Friday, March 6, 2009

Stick Around!

Hey guys, to those still checking up and following along, I'm safely back in the states right now. I'm working on uploading pics, writing about the safari, the train ride to Mombasa, adventures in Mombasa and Diani, the trip back home, and reverse culture shock. Phew! It feels like a homework assignment right now, but I owe it to myself and you guys to deliver. So keep checking back every so often for updates. Thanks!

Tuesday, February 24, 2009

Maasai Land

Sorry its been so long since my last posting. I've been on safari for four days and then took a train directly to Mombasa right when I got back, so I haven't had time. Of course, I'll write about these events soon. Here is the much-awaited Maasai Land post.

One of my favorite parts of travel is stepping on the plane knowing that in the very near future, I’ll be meeting incredible people and experiencing events I’ll remember for the rest of my life; it’s just that the specifics haven’t been worked out yet. You don’t plan on meeting wealthy Tanzanian bankers or getting ritualistic Maasai warrior burns when you plan out your travel itinerary back at home. But when you stay flexible and keep an open mind, opportunities open up for you that you might not even have imagined as even being options in the first place. These past three days have been one of those experiences in my life that I’m sure will make the cut as a “life flash” moment. I call a “life flash” moment any life experience significant and/or unique enough to qualify as things that will flash before my eyes the instant before I die (sorry if that sounds morbid, bit it’s something I think about every now and then).
I never really planned on going out to visit the Maasai when I got here. They were interesting when I saw them in a National Geographic magazine as a kid, but I just didn’t really share the strong appeal of meeting them in person that so many people here seem to feel. For several of the volunteers, living and working with the Maasai was their reason for coming out here in the first place. I had heard through the grapevine that there was a remote medical clinic out in Saikiri, a small village about 2 hours outside of Nairobi (don’t bother whipping out a map; you’ll be wasting your time). I figured going out there for a few days would be a great way to indulge my romantic fantasies about doing medical work in the middle of nowhere. And what better time is there than mid-February to indulge romantic fantasies?
The trip to the village was a mini-adventure in itself. Bonface rode a bus with Hanna and me out to Ngong, a market town some 30 minutes from where we lived. We walked a few minutes past hastily-erected fruit stalls and through narrow side streets to get to a small lot. There was no way we would have figured it all out if Bonface hadn’t accompanied us. In the lot sat an old pickup truck that must have been around since the Carter Administration, a matatu that would have been shot a long time ago had it been a horse, an a few motorbikes. Bonface tried haggling with them to get us a low price to Saikiri.
Everyone was offering us prices which were at least double the usual asking price: We were getting the Standard Mazungu Price. After much negotiation, we were left with two realistic options: We could shell out a lot of money ($4) and take a motorbike, which was relatively comfortable and fast, or we could pay $1 and take the pickup truck. We chose the pickup truck. At one point, this small truck was carrying 17 people, along with massive bags of grains and luggage. At least we didn’t have to ride with goats, which we later found out was a common occurrence.
This was one of those “Am I really here right now doing this?” moments which I seem to be having a lot of in Kenya. There I was, sitting in the bed of an ancient pickup truck with a small bag containing little more than toiletries, medicines, and my stethoscope heading out to the African brush to work in a small clinic. I’m not going to lie, I felt pretty damn cool. I mean, how many other people experience something like this in their lifetime? Over the shoulders of my fellow passengers, I watched the landscape slowly transition from the familiar grass and dirt to a world of red dust, bone-dry brush, and Acacia trees. This was the first time I had seen a place like this. I mean, I’d seen places like this in movies that were set in Africa, but this place looked so…foreign. With the language barrier between us and the other occupants, we could only look at each other and smile. I heard a cell phone go off. A man wearing traditional Maasai clothing was actually talking on his cell phone! That juxtaposition of the ancient and traditional against the modern was a bit much for my brain to handle on top of everything else it was trying to process at the moment.
After a two hour long ride down increasingly bumpy roads and through increasingly desolate terrain, we finally arrived at our destination. I grabbed my bag and jumped out the back of the truck and was immediately greeted by about a dozen kids wearing tattered school uniforms. We took pictures together, they asked about Obama (apparently, all Americans know Obama personally), and then pointed us up the road to the clinic. When we arrived there, we asked to see Maggie, the 28 year old nurse who ran the clinic. Maggie was the bee’s knees, we were told, and I was really looking forwards to working with her. She introduced herself, along with Carol from Brussels, Brittany from Newport, VA, and David and Emma, a young couple from Scotland that was in our orientation group. Carol was actually born in Kenya but had been living and going to medical school in Belgium. She was in the village for 7 months, super smart, and fluent in about 5 languages. Europeans have a way of making me feel a little stupid by admitting I only know 3 languages. Brittany was very fun to hang out with. We would drive ourselves crazy by reminiscing about and craving American foods like cheesesteak and Chik-fil-A waffle fries. It was fun and torturous at the same time, but when you’ve gone over two weeks without a Wendy’s Double Classic Cheeseburger Combo (without onions, with Dr. Pepper, please), it’s hard not to do what we did. (FYI: As I typed that last sentence, my stomach growled very loudly.)
Brittany took Hanna and I to see the school that she was teaching at. We got there right as classes were being dismissed for the day. The school was much larger than I imagined it would have been considering it was out in the middle of nowhere. About 400 students attended the school, many of them walking for an hour to get there. It seemed that every single student there that day shook our hands. Greeting everyone we saw was a running theme throughout our three days there. I thought about what people back home would think of someone who shook hands and said a simple hello to everyone they met; they probably would have thought they were weird or creepy, which made me a little sad to think about.
Like seemingly everyone else in Kenya, the Maasai children had trouble pronouncing my name. After struggling for a bit, they decided to give me a Maasai name: My new Maasai name is Lamyan, which means “blessed.” The kids assaulted me with a million questions: “What was I doing in Saikiri? What is your favorite football team? Why did I have so much hair on my arms?” When they asked about my arm hair, I pulled my shirt up to reveal my dense jungle of chest hair. Their reaction was priceless: There was screaming. There was laughter. One girl simply turned around and walked over towards Brittany. Brittany asked her to ask me about my chest hair, and she replied “No. I am scared.” Hahaha! The kids were really fun to hang out with and were hilarious. I promised myself I would try to play soccer with them before I left.
Hanna and I said our goodbyes to the children and walked with Carol and Brittany to the village. The Maasai village was not what I was expecting. Then again, like much of Kenya, I really didn’t know what to expect. Most of the two dozen or so buildings were made of corrugated steel sheets and wood rather than the mud and dung that I imagined. If I didn’t know any better, I would have thought that Saikiri was sponsored by SafariCom, one of the main mobile and wireless providers in Kenya. Half of the buildings were painted in the distinctive SafariCom Green and covered with its logos.
After exploring the village for a bit, we made our way back to Maggie’s place just as the sun was setting. Maggie had to go drop a volunteer off at the airport and would be back late at night. We all sat around the small concrete courtyard and helped prepare dinner and drank some of the most amazing chai I’ve ever had. I don’t know if the chai was just objectively good or it was the situation I was having it in, like the way a simple sausage with bread tastes incredible after a long day of camping, or wine that would be considered vinegar in any other occasion tastes like a bottle from God’s personal cellar when you’re enjoying it with new friends in a new place. Since I’ve been here, I’ve come to appreciate simple pleasures more and more. I never would have considered sitting around, talking, and peeling potatoes in a remote place with no electricity or running water to be my idea of a nice evening, but I was really enjoying myself. It was nice being able to take things slowly and talk about anything and everything and nothing. By being constantly connected via internet and mobile phone, we are paying the paradoxical price of being more isolated from each other than ever before. I don’t even know my own neighbors back at home; that situation is unthinkable out here. Out here, I marvel at the resilience and adaptability of the human race. We seem to be able to survive and even thrive in the harshest of conditions. Living without electricity and running water was a small adjustment to make, and I was pleased that it was more painless and easier to get used to than I imagined it would be. I guess the difference is that in America our infrastructure is so dependent on these things just in order to simply run, so when we lose these seeming necessities of life the effects are crippling. Out here people have lived this way for hundreds of years and many continue to do so. I also thought that for all the talk of the global economic downturn, there will be millions of people around the world who will remain virtually untouched by it. These people aren’t worried about securing mortgage-backed lines of credit to finance their business; they rely on their product and their word.
