Thursday, March 31, 2011

The wards

A few weeks back, E wrote about the families taking care of their loved ones on the hospital wards. As you can imagine, this lends itself to a very busy, crowded and noisy ward and we thought that you guys might like to see what we mean.

Imagine yourself trying to get a child calm before surgery or to fall asleep on the floor next to your child's bed in this room. It would be pretty tough for us as Americans since most hospitals are now full of private rooms and relatively low nurse to patient ratios. Also, you'll notice there's no electronic monitoring of vital signs that helps alert physicians or nurses of a crisis and sounds an alarm. I'm sure you'll notice a lot of differences between the US and Kenya, I know we did.

I took this at Kenyatta hospital in Nairobi but it's pretty reflective of any public hospital in Kenya (and actually better than some). The white lady you see at the end is the visiting urologist from Switzerland since I took this as we rounded on pre-operative patients.

Wednesday, March 30, 2011

The end of the day

Even before we saw the large dhows in Lamu, we really enjoyed watching the smaller dhows that fished on the reef outside our house. All of these dhows are handmade either by digging out a mango tree or built from wood by hand. The ones of mango origin are, for obvious reasons, quite narrow since the largest mango tree is only a few feet around. It’s pretty crazy to imagine someone squatting in this narrow space for several hours a day hand-lining for fish but they do it!




The narrowest dhows use outriggers to stay upright against the force of their large asymmetrical sail. M made the mistake one time of asking me about how the dhows without outriggers sailed upwind and I launched into a discussion using words like “center of lateral motion” and drawing diagrams of centerboards on napkins. He hasn’t asked again.

The boats are either pulled up onto the beach at the end of the day or anchored very close to shore. The hulls of the boats are actually burned or scorched to made them watertight. It’s always odd to come across a man burning his boat to make it more seaworthy. They use the dhows until they’re absolutely falling apart and then they abandon them on the beach.





On a run one day a few weeks ago, we came across a piece of a dhow. It was clearly the front part of the boat called the bow (rhymes with how, as does dhow coincidentally). M, always one for foraging, decided we should carry it home as a souvenir. So we took turns carrying our prize home. It was very heavy and water logged so M did most of the carrying but he was very pleased with it when we arrived home. We lay it in the sun and it is drying out nicely.



A few days later after a rough day at the lab with several ruined experiments, M looked at me and said, “Well, at the end of the day, at least we have the bow of a dhow.” This has become our funny joke and mantra whenever anything annoying or stressful happens in the lab which is quite often since Kenyan lab work is like herding feral cats. And M hates cats.

Some dhow pictures from sunrise a few weeks ago:




Monday, March 28, 2011

Medical Records

In Kenya, one can imagine that the system for keeping medical records differs somewhat from the US. Americans are data gluttons, and for every doctor visit, and especially hospital admissions, reams of data are collected, both paper and electronic. Most of this goes into the Black Box of American medical records, never to be seen again. How many of you have actually seen your medical record? If a doctor wanted to see your medical record, would you be able to produce it? I would guess that the answers are “not many” and “not easily”.

See the women below:



They’re holding small notebooks just like the ones that E wrote exercises in for her kindergarten kids. This is a portable medical record. If the patient sees a nurse at a local clinic, they write a summary of the visit, diagnosis, medications, etc in the book. The same goes for a hospital visit or admission. While it’s not a comprehensive record, it’s a very good summary that allows any caregiver to at least get some sense of the patient’s medical history with just a few minutes of reading. How much sense does this make?! I don’t see doctors too often, but when I do, it always feels like I’m starting over, and I don’t have much in the way of records to give them.

Patients here are given responsibility to keep their books and bring them to health care visits, and providers are charged with writing vital information in the book during the visit. What vaccines has the patient received? Do they have a severe allergy to amoxicillin? The system is admittedly rudimentary, but at least there’s a system. Where is this personal responsibility in US healthcare? We’re floundering over how to “protect” patients, and at least right now, protection means circuitous access to completely disjointed records. How about an encrypted medical records flashdrive that each person takes with them everywhere? Naysayers would point to security risks, but it is up to the patient themselves to protect their records, which I think everyone deserves to have the opportunity to do. Would these flashdrives be occasionally misplaced and someone might find out that Jim was prescribed Prilosec in 2007? Sure, but I also know that medical records rooms at a hospital are no Fort Knox, so what we have now isn’t much more secure.

