at the bottom of the gorge. 

The rain continued on the drive back to Eldoret and turned into a thick fog that made travel a bit precarious, but we made it home just fine thanks to Max.  All in all, we had a wonderful trip.

Saturday, April 4th, 2009
IU House, Eldoret, Kenya

Late last night, I was invited to go on a trip to Mt. Elgon to a nature preserve with a big group of people from the house.  As tempting as that sounded, I was still feeling jetlagged and frankly not sure I was looking for a hike up a mountain side just yet.  I went to bed expecting a nice relaxing weekend with nothing to do.  Sometimes, when there’s nothing to do, amazing things happen.

I started the morning taking my camera around the IU House grounds to try and capture some images of this beautiful place.  I’m not sure the pictures do it justice.  When you look at them, you have to imagine a warm breeze blowing through the leaves, the call of exotic birds all around and the smell of red clay and flowers newly opened with the onset of the rainy season.

One of the guards was sitting at the gate with his dog Jack and suggested I go visit River House at the end of the road (also a part of IU).  River House is gorgeous.  There are large glass doors with iron accents open so that the wind blows the white curtains through the rooms.  There is a small pool to the side of the house and beautiful landscaping all around.  Thinking I was alone in the house, I walked into the kitchen and startled Elizabeth who was preparing a meal.  I apologized for ‘sneaking’ around and she told me the lunch she was making was for a group of shelter children who would be coming to swim this afternoon.  She also said she needed a lifeguard.  More on that later…

I said goodbye to Elizabeth and made my way back to the hospital to see if I could find Emily and her grandmother.  Grandmother was sitting alone on the edge of Emily’s bed.  Emily was outside playing.  Through an interpreter, I learned that she likely had been suffering from Grand Mal seizures for the last 3 years for which she had not been receiving any treatment.  The pills she needed cost less than a penny a day.  I wrote a long note detailing her symptoms and with the Kenyan intern, made sure that her discharge papers included her much needed seizure medication.  I met with Emily and her grandmother back at her bed and made sure they knew how to take her medication.  Emily was discharged.  We are all hopeful that she begins to see some relief from her affliction. 

So, I went back to River House to report for lifeguard duty.  When I got there, the kids were just getting into the pool and Colin (who had mostly gotten over his food poisoning) showed up to help as well.  It wasn’t long before we joined them in the pool.  We taught them how to play Marco Polo and followed that up with a game of Sharks and Minnows.  The kids had a blast and it was a nice treat to soak in a cold pool for an hour or so.

We headed back up to the IU house where two of the locals (Simon and Lea) were planning to cook dinner.  Traditional ugali and beef stew.  Mary, Ashley and I pitched in.  Ugali is very simple; boil water, pour in corn flour, stir until it’s done.  It was a lot of work, but the final product was delicious and it was fun to make it with people who grew up eating it.

After dinner, Ashley, Simon, Kelvin and I decided to take a taxi to town for some live music.  We headed to the Sesia Club at the Eldoret Wagon Hotel.  The sign read “Your fun and cheers hub”.  This was going to be great.  The band was called Ja'mnazi.  They are a Kenyan cover band playing traditional music from all cultures in the country.  There was a large dance floor flanked by tables where people sat drinking Tusker Beer.  The dance floor was always full of people in mostly western style dress, mostly inebriated, and dancing in a style that makes even me look like I know what I’m doing.   It wasn’t long before other friends from the IU House (Benson, Victor, and some others) joined up with us.  We listened to music and danced until 1 in the morning.  It was a great time. (Apparently, you cannot take pictures in clubs in Kenya, so you’ll have to picture it for yourselves. 

Friday, April 3rd, 2009
Moi University Hospital

Today was my first full day in the clinic, and it was also my first chance to be on rounds with the pediatric team.  Bethany and I met up with Dr. Chitanga who is the team registrar (their version of a resident) next to the first line of patient cots.  We were also accompanied by 2-3 Kenyan medical students.  The registrar called for the first patient to be presented and a nervous student stepped forward with her notes in her visibly trembling hands.  She quietly and deliberately read through her notes while presenting her patient.  After a fumbling through a few questions from Dr. Chitanga, she ducked back into the crowd clearly relieved to be out of the spotlight.  I am told this is the result of the British system of medical education.  You are taught largely by being told what you are doing wrong rather than being given constructive feedback.  There is a clear demarcation between the ranks that does not tend to exist to the same extreme in the American system.

As we neared to end of rounding on our patients nearly an hour later, an additional 10 or so Kenyan medical students wandered onto the wards.  Surprisingly, the registrar only made a small comment about the ‘late-comers’ but did not seem bothered.  Today was an admitting day for our team which meant that any new pediatric cases came directly to us; it would be busy.  Before the first patients began to arrive, I took a minute to track down ‘Emily’s’ chart.  There was little in it of any specific use, but the doctors seemed to believe that she suffered from hysteria and was not having seizures at all.  She would likely be sent home without further treatment.  I found Emily lying on her cot with another headache.  “I don’t feel well today,” she muttered.  The only way to confirm her seizure activity without and EEG (electro-encephalogram) was to ask her grandmother to describe what she sees when Emily has ‘fits’.  It is very hard to fake such descriptions.  “Grandmother has gone to market to work today,” said Emily.  “Will you come tomorrow and see her then?”  “Of course.” She answered me with a big smile.  I returned to the team and helped admit patients for the rest of the afternoon. 

When a group of us arrived home after dinner, our friend Stephanie was standing in the driveway with a blanket in hand.  She and Collin had recently gone to Nairobi to complete security documents for their residency programs awaiting them in the states.  Unfortunately, they came down with food poisoning while there so the extra bunks in my room are now a makeshift convalescent ward for them.  I’ll likely stay in another room to let them recover.  Another eventful day.  The first of many I’m sure.