As the sun set, I realized another price that we pay for our modern way of life: For the first time in my life, I saw stars. Truly saw them. Thousands upon thousands of them. I could make out the Milky Way. I could peer into the seemingly empty looking spaces and discover even more stars if I squinted hard enough. We were looking for shooting stars and thought we saw one that kept lingering; we were actually looking at a satellite. I stood out there for about 10 minutes and just stared with my jaw on the floor. It was heartbreaking to think that I’ve been on this planet for twenty three years now and this was the first time I was seeing how many stars were actually in the sky. It also made me sad to think of how many people will never experience what I was experiencing, especially with increasing light and air pollution around the world. It was humbling and reminded me of how small and inconsequential we humans are in the big picture.
That night we cooked some food using a coal burning stove and ate by lantern light. We later freaked ourselves out with scary stories and even tried using a handmade Ouija board, which never did end up working for us. We said goodnight and I retired to my closet-sized bedroom. I checked my room for spiders and other creepy-crawlies more thoroughly than I usually would have since I was freaked out from the stories we were just telling. It’s a good thing I did, because there was a massive spider (by American standards) on the inside of my mosquito net that I probably wouldn’t have noticed had I not been so thorough. Ghost stories have their practical benefits, I suppose. The wind sounded like it was gale force as it wailed over the burlap and plastic roof of my shed. It was so loud, I had to take some Benadryl from my first-aid kit just to get to sleep.
I woke up the next day, groggily stumbled outside and peed while a herd of goats watched me, and ate a quick breakfast. I was ready to start my day and check out what this clinic was all about. Of course, we were on “Kenyan Time,” something I have a love-hate relationship with. The clinic opened at 9 A.M., but of course, in typical Kenyan fashion, we unlocked the doors a bit after 10. Everything looked ancient and was covered with a dusting of the powdery red dirt that’s found in the region. This damn dirt seems to get everywhere, carried along by the strong winds in the valley. Although the meds and equipment looked like they hadn’t been used in years, I found out that the clinic is wiped down and cleaned every morning!
A knock at the door signaled the arrival of our first patient. Carol, Hanna, and I would be running the clinic by ourselves since Maggie was teaching a community health class. Thankfully, Carol knew Swahili and Maasai and patiently translated for us. The resources situation was even worse than in the clinic in Kawangware. There was no lab, no electricity, and no running water; it made the Wema Clinic look like the Mayo Clinic. It was frustrating not being able to order even the simplest of lab tests on patients who needed them. Patients were given broad-spectrum antibiotics for almost everything since we didn’t have a microscope or the ability to do cultures and all fevers were assumed to be malaria. Those that needed lab tests or further treatment were referred to the hospital in Ngong, about 2 hours away by matatu.
Some experiences reminded me of some of my patients back home. When a woman came in complaining of pain in her left flank, I asked her the usual questions with the help of the janitor, who acted as a translator.
“How long have you had this pain?”
“Six months.”
“When did it start?”
“After I fell on my left side.”
This other woman came in with a recurrent urinary tract infection that didn’t seem to respond to whatever we threw at it. When I asked her questions like how often she was urinating, what the volume of her urinations were like, or if the urine was cloudy or had blood in it, her husband would answer all the questions while the woman sat quietly. How the bloody hell would her husband know whether her urine was cloudy or not?! Women really seem to get the short end of the stick in Maasai culture. They cook, clean, raise kids, and do the manual labor. The men are mostly around for “protection.” They must have taken a cue from the lions that live alongside the Maasai; the lioness does all the work while the lion sits around and protects. I’ve seen women carrying massive loads of grains and children while her husband walks besides her carting only the stick which all Maasai men carry. I was surprised to learn that female circumcision is still widely practiced in the area. I know it might be considered anthropocentric or whatever to consider the practice barbaric, but its hard not to.
We saw about a dozen patients or so that day. There was nothing too interesting, mostly malaria, upper respiratory tract infections, and the occasional headache or other common complaint thrown in for good measure. When doing this sort of work, you quickly realize how basic and routine things can get. But then again, we only have the capability to treat the basic and routine. As I mentioned earlier, I didn’t really know what to expect coming in, but I should have realized that this is what it would be like. There was tons of downtime between patients, which made me miss the clinic back in Nairobi which was busier.
We closed the clinic at around 5 PM or so. Maggie asked if Hanna and I wanted to do a home visit. Sure, I thought, it would be interesting to visit a patient in their home and deliver meds or whatever else needed to be done. We drove to a small village about 15 minutes away and walked inside the small hut. The person we were coming to visit was a mother who had lost her baby a few days ago. The baby had a congenital heart defect that wasn’t caught in time; even if the defect had been detected early, though, there would be no way she could afford the expensive treatment. The entire situation was very awkward. Hanna and I sat on a dirty dilapidated couch next to about half a dozen people whose language and culture we didn’t understand. All we could do was sit silently and stare into space as flies crawled all over us. All the women were in the room next to us with the mother who lost her child. After I couldn’t take it anymore, I asked Hanna if she wanted to go for a walk to escape the situation. We walked around the small village for a bit, hoping that Maggie would hurry up so we could get back home. Hanna remembered hearing something about how the Maasai don’t bury their dead and leave them outside to naturally decompose. I’m glad we never ran into the graveyard during our village exploration, because I’m not sure I could have handled the sight of a bloated and decaying 4 day old being picked apart by dogs and birds.
After about 2 hours of pure boredom, Maggie emerged from the hut. Now we would start walking back. No car. Through the desert. The hot, dusty desert. For over an hour, Hanna and I trudged along the dirt road back to the village. It was nice in a way, though, giving me time to think and appreciate the harsh beauty of the landscape. We got back and the sun set soon after. That night we would have two luxuries: Electricity and S’mores. Simon, Maggie’s boyfriend and a true Renaissance man, was going to turn on the diesel generator so we could have a bit of light and power for the television. We watched maybe 5 episodes of Prisonbreak on pirated DVD and made S’mores on the coal stove using African ingredients before the highlight of the night.
Earlier in the day I had decided to get ritual Maasai burns on my arm. The burns are made by rubbing a stick against a plank of wood until it begins to smoke and smolder. The red-hot stick is then pressed against the skin. After it heals, it leaves a nice looking scar of smooth shiny skin. How long do the marks last? I think the Maasai say it best: “Until you die…and then a little while longer.” I would be getting three dots slightly larger then a pencil eraser in the shape of a triangle on my right upper arm. The burns would be made by the Maasai watchman who guards the house and clinic at night.
I was expecting some elaborate ritual or something, but the whole thing felt sort of like a bunch of drunken friends getting together and doing it (I guess that says something about the type of company I keep). It was simple and about as painful as getting a tattoo. The stick was quickly spun on the wood until smoke came off of it and then it was pressed and held against my arm for about 5 seconds. The smell was a unique blend of burning wood and the unmistakable burnt chicken skin smell of burning flesh. When it was all over and done with, I had three small wounds on my arm that looked underwhelming considering the pain I went through to get them. They blistered nicely the next day, though.
The next day was pretty uneventful, which was nice because it gave me a chance to laze about and a good excuse to stop typing up this entry. Good bye!

