A walk on the wild side

Even after frantically swatting at them, desperately hoping that they would sustain some kind of insect concussion, they re-emerge, faster, stronger and louder than ever.

The worst part is the auditory hallucinations I suffer even if I manage to kill one of the little (blood)suckers. There are fewer mosquitoes in the East African highlands (and hence less malaria), but I still find myself without a good night’s rest.

 buzzzzzzzzzZZZZZZZZZz-SWAT! (3 sec of silence.) buzzzzzzzZZZZZZZZZZZZZZTHWACK!. 

So have gone my nights here in Eldoret, Kenya.

 I left Mbarara just over a week ago. I spent my last night there hurling pints of undigested foodstuff from days prior. (Just one uncooked tomato with my last cheese sandwich likely did me in. It could have also been the one meal of “fried Fish” I had when treating my data management colleagues out to dinner…but the tomato seemed the more likely culprit given the rapid onset of symptoms.)

 I spent the following day riding for hours in a Toyota Corona sedan (automatic shift), through rugged dirt roads to reach Kibale.

“So what happens if this car gets stuck?” I asked Deo, my driver, as we trolled through mud and small pools of water. “No, we won’t get stuck!”

"Chimps' Nest"

 I was less than pleased with my initial accommodations, a tiny “bungalow” in the middle of the jungle without any lights outside. Perhaps romantic for the adventure couple (of which there were a few, including one older one from Oakland)…but not so great for the solo traveler. Or, I should say, not so great for this solo traveler.

 The trip was well-worth it for the amazing tour of the jungle on foot. Even though I had only seen two chimps, I learned so much about their behavior. And just hearing them call out to each other was amazing. We spotted our first one high up in the trees…when the ground is wetter than usual, the chimps like to stay high up. “Magezi” was the 30-40 year old “alpha male”- ie the leader of the 120 chimps that were habituated for tourists. We waited about 45 minutes for him to come down, and he finally did…and I literally “tracked” less than 20 feet behind him! He kept looking back at me, but moved too quickly for me to get a good shot. And then he called out and banged his fist against the root of a tree (which emitted a drum-like sound) to signal to his peers his presence before scrambling up another tree. The best shot I could get with my i-phone was of this shy, big-bellied adolescent, Ebitooke (“Banana”).

Ebitooke. My kind of chimp.

I can’t think of any other word than AMAZING. Maybe awesome.

We drove to Fort Portal that afternoon which is a pretty little town in the foothills of the Rwenzori mountains. I was told that the Rwenzori is a favorite spot among avid mountaineers, given its technical difficulty. I decided to create my own itinerary and asked to go see the Amabere caves, which was well worth it. (The thought of Marburg virus did cross my mind…as did bats and Rabies…but I quickly got over it.) The caves were known for their “nipples” which were thought to be the breasts of a mythical princess, Nyinanmwiru, who, known for her unparalleled beauty, was banished by her father when a soothsayer revealed that her son would kill him and take over the throne. He also cut off her breasts to “make her less beautiful.” The princess managed to find a lover and gave birth to a son regardless. Amabere means breasts and the “nipples” which “leaked milk” were actually new stalagmite and stalagcite formations.

waterfall near the caves

 We then proceeded to walk to several crater lakes, including one that was more like “quickmud” than a lake. (I had been warned several times not to step in this mud, lest I get pulled down to the center of the earth.)

 


I spent a lot of quality time with my guides and driver and learned much of their families and personal histories. Two, including Deo, were orphaned at very young ages…not from AIDS, which was my first guess, but from car accidents and other illnesses. It was humbling to realize what it meant to be in a country where the life expectancy was 48 years for a man.

 I took a plane to Nairobi and spent Sunday evening in a hotel before flying out to Eldoret early Monday morning. The Eldoret plane stopped off in Kisumu before traveling for 10 minutes to Eldoret…a road trip which would have taken several hours, undoubtedly, so I was grateful for the quick ride. Eldoret is home the many a marathon trainee. It is about 2000m above sea-level (or 7000 feet). Though I fancied myself a runner at one point in my life, I have not attempted a run yet here.

 The moment I landed in Kenya I was aware of the marked difference in economies. The Kenyan shilling is 80 to $1; the Ugandan shilling is 2500 to $1. Even so, an average government doctor here makes $1000/month....and has to also pay to go through residency. Though medical school is largely free, this is not easy for many doctors who work multiple jobs.

My current accomodation is at the Noble Guest House which is set on a lovely piece of property, with many a garden. The rooms are very nice and the staff is kind. (They are already getting used to this Mzungu's habit of peanut butter on toast with bananas every morning....one of the staff even fetched a banana from the kitchen when the table ran out just for me :)) There are many other Mzungus residing here as well, including a large Missionary family from Texas.

 “God, we thank you for this meal and for allowing us to come to Africa…” Heard on my first night in Eldoret, in a twang that was as foreign and novel to me as the East African cluck.

“Missionaries!” Dave exclaimed when I told him. “What do Kenyans need Missionaries for? Everyone I met there was already Christian!”