Addendum: Right before posting, E and I went to lunch and happened upon this scene:





That's right, medical records being burned in the courtyard. Kenya: For every thing that it does well, it does two things badly.

Friday, March 25, 2011

Laundry Day at the Hospital




At Msambweni Hospital, like all public hospitals in Kenya, the staff are there for medical reasons. This means they do tests, give injections, change dressings, and consult with physicians when they are available. They do not do any non-essential patient care so everything from bathing, dressing, helping use the bathroom, and feeding are the responsibility of the patient’s family.

All over hospital grounds, you see the evidence of this patient care in the form of kangas drying on lines or on the ground. These are used as clothing, bedsheets, baby carriers, and everything in between. The women wash them behind the buildings and then hang them to dry, retrieving them each night so that they and the patient have something to sleep on.



You often see the patient in bed but at least one female relative is sitting nearby to care for the patient. Patients who have no family nearby can really suffer under this arrangement but most people, thankfully, have someone who can help them. Just like in the U.S., it seems that the quality of care you receive often hinges on an attentive family member.

Wednesday, March 23, 2011

The brightest room in Kenya

You may have gathered from our other blogs that the coast is very different from the rest of Kenya. The coast still has significant Swahili and Muslim influences whereas the rest of the country is heavily influenced by Europe and the US.

In most of the country, Kenyans wear clothes indistinguishable from those worn in the U.S. Some years ago, second-hand clothing was introduced in Kenya and it has since become a massive industry. Supporters say that the second-hand clothes provides low-cost clothing to people who otherwise couldn’t afford clothing while detractors argue that it hurts the local textile industries and reduces them to creating novelty fabrics for tourists. Additionally, we’ve heard multiple rumors that much of this clothing as been donated in clothing drives in the U.S. and Europe only to be sold to Africans so that middle-men become rich. The introduction of “western-style” clothes means that most people in Kenya wear jeans, t-shirts, business suits, sneakers, and high heels instead of traditional clothing except on rare occasions.

The coastal people deviate from the U.S. influenced dress. Men wear the bright color kikoi as skirts and women usually wrap themselves in 2-3 different kangas. The women here adhere to traditional modesty so they are completely covered except for their faces and hands. While such attire seems oppressive when they wear the black bui buis, most coastal women favor head to toe kangas in many beautiful colors. This gives them a lot more choice of colors and patterns and somehow seems much more expressive than the U.S.-inspired dress or traditional Muslim clothing.

The kangas are truly beautiful on their own but when many women are together, it’s an unbelievable riot of color. Since M’s study focuses on children ages 0-3, each morning the waiting area next to the lab is filled with mother’s and young children wearing these gorgeous kangas. As part of documenting the study, I was permitted to take a few photos and I snapped some of my favorite photos in Kenya. I think the pictures speak for themselves.

Heshora weighing a pregnant mama: (notice her belly covered in kanga)


The outer waiting area:


The inner waiting area:




That is one seriously cute bum:

Sunday, March 20, 2011

E’s siku ya kuzaliwa (birthday)!

Sunday was E’s birthday! We celebrated, Kenyan-style, of course.



Saturday night was a full moon. We’ve heard that it is the brightest full moon in 20 years. Not sure why, but we’re calling this one E’s Birthday moon. See below:



Later that night I took her to one of the nicer restaurants in Diani: Ali Barbour’s Cave Restaurant. That's right, folks, this restaurant is in a coral cave that’s about 100,000ish years old. While most caves elicit thoughts of dankness, this cave is actually open air; it was awesome to look up and see the starry sky. The food was great, and it was topped off by the waiters bringing a cake with basically a roman candle shooting fire out of the top. Like all cake in Kenya, it was super dry, but we ordered some banana and mango flambĂ© which more than made up for it.