Tuesday, February 17, 2009

Birth Day

Sorry, but my Massai Land posting will have to wait till another time. I had a pretty special day today and I wanted to write about it while the memories are still fresh and vivid in my head. Today, in the Kenyan slums, I delivered my first baby. It’s an event that I studied and trained for but was something that can only be experienced firsthand. It was a unique mix of terror, excitement, and joy. Like a soldier training to go into combat, its something that you can only prepare so much for, but when the proverbial shit hits the fan, you quickly find out if you’re ready or not. And like battle, it’s an event that is both feared and anticipated. There is much riding on it and many things can go wrong.
The day started off like any other. Last night, we got two new volunteers: Agneta from Denmark and Kensey from Canada. Both of them are doing the HIV program and are here for one month. They’re fun and easy-going, and I know we’ll all have a great time together. It’ll be interesting sharing a small cramped bedroom with three girls; I’m sure my menstrual cycle will sync up with theirs at some point.
We all grabbed some breakfast and made our way to the Wema Clinic in Kawangware. Dr. George wanted me to give the other volunteers a lesson on injections and sutures outside and would let me know if anything interesting came through his door. About an hour later, an expectant mother came in. Dr. George and I examined her and placed two IVs in her arms. She was severely anemic (the capillary beds under her eye lids were totally white) and she needed a blood transfusion, a service we couldn’t provide. She would need to go to the central hospital downtown and her husband would have to come get her. There was only so much we could do to stabilize her until he showed up. Dr. George went back to seeing patients and left me in charge of keeping an eye on her. All I could really do was chart her vital signs every few minutes and try to keep her as comfortable as possible. For a few hours, I went between showing some volunteers how to start an IV using a banana and checking up on the mom to be.
Things didn’t look good. She had a rapid and thready pulse, shallow respirations, and her blood pressure could have been better. These were some of the signs of early shock. If she totally crashed on us, we would be screwed. That would be a problem that could only be fixed by a surgeon and something beyond the scope of our modest clinic. She was also only 7 months pregnant. We gave her some fluids to get her pressure up a bit and some dextrose (sugar) to perk her up a little and give her some much-needed energy for the exhausting task which lay ahead. Odds were good that there could be a miscarriage or other complications because the bun wasn’t fully done cooking in the oven, so to speak. I had some of the other volunteers help me rummage through the medications and equipment to find resuscitation supplies to prep for a worst-case scenario. Let me walk you through the scene:
Remember that part in the movie Apollo 13 where the scientists and engineers at Mission Control had to improvise a CO2 air filter using only the parts available to the astronauts? It was a lot like that. We had no oxygen available for use. The resuscitation drugs available to us hadn’t been used Stateside since the 1970s. We had to cut up tubing to make makeshift airways for the baby and mother. We were blessed to have an old battery-powered suction unit. I looked over the equipment spread out before us and shook my head. There was much to be desired: defibrillators, monitors, endotracheal tubes…The list went on and on. But this was what we had to work with, and we were ready to improvise and make the best of the situation. We loaded up syringes with life-saving drugs, prayed for the best, and prepared for the worst.
I checked the cervical dilation. Nine centimeters. Strong contractions every couple of minutes. Oh crap. She was going to deliver here even if her husband showed up right at that moment. And where the $@#% was her husband?!? We figured he was probably enjoying a Tusker beer and some chips at a nearby pub while his wife was writhing away in agony on a foam and vinyl pad. Kenyan mothers don’t have the luxury of epidurals or any painkillers.
I tried remembering everything I could about pediatric resuscitation while I was donning my plastic apron. I looked more like a butcher than a medic. I would be taking the baby after I delivered it and doing whatever needed to be done with the equipment available. I had a small table moved beside the mother to use as a peds resuscitation table if it came to that point. I put down a scalpel, some gauze, Betadine, and an IV catheter on the table beside the other equipment in case I needed to do an umbilical cord catherization to deliver drugs and fluids to the premature baby. This was a procedure that would have been performed by a neonatologist in a well-controlled and clean setting back home. This baby would have to settle for a paramedic and a card table.
This baby would be coming out whether we wanted it or not. Now it became a waiting game. The other volunteers stood around, grasping syringes and gauze, waiting for directions from me on what needed to be done. After the water broke, things moved quickly. Dr. George said that the woman would need an episiotomy, a cut made to the vagina to make birth easier. Hanna and I spread the woman’s legs and handed him the scissors. He didn’t even bother with a local anesthetic beforehand; he just took the scissors and cut. I’ve seen some pretty appalling things before, but seeing that made me cringe a little.
In the 5 or 6 births I’ve seen before, things moved slowly and everything was very predictable. It happened over the course of hours. The birth today happened suddenly and without much drama or warning. The mother was barely awake to experience the moment she had been waiting months for. The baby, tiny and blue, just sort of suddenly plopped out onto the table. When I observed births before, I was doing just that: Observing. I could stand back with my arms crossed and marvel at the miracle of birth from a distance, comfortable in the knowledge that experts were around to handle any problems that might come up.
I didn’t have that luxury now. There were a million things that were going through my head at the time and I couldn’t appreciate the moment the way I imagined I would, especially since I was expecting the worse given the situation. When the baby was finally born, I wasn’t thinking “Cool! I delivered my first baby! I hope the mother names it after me!” I was thinking “Clamp the umbilical cord 7 and 10 inches away from the baby after it stops pulsating. Keep the baby the same level as the mother. Suction the mouth and then the nose.” The baby was covered in a smelly green-brownish crud called merconium. A merconium-covered baby is not a good sign. Besides not looking and smelling pretty, merconium means that the baby was likely distressed in the womb. If merconium gets aspirated into the lungs, it can easily cause a deadly pneumonia.
My heart stopped for a few seconds as I waited for the baby to start breathing after it was born. In paramedic school, we learned about something called the Pediatric Resuscitation Triangle. Ninety percent of pregnancies turn out totally normal. There isn’t much involved on our part with these pregnancies. You just basically make sure that the baby doesn’t hit the ground (it’s tougher than it sounds; newborns are slimy and slippery), suction the airways, clean the baby off, and hand the bundle of joy to the grateful mother. Think about it: Humans have been having babies for millions of years without midwives and hospitals. It’s a natural act.
It’s the 10% you dread and prepare for. The base of the triangle is stimulating the infant by rubbing it with a towel and maybe flicking its feet a little. This is the base of the triangle because more often than not, it perks up the infant. Above this is blowing a bit of oxygen in its face. As I mentioned, this wasn’t an option for us. At the tip of the triangle are advanced heroic measures like drugs and CPR. Thankfully, hardly any newborns require this level of care. But when you get to this stage of the game, the situation is likely headed for heartbreak. When people watch shows like ER, something like three-quarters of people survive cardiac arrest. In real life, the figure is less than 10%. I love that show, but damn it for getting people’s hopes up.
I stopped holding my breath when the baby took her first one. I clamped the cord and cut it (a task which I would have given to the deadbeat dad had he been around), rubbed the baby down with gauze to dry it off and stimulate it, and suctioned the mouth and nose. The baby was blue but breathing. Its heart rate was good. I just wanted it to cry and move around a little. I think it was the first time in my life that I actually wanted a baby to cry. I moved the baby to the bed, shoved a tube down its throat, sucked everything out of its tiny stomach, placed an ill-fitting mask over its face, and started to force air into its lungs using a bag. For you medical folks reading this, the 1 minute Apgar Score was 4. For you non-medical folks reading this, that’s bad. Eventually the baby pinked up a little and stabilized (5 minute Apgar of 7, FYI). I did a quick exam (a “10 fingers, 10 toes” sort of deal) and weighed it: 2.4 Kg, which was great considering it was premature.
So. I had just helped bring a new life into this world. Delivering babies by the side of the highway in America with fancy equipment and trained help would be cinch now. And I wouldn’t have to tell the fearful mom-to-be that it was my first time. And to those volunteers there that day helping me out: Thank you! You guys were awesome!
After some antibiotics to prevent pneumonia and some steroids to help develop its premature lungs, I think <*fingers crossed*> that the baby should be fine. Welcome to this crazy, exciting, and wonderful planet, little kid; you’ll have a great time here!

