Light & Fast

cold coke in a bottle is like heaven. i try to visit daily on clinic days.

prices are highly negotiable in the markets and for tuk or taxi rides.

beans and maize with rice. i could eat it every day. ugali and scumawiki every now and then.

riding on the back of a boda, no hands, no helmet, for 20 bob. priceless.

oh, and they drive on the “wrong” side of the road here.

hardest case: rapidly progressive paralysis in a woman just starting ARVs, who finally scraped the money together for a ct of the head. i threw the kitchen sink at her. or, a 22 year old boy with two weeks of what i think was heart failure secondary to tuberculous pericarditis. of course, that was just a guess.

even patients with tb and hiv get heartburn and shoulder strains.

i hate mosquitoes. especially when they bite through the net at night.

“habari”, “sema”, “sasa”, there are so many ways to say hello. handshakes and hand holding. fewer good byes.

does anybody else think that swahili sounds like japanese sometimes? that would probably be because i know neither.

having no water on the 4th floor with 4 people is tough. you have to commit to it.

guava juice is good all over the world.

wearing a tb mask is impossible when almost any cough or fever could be tb.

moses had his cell phone brought to kisumu by a random man almost 3 weeks after losing it.

even the computers here have a virus epidemic.

walking. we don’t walk at home nearly enough.

i’ve eaten a lot of eggs, ramen, toast, pasta and indian food.

it’s hot today.

I wrote a report in junior high school on malaria. And one on tuberculosis in freshman year college. Not that I really knew anything about these back then, but not once did I ever mention the crazy interaction of these diseases with HIV. Which makes sense since our knowledge of these diseases and HIV was still evolving in 1991 and 1995.

These two diseases explain the majority of sick cases I see in emergency clinic.

TB accelerates HIV (higher viral loads and lower CD4s), and HIV accelerates TB (at least 10 fold reactivation rates). So you can imagine what happens in endemic areas. Worse yet, untreated TB in a patient starting HIV treatment can make the patient paradoxically worse (immune reconstitution syndrome), and TB can be notoriously difficult to diagnose. (e.g. sputum stains are only positive in half of patients with active disease).

So I’m resigned to having a very low threshold for starting patients on TB treatment presumptively, and getting those positive AFB stains back every now and then is a bit of a comfort. Though maybe not for my skin test in a few weeks.

It wasn’t until intern year that I missed a thanksgiving celebration. And that year I was on-call for both Thanksgiving and Christmas.

This year, my Kisumu roommates and I – a Canadian pre-med, a Nairobi med student, a newly arrived ucsf peds resident from michigan, and I – “celebrated” Thanksgiving together at the green garden for dinner. We had just spent the entire day at a Faces clinic workshop day filled with typical conference-like breaks stuffing ourselves with tea and chapati and other fried breads just to stay awake. So we weren’t really that hungry.

2007 Thanksgiving Dinner: lamb curry, guacamole and taro chips, somosas, and a pilsner. Fancy by our home cooking standards!

Moses and I went to Kakemega forest yesterday for the day, which is the country’s major rain forest area. It was full of medicinal plants and monkeys, and features a community environmental education program and nursery. As far as rain forests go, it had its typical share of parasitic vine like trees, hardwoods, and sprays of flowers glowing in the filtered light, as well as the streams of preoccupied ant colonies and leaping monkeys. Our guide had us touching and tasting a ton of plants, until she had to be replaced by her friend because she was feeling ill. hmm….anyways….

But it was the trip there and back that I’ll want to remember. Instead of hiring a private driver roundtrip at about 5000 shillings, we decided to take public transport for about a tenth of the price. We loaded into matatus to get there and for the last leg back, which are mini-bus collectivo-like transports that stop and start all along the way, stuffing in people to a ridiculous number. At my highest count, our 16 seater minibus was barreling along in the rain with 20 adults including the driver and conductor, 4 children, 2 sacks of grain, a plank for an extra seat, and a chicken. I had elbows and butts and luggage all up in my grill. And leaving the forest, and not wanting to call a private taxi to pick us up, we employed the assistance of two bodas, which are bicycles taxis and not scooters like in kampala. So Moses and I rode on the back of bicycles for about 13 km of dirt road.

I have a sweet picture of me pedaling the boda myself on one steep hill where my driver got off and pushed. But looking at the picture last night, I suddenly realized that I came all the way to East Africa just to be another Chinese guy on a bicycle. Original idea, huh?

i presented a journal club discussion today on a meta-analysis on the efficacy of treating HIV patients with INH prophylaxis in preventing active TB and death. if you’re confused, it’s normal. this was a topic Kate meant to do before she came down with malaria. but it was a good discussion with the clinical and medical officers. first, demystifying the technical stuff around a type of study called a meta-analysis, which is really designed to combine and summarize a stack of studies into a readable concept. but even docs at home struggle with this seemingly magical method. second, going beyond the stats and grappling with the challenges of implementing scientifically proven therapies in real life situations. especially in a place where tb tests aren’t done, chest xrays are expensive, many patients have active tb, and the tb prevalence is so high that reinfection with tb clouds the concept of treating old, dormant tb. nevertheless, powerpoint makes any complicated topic look pretty…

for the rest of the day we’re seeing kids and pregnant women—right in my wheelhouse as an adult medicine physician, huh? luckily i have the safari animal stickers that lisa, our peds resident, has given me to ward off all the bad things i could do. obviously i’m exaggerating, but i’m hiding out in emergency where both adults and children will come with urgent issues. lots of rashes, malaria, coughs and abnormal chest xrays. funny that i’m more comfortable with febrile coughing kids than healthy kids. committing to months of empiric 4-drug tb therapy for severely underweight immunosuppressed kids based on the story and an xray just makes sense.

i got to sit with a CO named Sam during regular PMD visits, and it was quite a different experience. By the way, Medical Officers (or MOs) are more like the doctors at home, and have attended medical school with post-graduate internship and other training. They tend to act more as consultants around here and act as administrators for the clinic. Whereas the COs (or clinical officers) have a shorter training period of training and work afterwards, often doing the bulk of patient visits day to day.