 True. What is striking about Eldoret is the number of NGOs- religious and otherwise- that there are around here.

Note the Swami Narayan Temple in the back

My days here were similar to my days in Mbarara- trying hard to capture the process of TB care among patients with HIV, understanding what measurements we already have of this process and what we need to further capture in order to describe the gaps in care. For example, determining how long it takes from the time that a patient is diagnosed with TB to the time that they receive the results is an important middle step to measure- many individuals live far away and trying to contact them may be a challenge. Some, I was told, even come from as far as South Sudan. The ultimate goal for these individuals is to not only start them on TB meds, but also start them on HIV meds if they have not already started them. We have good studies that have proved that earlier initiation of antiretroviral medication saves lives.

So went my last week. It seemed a bit slow at times, and all the driving made me want to stay around Eldoret for the weekend…even though there are few things to see around here. I am hungry for good (bourgie) food and am really looking forward to my return home.

Dancing the rains

“I danced the rains down in Africa,” by Toto seems to be a local hit. I have heard it about 3 times since I arrived here. And surprisingly I am one of two Mzungus in the Acacia Guest House, so I know they are not playing it just for me.

They can’t play it enough, as far as I am concerned.

Acacia Guest House

My first few days working have largely centered around trying to understand the specific processes involved in assessing individuals with HIV for tuberculosis- from the time they walk through the door and are evaluated with the "four-symptom screen" (cough, fevers, night sweats and weight loss) to the time their sputum results are returned to the clinic and they are either transferred to the TB-HIV clinic or kept in the "ISS" (Immunesuppression Syndrome) clinic. The goal is to determine where there might be gaps in management. 


The hard part is trying to get as much work done in as little time as possible without being an imposition or appearing rude. 


Ugandans are extraordinarily polite and will not make any attempts to correct any faux pas- cultural or otherwise. (By the same token, Americans are forever ingratiating- mostly stemming from sincere guilt, sometimes a bit less genuine in intent.) I was acutely aware that I might be asking too many questions and imposing a bit too much and so every question I had was often followed by an apology. I would often catch my data management colleagues exchanging glances at one another as we went through the steps of data entry. I imagined it was the polite Ugandan equivalent of the eye-roll. 

on my walk to the university campus: a coffin making shop

On the way to work

I take it women don't drink Guinness in Uganda
(Note the billboard in the background is an advert for a radio program "Wassup Mbarara!")

I spent a bit of time in the ISS clinic with a co-fellow from Harvard who had been living there since August. Like many of my colleagues, he was already incredibly accomplished- had several dozen publications, helped start an NGO in Liberia, had transformed HIV-TB care in Mbarara by creating a "TB suspect room" whereby individuals who reported a cough plus one of the other 3 symptoms were promptly shuttled to a separate room, had a mask placed on them and then sent to the lab to submit a sputum specimen. 


"Surprisingly, I've never converted (developed latent TB)," he marveled. I suggested that the open windows, which let in fresh air and sunlight and allowed for decent ventilation, might have had something to do with that....a comment which might have undermined his efforts. I quickly followed with a praise of his amazing efforts, which I genuinely believed. It is so hard to figure out what is the best way to direct your efforts and know how much of an impact it will have and how futile it will be in this part of the world. You don't want to be just some other guy making big sweeping changes that will yield little. I am not 100% sure of the reduction in transmission rates that his TB suspect room will achieve, but overall the process has become so much more systematic, that invariably the effort has likely improved other outcomes.


I had lunch at "the best Indian restaurant in town" with an expat who serves as the MUST-MGH Harvard Collaboration Program Director. (Sadly, though there are many Indian families in the area, few have invested in good restaurants, and Hem’s is one of the newer establishments.) A family physician who worked in an HIV clinic for 22 years (at a time when HIV was the domain of primary care providers, internists and FPs alike), she decided that she wanted to try something new. So she applied for this job posted by a former UCSF ID faculty member who is now at Harvard and now largely serves as an administrator in Mbarara. She has lived here for about a year and will likely be here for another one or two. She spoke of the fact that it took her several months to learn and understand some of the cultural nuances here, and even now there are times when many things are lost in translation. I laughed at her stories of cultural missteps. She keeps a cat at home (which is strange for them) and when she was buying bedsheets from a local vendor, the vendor showed her bedsheets with cat prints thinking that such was her cup of tea...when in fact all she wanted was "nice clean white German sheets." 


An hour and a half later, we received our meal of chapattis, paneer and masala pappadum:

That afternoon I traveled with Sara, a research assistant and nurse, to do a home visit on one of the patients enrolled in the UWARTO project which uses a wireless device to track adherence. Enrolled patients have a pill box that sends a signal to the researchers every time it is opened. We traveled only about 15km to get to a patient's home, but it was 15km into the bush, including a short hike up a steep hill. 

Fieldwork with R our Driver. On the road he mentioned that the Indian population never intermarried here, only the Americans...