Monday, February 16, 2009

Bad Air

(Note: I'm working on my epic post about being out in the Maasai village. It'll be divided up into two parts. Until then, I wanted to write about a subject that has recently become near and dear to me. I hope you enjoy it and maybe even learn something from it. Don't worry, I'll have the travel post up in a few days; consider this the appetizer before the main course.)

What’s the deadliest creature on the planet? If you guessed hippos, sharks crossbred with rocket launchers, or Chuck Norris, you’d be wrong. The deadliest animal in the world, responsible for between 1 to 3 million deaths each year, is the humble Anopheles mosquito. The Anopheles mosquito is the vector for malaria. I didn’t fully appreciate how terrible and prevalent this disease is until I came here. We see it in the clinic every day. In fact, 90% of malaria related deaths occur in Sub-Saharan Africa.

There have been campaigns launched by The World Health Organization, The Bill and Melinda Gates Foundation (Bill Gates called malaria “the worst thing on the planet.”) and many others that rival the Normandy Beach landings in their scale and audacity that are attempting to slow malaria’s spread. But the scary thing is that malaria is quickly spreading. And with urban populations increasingly encroaching on wilderness combined with the unpredictable effects of climate change, malaria will only become more of a problem in the coming decades. The number of malaria-related deaths has more than doubled since the last generation.

Malaria’s impact on mankind can not be overstated. It has left an indelible mark on human history. Malaria has been around for as long as we have. Alexander the Great was not Great enough to overcome malaria. The lowly mosquito stopped the seemingly unstoppable hoards of both Attila the Hun and Genghis Khan. Abraham Lincoln, George Washington, and Ulysses S. Grant all suffered from malaria. It caused over one million Union casualties in the Civil War. More soldiers died from the disease in the Pacific Theater of WWII than from actual combat. Some scientists estimate that 1 out of 2 people that ever lived died of malaria.

Malaria gets its name from the Italian word for “bad air.” This is because the disease was thought to be caused by gas fumes from swamps near areas particularly affected by the disease. Of course, we now know that the disease is caused by mosquitoes which breed in swamps and other pools of water, but it’s easy to imagine how swamp gas could have been thought of as the cause of the disease in the days before modern medical science. The illness is caused by miniscule worm-like parasites called plasmodia. These parasites inhabit the salivary glands of female mosquitoes. Only female mosquitoes drink blood because they need blood proteins to feed their young. Feel free to insert the obligatory “all women are blood-suckers” joke here. When the mosquito feeds, it releases some of its saliva into our bloodstream to act as an anti-coagulant, similar to what leeches do when they feed. This is when the plasmodia enter our circulation. You can fit over 50000 plasmodia onto the period at the end of this sentence, but it takes just one parasite to kill someone.

The parasite finds its way into a liver cell, where it quickly replicates over the course of a week. The life cycle of the malaria-causing parasite is intimidating in its complexity, which is one of the reasons efforts to develop drugs against it are fraught with difficulty. For two weeks or so, the affected don’t realize they are harboring a deadly creature and feel nothing amiss. The first signs that the immune system has been triggered are headaches and muscle aches. Later, the body starts to violently shake and shiver – an attempt to generate body heat to kill off the invading organism. After that the victim spikes a fever, sometimes as high as 104 degrees Fahrenheit. Finally, a drenching sweat concludes the cycle. This classic cycle – shivering, fever, and sweating – repeats itself every three to four days, depending on the type of malaria. Other symptoms include nausea, anemia, seizures, and in severe cases, coma and death.

There are 4 distinct strains of malaria: Plasmodium vivax, P. ovale, P. malariae, and by far the deadliest, P. falciparum.

P. falciparum is the type of malaria we most commonly encounter in our clinic; falciparum is responsible for about half of all malaria infections but over 95% of its deaths. Falciparum is the only type capable of infecting the brain and has other unique features which makes it especially deadly. Sometimes patients develop disturbing-looking bodily contortions caused by the brainstem pushing out through the bottom of the scull, the end result of increased intracranial pressure. Seeing this posturing in a patient is a very ominous sign, and they will most likely end up dead.

The disease is diagnosed using symptoms and a blood smear called a Romanovski stain which looks for the parasite within blood cells. There are more sophisticated and accurate methods of detection, but they aren’t realistic options for the poor countries most affected by malaria. Malaria has devastating effects on economies. The disease can create mental changes and defects which can persist over a lifetime. As a result of the weakened economy, governments have trouble providing health care to its citizens, resulting in more malaria cases. It’s very much a “chicken or egg” type situation; are economies bad because of malaria, or are there so many cases of malaria because the economy is so bad? Stopping the vicious cycle is a seemingly impossible undertaking.

A multi-pronged approach is needed to slow the spread of malaria. Everything from low tech mosquito nets to cutting-edge multidrug cocktails are deployed in the battle against the disease. When it was introduced, the insecticide DDT was seen as a God-sent. It was cheaper, more effective, and longer lasting than its predecessors. Malaria cases plummeted with the start of its widespread use. Then Rachel Carson published Silent Spring, a book considered by many to be the start of the environmental movement. Her work showed how DDT weakened the egg shells of some animals. The problem wasn’t DDT’s use for malaria control, but rather its abuse by farmers; DDT was so cheap and effective, farmers practically drowned their plants in the stuff to keep insects away. From the farm soil, DDT drained into ground water and streams where it created its environmental effects. Silent Spring painted such a damaging picture of DDT that its agricultural use was practically banned, which in turn made it difficult to procure cheaply for malaria control. With this, malaria cases worldwide shot up. Rachel Carson is indirectly responsible for more deaths than Adolf Hitler.