We generally sit in with COs on emergency cases, where we can usually be more helpful with nonroutine exam skills, broadening differentials, and devising therapeutic plans. The national guidelines and algorithms on opportunistic infections and symptoms are not published yet (as opposed to the national guidelines on routine antiretroviral therapy and expected complications), so we can be more helpful. But in routine primary care follow ups, the COs run the show. I just try to be useful and ask occasional questions and write out the prescriptions for refills. The clinic has a very elaborate flow, with patients going through registration, vitals, community health workers, the lab, and nurses, so a lot of the questions and concerns have been raised or addressed by the time the COs get to them. Sometimes they aren’t, of course. It was a great experience, at least 40 patients in the day and many of them with rising CD4s, return of weight gain, and big smiles. Yeah, a lot of smaller concerns like peripheral neuropathies and headaches and rashes, too. Lisa gave me a handful of stickers for the kids, which have gone over really well.

Today we talked about quality of care, and methods for measuring how well COs are practicing and determining ways of fixing problems that the COs feel are problematic. An interesting discussion in light of our similar efforts at home.

I’ve posted some more Masai Mara pics to my Flickr account. Click on them to see the larger version.

6:30 woke up to the rooster cries and dog yelps and slamming doors of awakening roommates. untangled myself from my mosquito net and washed up. no bites. (yes!)
7:00 toast with jam and juice
7:30 walked to clinic, about 20 minutes.

8:00 arrive in Lumumba Health Center, Faces Clinic. Said hello to everyone and checked in at emergency, where I was to work today.
8:15-11:45 saw patients with Elveria, a clinical officer at Faces for about 14 months. We saw about 10 patients, most not really emergencies, but babies and adults ranging from “weakness” to “fever” to “cough” to “needs to go home” to “diarrhea.”
11:45 broke for sweet tea and a chapati. (mmmm…chapati) we were late for tea.
12:00-3:00 more patients, some chronic diarrhea. Our sickest was a 2 kg 3-month old baby with fever and thrush, for whom we recommended hospitalization for fluids and workup for presumed HIV and possible TB. Another 6 month old with probable malaria.

3:00-3:30 Lunch. They were out of food at the banda across the street, so they made us “chips,” basically french fries. Plus two cokes in bottles for about 20 shillings each (~30 cents).
3:55 Enjoyed about 15 minutes of afternoon rain and wind, which came and went. (My favorite part of the day)
3:30-5:30 About ten more patients for the second half of the day, with followups. Poor Elveria has to translate a fair amount for me, but we have fun exchanging diagnostic and theapeutic plans. I’ve taken to having the Kenyan national guidelines and my Sanford HIV handbook open in front of me. Most interesting was an HIV positive mother not yet on ARVs or with baseline labs, who was weak with about a month of diarrhea, anemia, fever and splenomegaly (big spleen). Malaria had been ruled out and treated anyways, and planned to treat for infectious diarrhea but concerned for TB, malignancy, viral (i.e. CMV). We’ll see her in a week or sooner after labs since the day was running long and they lived a long way away.

5:30 till about now Headed upstairs trying to email loved ones, connect to the internet (faster when nobody is around), and send some files back to my workgroup at home. probably go home and make some rice with vegetables, eggs, and greenbeans. mmm…

sick people with bad disease, epidemic levels of bad disease. patients without means to pay for lifesaving medications and tests. diagnostic dilemmas and uncertainty. myths and misconceptions. unhealthy individual and cultural behaviors. lack of continuity, time and resources. underlying currents of poverty and inadequate resources and infrastructure. the reality that patients can get sick and sometimes die from problems we can prevent and treat but don’t.

if you couldn’t guess, i’m just thinking about how similar and generalizable the clinical challenges we face here are to the issues we face at home in the U.S. sure it’s a spectrum, perhaps several orders of magnitude different, but it’s a reminder that we aren’t here to rescue anybody. nothing romantically heroic about it. i’m here to learn, experience and share with other providers, and to care for patients. the key is being a part of a bigger, sustained relationship and exchange of ideas. maybe then we’ll get somewhere.

don’t get me wrong, i’m loving it. the challenges, the problem solving, the smiles, tears and emotions. that’s why i’m in medicine.

We rent a nice top story flat with three bedrooms. A view of the Hindu and Hare Krishna places of worship. I’m living with a UCSF pediatric resident, a medical student from Nairobi, and a Harvard graduate taking a year to volunteer here before applying for med school. A lot of people are coming to FACES to work in the outlying clinics, and stay overnight in the flat.

It’s home. Kitchen, a place to sleep, living room with television (with a lot of American programs, as well as translated, Spanish soaps) and an unusually large collection of CDs and DVDs. We even have a housekeeper who will keep our clothes clean and pressed. A guard to welcome us home each day. Electricity is daily, more than I can say of Kampala. And no internet, but everyone here has cell phones with prepaid minutes.

The shower is tricky – running from scalding hot to cold cold. I’ll have to ask kate what her secret was for avoiding the burns and sparks.