Enjoying a Tusker like a lady Sultan:



The cave bar:



The view of the sky from our table:




Sunday morning was pancakes, omelets, and fresh fruit. A few weeks ago we met a local artist and E had her eye on a particular painting, so I covertly bought it for her as a gift. I wanted it to be a surprise, but quickly realized that we’re basically together all of the time, so last week when we got home from work one day, I just said rather awkwardly “I have to go out for a while”. She gave me a crooked look, and being the bright girl that she is, I’m sure knew what was going on, so let me go without further questions.



We topped off the birthday weekend with a mango birthday cake. And by cake I mean mango with a candle in it. We’ve gotta get in the mangos while we still have the chance!

Friday, March 18, 2011

The Young Man and the Sea

Ernest Hemingway, among other stodgy old men, once visited Malindi so on Saturday night, we ate a delicious seafood dinner at a restaurant called “The Old Man and the Sea”.

Sunday dawned and more coffee was consumed before we retired to the Driftwood club for a day of sunning and swimming. We paid the daily rate ($9 for both of us) and that granted us access to their pool and lounge chairs right on the beach. Our view:



This gave us a unique vantage point on the beach since we were set up about 10 ft from the beach but could clearly see everything that was going on. It was the first time we’ve been to the beach and not had to flee annoying beach boys. The people watching on a beach in Kenya is absolutely fascinating.

There are a lot of people in bathing suits but there are also a lot of women in bui bui’s:



Also, mangoes can be procured and eaten immediately which pleased Max immensely:



Fruit hawkers move up and down selling cut fruit:



I absolutely adore the babies feet dangling out of the kanga on her back!! You see it everywhere here and it’s so sweet.

Men hunt for octopi and crabs on the reef:



Yes, they pull them directly off the reef even though it’s a protected area. They can’t enforce the laws on the road so beach enforcement is unsurprisingly lax (or non-existent).

And the Maasai warriors show off their traditional attire to tourists:



Anyway, after a relaxing day of people watching, we got back in the car to drive home. Driving is always hilarious in Kenya because many of the signs are so funny. Case in point:



Also, anyone want to stay at a hotel which will sink the first night you stay there?



Anyway, we made it back safely and had a great week in the lab. We hope you all have a nice weekend.

Thursday, March 17, 2011

Invading Portugeuse and Dhow Foraging

After the Gede ruins, we drove onward to Malindi seeking the elusive coffee that we heard could be found there. Malindi is a coastal town so it’s basically 2-3 streets all running parallel to the water and not much else. On the way into town, we stopped at the only historical site in Malindi: the Vasco de Gama monument.





Vasco de Gama arrived in Malindi in 1498; this was no small accomplishment because he had to go around the southern tip of Africa since he was about 400 years too early to use the Suez Canal. Understandably though, the local Kenyans weren’t that impressed because his forces immediately took over Malindi and Mombasa and established trading forts there to the detriment of the locals. The monument stands out on a deserted tip of land just outside Malindi and is apparently regularly defaced by local hooligans. On this day, however, it was pretty clean.

The vantage point of the monument allowed us to see the whole town and we observed that it was low tide and that the dhows were sitting on the beach. Dhows are traditional Swahili fishing and shipping vessels that move up and down the coast from Lamu in Northern Kenya, all the way to Zanzibar in Tanzania. Some of these vessels now do tours for tourists but the majority of them still fish. Dhows are built entirely of wood and range in length from 15 feet to about 40 feet.

Dhow on the beach at Malindi:


We’ve really enjoyed watching the dhow sailing in front of our house and were excited to see that the Malindi dhows had the decorative wooden pieces on the bow (front) of their dhows that are common in Lamu and Zanzibar. See the carved blue wooden piece on the front of this large dhow in Lamu:



Since we both love the water and unique art, we knew this would be the perfect souvenir to bring home. When we visited Lamu last October, we had tried to find someone to sell us some weathered versions of the blue pieces but no one was willing to part with them. Now, I could sense though that M was up to the challenge of trying again. We drove to the beach and spotted a man working on his dhow. Leaving me in the car, M went to speak with him and the guy pointed him in the direction of the fundi (Swahili for expert) who manufacturers dhow parts. After a quick negotiation, M returned with not one but two boards that had the weathered look we were seeking. Total cost: 1,200 KSH or about $15. I was thrilled. Now we just need to figure out how to get them home but I’m sure it’ll work out.