The scariest thing about malaria is how quickly it develops drug resistance. Since it multiplies so quickly and in such great numbers, the malaria plasmodia can develop mutations which give it resistance to antimalarial drugs pretty quickly. We see resistance to chloroquine - the most common drug used to treat malaria – fairly often in our clinic. Stuff like this keeps me up at night. As I mentioned earlier, developing drugs against malaria is very difficult. Thus, there is an ever dwindling arsenal of effective drugs to fight against malaria, which is quickly becoming resistant to more and more types of drugs. There is currently no vaccine against malaria but scientists are frantically working to develop one. I’m lucky that I can afford doxycycline, an antibiotic that for some weird reason works against a parasite like malaria. I take one every night and it <*fingers crossed, knock on wood*> prevents me from getting malaria. There are other drug options available to prevent malaria transmission, but none of them are realistic options for poor countries, either because of high cost or distribution logistics. So the only real options for malaria control are prevention and quick treatment. Getting “quick treatment” isn’t always an option for many. Falciparum malaria moves fast; there are many stories of children laughing and playing soccer in the morning and dead by nighttime. The clinic I worked in when I was in Saiikiri was a closest one around for many people; the next closest one was 60 kilometers away. Most of our patients walked for hours and hours through the hot brushland to see us.

And that’s what it all comes down to. For all the thousands of scientists toiling away in labs around the world, for all the politicians diverting funding towards malaria eradication efforts, it’s the small and simple rural clinic that sees and treats malaria patients. I love being on the frontlines of medicine; it’s the reason I became a paramedic. And here I am in Kenya, on the frontlines, trying to stop malaria...One patient at a time.


Monday, February 9, 2009

Changes

I’m sure most of you reading this are old enough to remember when playgrounds were actually fun. Sure, they may have been full of bare metal and sharp edges with a lovely base of hot asphalt to cushion any falls, but they had a certain charm to them. Modern day “new and improved” playgrounds have sapped every ounce of fun out of the experience. Now everything is made of hypoallergenic plastics, slides are no longer capable of delivering burns to exposed flesh, and my favorite playground toy, the merry-go-round (the kind that was manually-powered by the fastest kid in the group and would leave you dizzy, nauseous, and grinning), has become extinct because it was deemed too dangerous by overprotective moms. That’s how I think of Kenya and America; Kenya may be “dangerous,” but it sure is fun.

I now realize how sheltered and coddled I’ve been back in America. The news and media back home love to keep people in fear because fear sells: “Something in your pantry can kill you and your family. What is it? Find out on Channel 6 Action News at 11.” Everything back at home feels so sterile and tame now. I think it’s even possible to be too safe. Little kids aren’t even allowed to play out in the woods by themselves these days. You’re labeled a bad parent if you allow your children to “play outside and come back by dark,” something which was a large part of my childhood and I couldn’t imagine growing up without.

Why? Because everyone is scared of threats that don’t exist or have been blown completely out of proportion. I’m sure there were just as many child molesters riding around in nondescript white vans and praying on children when I was growing up, but back then we didn’t have Chris Hansen and To Catch a Predator to shock us into thinking everyone might potentially be a pervert. Think you’re above thinking that way? Imagine you see a single middle aged man taking pictures of little kids in a park. It’s a totally benign and innocent act, but tell me that the thought wouldn’t cross your mind, even for a second, that the guy was sleazy and had impure motives. I’m guilty of thinking that way myself, and it’s a sad state of affairs to have “guilty until proven innocent” be our default way of going about life.

Nairobi has the unwelcome distinction of being the most dangerous city in Africa, which makes it a serious contender for most dangerous city in the world. This place makes the dodgy parts of L.A. look like a country club. Murders, carjackings, robberies: All a part of daily life. They even have a term for it: Nairobbery. I’ve witnessed at least two beat-downs since I’ve been here, and they were both pretty brutal. Not the “Bro, I’m gonna kick your ass so hard” crap I’ve seen back home in bars. I’m talking about terrifying ex-convict looking types with knife scars and tattoos going to work on a guy with a metal pipe, the kind of beating where you know the guy on the receiving end is going to be deformed for life, assuming he’s lucky to escape with his life in the end at all. Over here, life is cheap and hard, and I’ve seen this saying be proven time and time again. Even though I’ve only been here two weeks, I’ve already noticed changes in my own personality.

Living in Nairobi and working in the slums of Kawangwana has hardened me. I think about that quote from Fight Club, the one about showing up made of dough and leaving carved of wood. I’m more of a man now because of what I am seeing and doing. Life here is a sensory onslaught and it’s impossible not to be affected in some way. Here it’s either eat or be eaten. In a city where more than half the population is unemployed, it’s survival of the fittest. I’ve realized how thin the veneer of so-called “civilization” really is, and how easily it’s stripped away when you’re hungry and desperate. In this city you’ll never go anywhere unless you jump out in front of moving traffic and you’ll get ripped off unless you act like a bit on a jerk and drive a hard bargain. That’s just the way things are around here.

I think about some people in the States, effeminate metrosexual hipsters, spoiled brats who’ve never been pushed or challenged in their lives. I seethe with a strange sort of rage when I think about them these days. I want to start fist fights with them. I hate them a little bit now. I’ve heard similar sentiments from my friends in the military towards civilians; I guess hardship truly does build character. I want to tell them that their whining and complaining about their life on MySpace is trivial and petty compared to what most people around the world face. Did your emo girlfriend forget to buy My Chemical Romance tickets online and now the show is sold out? That’s the biggest problem in your life?! Boo ‘effing Hoo. Try telling an 8 year old kid he’s HIV positive and will likely die before he’s old enough to buy his first beer. I’ve had similar feelings while doing my EMS training in the streets of inner-city Durham and walking around Carrboro afterwards, but now the feelings are intense.

I have less tolerance for bullshit and beating around the bush. I’m more efficient and direct now. I think about how I used to placate, to not rock the boat and let people walk over me. That’s stopping here and now. I’m more confident, independent, and little bit wiser. I’m glad I cut my teeth in other major cities before coming here. New York, Berlin, Istanbul, even New Delhi don’t compare to the chaos that is Nairobi. They all feel like training for this place. I’m constantly reminded of how wasteful I’ve been. You don’t appreciate how much water is involved in a toilet flush until you have to fill the tank up by hand. When I get back, I’m sure I’ll complain less about things that don’t really matter in the big scheme of things. I realize now what is truly important in life and will take less for granted. I feel my priorities have been readjusted for the better.

But you know what? Despite the violence and dust, the ubiquitous poverty and corruption, I’m happy and satisfied here in a way I don’t know I’ve ever felt before. I’m already sad I have to return to a world filled with ennui and boredom, a culture of celebrity gossip on TV and other trivialities and distractions designed to kill time everywhere else. Ask yourself some questions: When was the last time you truly feared for your life? When was the last time you were challenged and came out the other end realizing you had the ability to surprise even yourself? When was the last time you went on an honest-to-goodness adventure?

What I’m doing here and now isn’t out of your reach. I’m not some extraordinary person; I just chose to position myself in a situation where the extraordinary is more likely to find me. Sure, it took a bit of time and money, but if you want it bad enough, you can make it happen. Over here I have purpose. Here I am driven. Here I feel truly alive. And I’m already making plans for my next trip…

Whoever you are: some evening, take a step
Out of your house, which you know so well.
Enormous space is near…
-Rilke

P.S. Abba, thank you so much for the book. I read the entire thing in a couple of sittings. It was the perfect book for where I am right now, both geographically and in my life. I found myself nodding along to much of what he was saying. The book I’m referring to, for those of you who are curious, is Travels by Michael Crighton, and I highly recommend it.

Party Time!

The past few days have been a whirlwind of activities. On Friday night I went to a farewell party for two of the volunteers. Both girls were friends from Australia and were returning home after 6 months of working in an orphanage in Kibera, the second largest slum in the world and a ‘suburb’ of Nairobi. I couldn’t imagine how they must have felt; I know I’ll be devastated returning home after only a month over here. The party was great, with people bringing food and booze and a Twister mat. There were about 15 or so volunteers who showed up and we were all trading stories of our experiences thus far, places we wanted to visit, things we liked and didn’t like about Kenya; standard stuff for the situation. Then I mentioned that I would be leaving for Mombasa in about a week and would be staying with a guy named Mike.
The party went silent.
“Crazy Mike?”
Umm, I wasn’t sure. After a bit of questioning, it was clear that, yes, I would in fact be living with this Crazy Mike character. I pressed on for details. I wanted to know: Was this the good sort of crazy, like “Mike’s a crazy guy and a lot of fun to be around,” or Crazy crazy, as in “I’m Napoleon’s reincarnation and you must offer me tributes of papaya and bellybutton lint on the 3rd Wednesday of every month” crazy? Apparently it was the latter.
Oh crap. I’m stuck in a room for 2 weeks with this guy?! I wanted to know why they thought he was crazy. Everyone, it seemed, had a story to contribute:
“He said Kenya is just like Canada.” (I’m honestly not too surprised he was Canadian; Canadians are often a little weird.)
“He slept outside on the first night for some weird reason.”
“He told us he was shot and stabbed while traveling somewhere, but he didn’t have the scars to prove it.”
“He talked about how he wanted to die in Kenya.”
Ohhh Kaaayy. This would be interesting. This guy sounded like a total space cadet, a few fries short of a Happy Meal. I’m going to try to keep an open mind about him. I asked Bonface the next day if I would be staying with some guy named Mike. He laughed for a minute straight. Great. I’ll keep you guys posted.
Later on in the night, it started to rain a little. It was the first rain I’ve experienced since I’ve been here. The rain had a particular feel to it that’s hard to describe, like how English meadows look a little different than the ones everywhere else and how California sunlight is unlike sunlight anywhere else in the world, even though rain and sunlight sound like universal phenomenon that play out the same everywhere you go.
When it was time to head back, Hanna and I split a taxi with two other volunteers. One of them, Justin from Arizona, told me to try khat. Remember that stuff that looked like grass that the child soldiers in Black Hawk Down were chewing? Yeah, that stuff. It has a mild narcotic effect similar to cocaine or meth and is sold in streetside stands. The code for “We Carry Khat Here!” is a banana leaf hanging on the front of the stand. They use a banana leaf because that’s what is used to transport it across the country. It only grows in the Western provinces, and quickly looses potency after it has been harvested. I made a note to myself to give it a try. It’s pretty harmless, like chewing coca leaves in the Andes, and I can’t try it back at home, so why not?
On Saturday, a bunch of us volunteers went to the famous Maasai Market that takes place every Saturday in downtown Nairobi. It’s an open-air market that spans an entire city block and is filled with wooden carvings, fabrics, jewelry, and all sorts of other random trinkets. Talk about a high-pressure sales staff. Everywhere you go, especially if you’re Mazungu, you hear “Greetings! Where are you from? Have a look at my stuff, please!” It was fine in the beginning but began to wear on me as the day progressed. You’re expected to bargain. A good rule of thumb is to go down 300% from the initial offer and work around there. There are other tricks and tips, and I thought I was doing a good job. It was one of those situations where after the deal was done, both the salesperson and I walked away thinking “Sucker!”
After buying some gifts for friends back home, I compared prices with some other people. Apparently, I wasn’t as good of a bargainer as I had imagined. Oh well, I told myself, I still saved money compared to if I had bought the same thing in a tourist shop somewhere else in town. Even if I had bargained as well as an experienced Arab trader, I could never get the best deal possible because I was Mazungu.
Any city as dangerous and wild as Nairobi is sure to have a pretty great nightlife, I figured, and I wasn’t disappointed. Later that night, Hanna, Rachel, her sister, and I went out to a place called Simba’s downtown. It was outdoors, which was great since the weather was especially lovely that night. It reminded me of the Biergardens in Germany, with people sipping beer under large tents, a live band playing local music, and meats being grilled nearby. I was told going in that as a young, attractive Mazungu man, the women would be all over me. I laughed this off when I first heard it, thinking “I wish.”
I had no idea how true it would be.
The first girl grabbed my arm when I was standing by the bar ordering a Tusker beer, the local favorite. She told me I was handsome, that my hair was great, and then pinched my nipples. She was totally hammered. I later found out from her friends that it was her 25th birthday. Nice. I went back to join my friends at our table. On the way back, another woman stopped me, an attractive older woman, and started talking to me. Even in my wildest fantasies I couldn’t have imagined this happening! Yet here I was, a few minutes into the night and I had already had two good-looking girls hitting on me! I felt like a piece of meat, being desired only for my body. It was awesome!
I’ve done a fair bit of traveling, and I can say without hesitation that Nairobi has some of the most stunningly beautiful girls I have seen gathered in one place. And they’re not just vapid eye candy; overall, they’re very interesting and nice and fun to talk to. I could tell tonight would be memorable.
As we were headed out of Simba’s to go to a club called Florida 2000, a Mazungu in his early 30s stops me and says “Dude, if you’re here for one more night, go to Club Topaz.”
“Thanks, but I’m on my way to Florida 2000 right now.”
“Well, that place is fine if you want your crotch grabbed.”
“Umm, what’s wrong with that?”
<*Silence*>
Florida 2000 had a deliciously sleazy feel to it, like a high-class European brothel or something. There were massive bouncers in suits manning the front doors and red lights illuminating the hallways. I imagined some guy in a polyester leisure suit doing blow off a stripper’s back in some room upstairs. We had gotten there a little early. There were only about half a dozen people on the dance floor, with a few creepy old white dudes staring from the sidelines. I got some beer ($1.50 Carlsberg!!) and drank to get myself in the dancing mood. When the dance floor reached a critical mass, I waded into the sea of humanity. Immediately, I found myself dancing with someone I never would have dreamed about having a chance with back home. Wow, was this really happening to me?! We danced for a bit, she gave me her number and told me to call her, and left giggling with her friend. Over the course of the night, about four girls danced with me. We left the club early in the morning. I had had a blast, and promised myself to come to another club before I left Kenya.
The next morning I woke up sore and sick. Last night had finally caught up to me. Through the haze, I vaguely recalled something about going to the Carnivore restaurant for lunch. This is a restaurant which is consistently ranked among the Top 50 in the World. You can try crocodile and ostrich over there (sadly, giraffe is no longer on the menu) along with other more pedestrian choices such as chicken and it was an all-you-could-eat deal. Seeing as how gluttony is my favorite Deadly Sin and how much I love grilled meat, there was no way I was going to miss this before I left Nairobi. And to top it all off, the entire thing would be paid for by a wealthy Tanzanian banker who was in town on business and was friends with Rachel’s sister. Just how wealthy was this guy? He offered Hanna his $4000 watch, just because. He offered to fly us out to Tanzania for the weekend, all expenses paid, no strings attached.