Our dhow pieces:


A closeup. Notice the iron nails that cause the rust:


Finally, we drove into Malindi and found coffee! Despite the fact that one can drink “Kenyan blend” coffee at nearly every Starbucks in the world, you cannot really get good coffee in Kenya. Those Malindi Italians though have imported not only coffee but also pretentious espresso cups in which to consume it which we thoroughly enjoyed. Now if someone in Kenya can just invent the “to-go” cup of coffee, I’ll be a happy girl.

Tuesday, March 15, 2011

North Coast: Gede



After most of our company from the US departed last week, E and I decided that we needed a little getaway… from our getaway. Seriously though, the last few weeks have been pretty stressful while we’ve been trying to figure out a lab-related plan of attack for the last few months of our stay. Plus your pipette muscles get sore after the 20,000th aliquot of the day so we just felt the need to get away from the house for a few days.

We settled on Malindi, a town about three hours north of Mombasa (the 'North Coast'), which has in recent years become somewhat of a hub for Italians. More on that later.

Some friends of ours in town helped us find a very cheap car rental place in Diani, and we headed up the coast on Saturday morning. Crossing the ferry was thankfully uneventful, and before too long, we were on the open road heading north. Our first planned stop was the ruins of an ancient Swahili town called Gede.

Gede was built in the 14th century by a Swahili tribe, and was quite prosperous for hundreds of years. The Swahili are a coastal tribe with territories from Somalia to Tanzania and were often the middle-men between Arab traders and inland African tribes. They converted to Islam through their interaction with the other traders and were among the wealthiest Africans because they controlled access to foreign goods. The influence of the Swahili culture has since diminished and several signs in Gede referred to the “Golden Age of Swahili Culture” as the 15th century. Gede, therefore, was built in this heyday.

By the 17th century, Gede was abandoned, either because of neighboring marauding tribes, or because the water table inexplicably dropped and the wells dried up. Regardless, the town was lost until the late 1800s, at which point it was lost again until about 1930. Very forgetful, those Kenyans.

During excavations of the site, archeologists uncovered a sophisticated, prosperous city. Fine china, Chinese money, Venetian glass, Spanish scissors, Indian iron lamps, and other items were found, indicating an expansive trade network through the Indian Ocean. The site has since been designated a national park and is protected from logging and such. Most of the remaining city is constructed from coral blocks; there was a large surrounding city that housed the lower and middle class, but their dwellings rotted away long ago.

E and I arrived and decided that for this kind of site, a guide would add a lot to the experience, so we found little Alphus, who proved to be as good of a guide as he was tiny. See below.



Here’s me in the main mosque (there are nine in the town):



We learned that the mosque was partitioned so that women sat on one side of the wall and men, including the iman, sat on the other. In order that the women could hear the main prayers, the Swahilis fashioned these echo chambers (that's the little alcove I'm standing in above).

The iman could recite into a small hole in the wall and his voice was amplified throughout the mosque. I made a small attempt with a very American “hello” before Alphus shoved me aside and performed a haunting call to prayer as we stood in the forest mosque. It was quite surreal.

A “pillar tomb”, unique to the Swahili Muslims:



The buildings are all named very descriptively: “The House of Scissors”, “The House of Chinese Money”, “The House of Cowries”, etc. based on where they found various artifacts. Since there is no written record of the town of Gede, they can only go by what they find in their excavations.

Here is a water channel where the townspeople bathed before entering mosques. The city was designed with water in mind with bathrubs and latrines so you can see the issues if the water suddenly dried up:



A short diversion, but an interesting one, nonetheless. Though there’s a ton of history in Kenya, being the Cradle of Mankind and whatnot, there’s not a lot of old architecture. Most settlements, even today, are made with materials that don’t hold up well to the elements. Clay, wood, and palm fronds comprise the vast majority of construction in Kenyan villages. Coral blocks are used by the rich and for the more important structures like mosques, so I guess that mosques are the Kenyan equivalent of the cathedrals in Europe.