Unfortunately, at that moment my digestive system could hardly process a piece of toast, so a decedent orgy of roast flesh was out of the question. I contemplated staying in bed all day and recovering. Then my stomach started to growl and I figured every time I spent all day in bed, I ended up feeling just as crappy as when I started out in addition to feeling guilty for having wasted the day. So I manned up, put on some clothes, and got some lunch at the Nairobi Java House.
The Java House is at Nakumaat Junction near where I’m staying and has amazing food at reasonable prices. It’s one of those restaurants where you glance at the menu and have a lot of trouble deciding what to order because everything sounds so good. I got the chicken quesadillas with guacamole, sour cream, rice, and refried beans, with a glass of fresh-squeezed Passion Fruit juice to wash it all down. It was a nice break from Ugali. The food, as usual, was delicious, but I was totally stuffed. So, turns out that Kenyans know how to make decent Mexican food after all, which is more than I can say for the Germans (if you don’t know what I’m referring to, let me know and I’ll send you the relevant blog post from when I was living in Germany).
We had eaten later than usual and I was very concerned that I wouldn’t have the stomach capacity to get the most out of the Carnivore experience. I told Hanna that I would force myself to throw up if I still wasn’t hungry by the time we started eating dinner, Ancient Roman Style. She laughed and thought I was joking. Obviously, she doesn’t know how seriously I take food and eating.
Luckily for me, before going to Carnivore we would spend some time at a small waterpark called Splash. I figured I could burn off some of my lunch by swimming laps or treading water or something. But when I got there all I wanted to do was float in the water, read my book in the sun, and ride the water slides. I can now add “Seams between waterslide sections” to my quickly growing list of Things Not to Take for Granted. You’d be surprised how poorly-joined section seams can really bring your waterslide experience to a screeching halt, both literally and figuratively. All in all, it was a nice change of pace, and just what I needed to recover from the night before.
I asked where the Tanzanian banker was and if he would be joining us at Splash. Apparently, he had gotten a phone call from the Tanzanian ambassador. Classy. Turns out that while he was gone, his bank had been robbed. Twenty million Shillings were stolen.
Ouch. Looks like we wouldn’t be eating at Carnivore that night. I felt bad for him, but also a little pissed at the robbers; why couldn’t they have robbed the bank after I had eaten at Carnivore!? Oh well.
Later on that night we ended up eating hot dogs for dinner, which is about as far as you can get gastronomically from dinner at Carnivore. Don’t worry, loyal reader(s), I’ll eat there before I leave and tell you all about it.
The weather was wretched on Monday morning. Hannah and I dragged ourselves out of bed, started on the half hour walk to the clinic, and remembered that we told Dr. George we might not be in on Monday because we were going out to Maasai Land (which, disappointingly, isn’t an amusement park, but is one of the places where the Maasai tribe lives). We just really didn’t want to go to work that day. So we decided to play hokey and check out the animal orphanage at the edge of town.
After being told by a few people that the orphanage wasn’t worth it on a weekday, we decided to check out the National Museum instead. We hopped a bus to downtown and trekked towards the Museum, slipping off to the side of the road every now and then to consult the map in Hanna’s guidebook. If we looked at the map in the middle of the street, people would have been able to tell we were na├»ve, vulnerable tourists, would descend upon us like wolves, and try to exploit us. Apparently, that was all wasted effort since everyone already knew we were visitors, no matter how confidently we walked the streets and feigned looking like we knew where we were going.
We passed through Nairobi University, which had a pretty nice campus with signs that said “Corruption Free Zone” or something like that. It was funny because just the other day Phil from the lab at the clinic was telling us that if you have enough money and the right connections, you can get into any university program, including law and medicine. Remind me not to get sick or end up in court over here.
The entrance fee at the museum was 800 Shillings for non-citizen adults (about $10), but we managed to charm them and get in for 400 Shillings. We gave the admissions guy 1000 Shillings each and didn’t get any change back. Instead, he scribbled “600 Shillings” and his signature on the back of our admission ticket. He told me to give him the ticket when we were done and he would give us the change.
The entire time there I couldn’t fully enjoy the museum because I wanted to know whether or not I had just been scammed. It wasn’t even about the money, just the principle of the thing. The museum was nice, but was a little smaller than I was used to. There were exhibits on African customs and traditions, some fossils from ancient humans discovered in Kenya, a bunch of mounted animals (Lisa, there was a room filled with 600 stuffed birds. I immediately thought of you and what your reaction would be like in there). My favorite exhibit was called 24Nairobi. A bunch of photographers were sent all around Nairobi and documented a single day. It captured the essence of Nairobi in all its chaotic, ugly, and beautiful glory. I’m not sure if it’s online, but if you can find the pictures, please look at them. Not only are they amazing photos, but they might give you guys a glimpse of what it’s like to live over here.
The moment of truth had finally arrived: Were we going to get our change back? We cautiously approached the admissions counter. Damnit! Some lady was working there!! Of course we had been scammed! How could we have been so stupid?! We told the lady about the change, showed her the writing on the back of the ticket, and were handed 600 Shillings, no more questions asked. Hmm, guess I shouldn’t have been so cynical.
The rest of the day went pretty slowly. We ate at an all-you-could-eat buffet. The staff seemed amused by how much food I could eat. I found out that intestine actually tastes pretty good but has a (I’m not sure if this is the right word) disturbing texture to it. We also talked to Joe about going out to Maasai Land for 3 days to work in a clinic out there. The clinic is run by a 28 year old nurse named Maggie and has no electricity or running water. It’s the nearest clinic for 60 kilometers, is out in the middle of nowhere, and sees all sorts of crazy stuff. It’s the sort of place where you’re forced to do sutures by lantern-light. Just the experience I was looking for.
If things get ironed out in time (which I’m sure they will be), we’ll be leaving on Wednesday and coming back on Friday night. I’ll be leaving for Mombasa Monday evening on the Lunatic Express. Seriously, the railway between Nairobi and Mombasa is nicknamed the Lunatic Express. Look it up. Anyways, if I don’t post anything between Wednesday and Friday, you’ll know why. I’m looking forwards to eating Maasai food, which features delicacies such as fresh-squeezed milk mixed with cow’s blood (they just stab the jugular, drain it, and let the cow chill afterwards. I hope they give it cookies and juice when it’s done donating blood) and a drink called Mursik, a concoction which consists of milk fermented with cow’s urine and ashes. It supposedly lowers cholesterol. I’ll let you guys know how it is.