It’s still before noon on Saturday! Stay tuned for the rest of the story.

Also, congrats to all of my med school classmates who found out that they matched yesterday! We wish that we were there to celebrate with you. Now that you have a job and more free time, come visit!

Friday, March 11, 2011

Kenya in bloom

One of my favorite things about Kenya is how bright the colors are. The sun is so strong that all the colors seem much more vivid. At noon in Kenya, you actually have no shadow because the sun is directly overhead. It's pretty crazy.

Since the growing season is virtually year-round on the equator, there are amazing flowers all the time. The flowers vary from place to place but all are strikingly bright and beautiful.

The bougainvillea on the coast:






Jacaranda trees up country:





It is one thing I'll certainly miss at home!

Wednesday, March 9, 2011

Freezer Diving

So here’s what I did last week while M was at the conference:



That’s a -86 degree freezer that I have my head in. I actually got my entire upper body in it at one point. I also managed to freeze off my fingerprints because I was too eager to grab all the boxes I needed and didn’t wear the required ski gloves. I could have waited for one of the Kenyans to come back and help me but patience is not a virtue I possess.

So, what was I freezer diving for you might be thinking? Samples for M’s research. So, in laymen’s terms, the goal of M’s project is to link maternal infection (or lack thereof) while pregnant with the immune response of the babies after they are born. The working hypothesis is that women who were infected with malaria, schistosomiasis, hookworm, etc. while pregnant will have babies who are less able to mount a proper immune response to illness. It seems obvious but no one has proved this point yet; doing so would mean that women in the developing world will actually get treated while pregnant because there’s a cost-benefit in terms of the child’s health and (mostly foreign) aid agencies will pay for it.

So, the project involves testing samples of the babies blood for response childhood vaccinations (hepatitis, H. flu, tetanus, diphtheria) at 6 month intervals from birth to 36 months. All of the babies were born between 2006 and 2008 and they have been collecting blood samples from these babies ever since.

Since the project agreement requires that samples be taken in duplicate, there should be one test tube from each visit in Cleveland and one in Kenya. We were told that the ~3,000 samples M needed were in Kenya; this was not the case. No one is quite sure what happened but somehow all the samples were shipped to Cleveland about 2 weeks before we arrived. Like ships passing in the night, we just missed them.

So, I’m sure you’re thinking this isn’t a big deal, just send them back!!! No can do. There are several people in the lab running different tests on the samples and they were not happy with the idea that they would disappear back to Kenya for a year. So, a plan was developed to take a small amount from each sample and send them back to us. These samples could arrive in waves as people came from the lab every few months. As you can imagine, it’s rather annoying to pipette a small amount from 3,000 tubes into other tubes but it was really the only option. Also, the term for pipetting a small amount is “aliquoting”. Fun fact.

M and his samples:


Unfortunately as the months have gone by, only about 1,200 samples have arrived. Academic research is actually a pretty competitive environment and since very few other people in M’s lab would receive any direct benefit from getting him the samples, they haven’t arrived at quite the pace we had hoped. M has used his time very well, setting up the UTI project, shadowing in the hospital, and doing whatever lab tests he could while he waited but it was looking a bit dire last week.

As we previously mentioned, this week the primary investigators on M’s study were in Kenya and we all sat down to discuss these issues. Our main concern was that M have some publishable research completed by the time we leave so that he can apply to residency programs. After several long meetings, a plan has been devised that involves us running a lot more tests on the samples we have here and hopefully M will get some publishable data from that. We’ve calculated that it’s about 12ish weeks of work for both of us full-time in the lab but obviously I’m happy to help.

His and hers pipetting:


So, why was I freezer diving? Well M’s advisor pointed out that there were 600 follow-ups done last September that hadn’t been sent to Cleveland yet and that if we wanted to go through them to pull out the relevant 50 of them, we could do that. It was all the incentive I needed while he was away! Fifty more is a big increase when you only have 1,200 and I actually netted about 65 so it was a big win.