Sunday, February 8, 2009

Ditch Medicine

Sorry that its been so long since my last posting. The internet has been especially screwy the past few days and I haven’t been able to get this post uploaded. Its also been about 3 days since we’ve had running water at the house, but we manage. Our toilet is more like a chamber pot than a toilet these days. I literally spend 2/3 of my time and money at internet cafes waiting for pages to load (assuming they will load in the first place). I won't take so many things for granted when I get back home.

I realized that working in a clinic in the slums of Nairobi would be a departure from the way medicine is practiced in America. In fact, experiencing those differences were the reason I came to volunteer here in the first place. I just never anticipated how different things would be. The whole experience has been an eye-opener, and I’m only getting started.

Over here I see diseases everyday that I’ve only read about. I saw a scorpion bite yesterday. Anti-Malarials are handed out like candy. So are antibiotics, sadly, for the mildest sore throat, which only adds to the growing problem of antibiotic resistance. The only exposure most of us in the West will ever have to Tuberculosis or Typhoid Fever is through playing Oregon Trail. Over here is seems that every other patient has one, sometimes both, of these diseases. Have worms in your stool? Join the club; it’s just another accepted part of life here. I treated a man the other day with AIDS who told me he had been having unprotected sex with his second wife for years while he was aware that he was positive; he didn’t want the social stigma that’s still attached to AIDS. All of his friends and family would completely ostracize him, he told me. I asked him if he had had either of his two children tested for HIV. Not yet, he replied. It seems strange that there is still a stigma attached to HIV in a country where 6% of the population is positive.

I saw a woman today with Brucellosis, something you get from drinking unpasturized milk, a disease which is unheard of and unthinkable in the West. Her prognosis is not good. With every case I’m reminded of how easily most of these infections could have been prevented with basic sanitation and other basic public health measures. Needless to say, implementing the needed changes is something that’s easier said than done. On the other hand, I haven’t seen a single case of diabetes, heart disease, or COPD, diseases which I’m sure will become more prominent here in the coming years with the spreading McDonaldization of the world.

Even the health care sector isn’t immune from corruption. Bribes are just an accepted part of getting things done. Much of the money sent in by well-intentioned NGOs such as the World Health Organization is siphoned off to line the pockets of corrupt officials, with only a trickle reaching the people who need it most. Everyone knows it occurs but nobody does anything about it. The lab technician at the clinic told me how he was strong-armed by outside officials to cook the books to make it seem like he had performed more NGO-sponsored TB tests than he actually had. That way, the money that should have gone towards TB tests ended up as someone’s new drapery set and nobody is the wiser.

The way things are run around here clinically are also…different. You know, that cyanotic baby would really pink up with just a little bit of blow-by oxygen. Tough luck, even oxygen isn’t an option here. Want to see if that guy with the irregular heart beat is in A fib? You can only speculate, because an EKG around here is as conceivable a piece of medical equipment as one of those medic droids from Star Wars. Can’t start a line on a patient who really needs one? Grab a scalpel and do a venous cutdown, a procedure which has been rendered obsolete years ago with the advent of central lines and intraosseous infusions.

Some of the sanitation and safely practices would give our Occupational Health and Safety Departments back at home nightmares. Used syringes with needles are tossed in the trash can by the bedside. You read that right: Sharps containers are optional, even for HIV and Hepatitis contaminated needles. I’d hate to be the janitor there. Glove use seems to be more of a suggestion than a rule. I’m starting to get sloppy and have picked up some bad habits as well. I wore gloves when checking cervical dilation on an expectant mother (duh) but didn’t when mainlining meds into a HIV and Hepatitis B positive patient. We don’t have the luxury of sterile Tagaderms here, so tape is placed over the IV site without a second thought to secure the line. To sterilize instruments, I witnessed them being boiled in a simple pot filled with blood-tinged water from a recent birthing and then removed from the water with unsterilized hands. When I saw that, I didn’t know whether to laugh or cry. Hannah and I are thinking about pooling funds to get them a pressure cooker to serve as a poor-man’s autoclave. Sterility is an ideal, a seemingly unattainable one. They don’t do these things because they are sloppy; they do them because they are pragmatic and have to work within their given constraints.

Despite all the craziness, I love it at this clinic. I actually think the craziness is one of the things I love most about it, the same thing I love about being a paramedic. I have autonomy and I’m learning a lot everyday. Everyone calls me “doctor,” even though I constantly correct them that I’m not one. I’ve given up on that and have just come to accept it. I always hear the sisters saying “doctor, come quickly to see this patient,” or “doctor, can you start a line on Felix in the other room?” Dr. George basically lets me do anything I’m comfortable doing. Every expectant mother that’s come through so far has either delivered after I’ve left or had a complication that couldn’t be managed at the clinic. But the next birth that comes through I get to deliver. I’ve also learned a lot from the lab technicians. I can now do a Widal test for Typhoid Fever, an acid-fast sputum stain for TB, and a Romanovski stain for Malaria and can interpret the results. I’m learning about the drug regimens for TB and Malaria, which can get pretty complicated.

The great thing about this clinic is that stuff gets done with minimal hassle. Patients walk in and get the treatment they need within a few minutes and then walk out the door. They pay what they can and Dr. George takes many patients pro bono. Everyday five orphans are sent from a local orphanage to get checked out by Dr. George. When we see poor starving African children on TV back at home, we tend to comfort ourselves by telling ourselves that these kids don’t know any better, that their situation is all they’ve known for their entire lives and misery is relative. But the sad reality is that most of these kids are in pain and agony for much of their lives and just stoically deal with it because cheap, simple treatments may be beyond their grasp.

Over here, insurance, HMOs, and malpractice are the last things on our minds. We practice medicine the way I imagined doctors practiced medicine when I was a child. Back home, it’s disheartening to see doctors spending two thirds of their day behind computer screens catching up on charting or whatever else instead of interacting with their patients. I’m sure that’s not how they want it to be either, but that’s their reality. Here the patient’s interests come first, just as it should be. Lab tests are ordered because we think they might shed some light on the patient’s condition, not because we’re trying to cover our asses in the event that someone might sue us down the road for missing a one-in-a-million diagnosis. People don’t come to us seeking drugs. We don’t have time for people who’ve chipped their nails and want medical attention and someone to hold their hand. You think I’m joking about that, but ask anyone who works in emergency medicine how often things like that happen.

Since being here, I’ve recognized how much waste is involved in the delivery of American style health care. I think of the armful of waste generated when starting one measly IV back at home. Do we really need a product insert, a box, a blister pack, and other superfluous packaging for one pill? I also often think of the money wasted on useless procedures and tests and how far that money could go over here. During my ICU rotation in medic school, I saw a man who was slated for execution in a few months. He had spent over a week in a $13000 a day intensive care bed (funded by taxpayer money, of course) because he had attempted to hang himself. He was essentially brain dead with zero chance for a meaningful recovery but was being kept alive just because we as a society are not yet advanced enough to accept euthanasia. Deworming one child costs 70 cents. Let that sink in.

I can see myself doing something like this with my life; traveling the world and using my skills and knowledge to help those who need it the most. I still love emergency medicine and I’m glad I trained as a paramedic before becoming a doctor, but I can see myself burning out on it after a few years. I already resent humanity a little more than I did before my paramedic training. I’ve seen the jaded doctors who work in some ERs, callous to whatever happens because they have to be just in order to just get through the day. Is that really how I want to end up when I’m older, viewing patients as an annoyance rather than a chance to help, teach, and learn? There are only so many times you can deal with ungrateful drunks and crackheads without it affecting you. It’s hard not to hate the world when you see a drunk driver walk away with a few scratches while the innocent family of the car he hit lost a father and a husband.

Of course, I’ve seen some horrific things here that I’d rather not talk about in this blog because no amount of writing can begin to do them justice. I’m not sure one can understand certain things unless they’ve witnessed it for themselves firsthand. These are the things I’ll take with me to the grave and will think back to for the rest of my life, but I think I’m a better human being for having witnessed them. I’ve already changed and its only been a week. We’ll see where the rest of this trip takes me.