My plan was just to observe the interaction, but I soon found myself assuming a more comfortable role. She was complaining of profound fatigue, lightheadedness and a sore throat. I looked in her mouth and it was heavily coated with thrush (a fungal infection). Her heart rate was normal and this reassured me that she was taking in enough food and drink to keep herself relatively hydrated. But we advised her to go to the hospital regardless. She was hesitant to travel the distance because she didn't have an appointment and she was afraid they would reprimand her for not disclosing her symptoms earlier. It was true that she would not be able to be seen in the clinic without an appointment- the clinic, which saw 20,000 patients last year, 9,000 of whom are considered "active patients," is simply too overwhelmed and understaffed. 


(A brief note on the Ugandan brain drain: a well-paid nurse gets a monthly salary of $90. Most graduates of Ugandan medical schools seek employment outside of Uganda. NGOs in neighboring Rwanda and distant Swaziland pay 6x as much than the Ugandan government. The real kicker is the training- residents have to pay to be a resident and often wind up having several side jobs (running pharmacies, nursing homes, etc) to make ends meet.) 


I wrote down the name of an antifungal treatment which is likely quite expensive, but she said that she would have her husband pick up a prescription. I advised her to not take the antihistamine she was given by the pharmacy lest it make her dizzier. And I again reiterated the need for her to be evaluated more thoroughly. I wondered if I was actually doing a disservice by examining her, giving her perhaps false reassurance about her condition. 


 I asked Sara what would have happened if she needed to go to the hospital emergently, because for a while I wasn't sure if she merited a more thorough evaluation. Sara said that all they could do was advise her to go on her own- there was simply not enough money for the researchers and field workers to transport all patients who would need to be seen in the hospital. I felt better after having watched her for a bit, but the thought was greatly troubling. We gave her the bag of sugar that is offered as renumeration for her participation in the study and left. 


The following day was busy touring the campus again, and then having several meetings with the data entry folks as well as the lab technicians. Part of the tour I took was given by the Associate Dean of the university. The “Professor” was lovely and charming and would often ask questions which we were not meant to answer- though we probably could have responded, he would answer them quickly for us. It was as though we were his pupils. “And why is it that the sun rises in the morning and sets at night? (Brief pause) Because the earth rotates around the? (Brief pause) Sun.”

Giant storklike birds on campus

I spent the early part of the evening at the plush MGH guest house. Built by one of the researchers at Harvard who previously worked at UCSF, it was reminiscent of a suburban home in Marin or Sonoma, complete with Spanish tiles and granite countertops. It boasted an incredible upper-level veranda that overlooked the southwestern hills and a garden that was filled with fruit trees of all shapes and sizes. My original plan was to have dinner with some of the folks who were residing there, but I had to hurry home for a late night conference call with my mentors in California. I was envious of those who were residing there and couldn’t help but wonder how much easier it would be for an American to live in this part of the world if you had a home like this. Though I am grateful that my own current living quarters is clean and well tended with good service, the lack of a fan (which prevents me from using my stifling mosquito net) the loud soft rock in the late evening and the early morning buzz of mosquitos by my ear has kept me from a good night’s rest in several days.


My sad dinner consisted of a cheese sandwich and fries, but the lovely wait staff at Acacia, who had noted that I had not eaten my crust the night before, removed the crust for me even though I had not asked.

My one true African meal for lunch earlier that day: Dodo (greens), Matooke (plantain), beans, "Irish" (potatoes), Chapattis

Tangawizi! for Dave.

Tomorrow it is off to see the chimps in Kibale for the weekend, before I fly out to Kenya. 

Travels with Myself...

I am sitting at the Acacia Guest House, in Mbarara, Uganda, listening to the competing sounds of very loud soft rock (Phil Collins and the like) and a "football" game on a small flat screened tv that is sitting high up on the whitewashed wall of the lobby. I arrived in Entebbe yesterday at around noon, after a 4.5h flight from Dubai. (My parting with Dave was not without its requisite tears- as much for not being able to experience this new part of Africa without him as for not really knowing why I was going and where this new research endeavor would lead.) The entry through immigration was quick, even with my need to purchase a visa on site.

I was greeted by Lucas, the driver sent by a travel agency that was recommended to me by the folks at Harvard and UCSF. After quickly getting my new SIM card, we proceeded to travel another 5 hours by car through jungle ("the banana republic"), rolling green pastures, and small shabby towns with their brightly painted stores and rusted iron awnings. Lucas and I chatted about each others families, Ugandan politics and the essentials. He has worked for Moses's Travel Agency for about 4 years now, and prior to that he worked as the driver for children with disabilities at Mission Hospital. He had 3 children; 2 are twins and one of the twins had some delay and left arm and leg paralysis due to anoxic brain injury during birth. All lived in Kampala with their mother, whom he met working with the UN and the Red Cross in Rwanda (as a driver)- though she is Ugandan, she is from a different tribe (in Mbarara). Lucas himself is from Jinja (at the mouth of the Nile), located in the central-western part of Uganda that he feels is a bit less developed and more neglected as many of the chief ministers hail from the southwestern part of Uganda (where we were traveling and from where the current President of nearly 25 years, Musaveni, hails). Though I couldn't catch everything Lucas had to say (a combination of my relative deafness and his accent), my general sense from our conversation was the Musaveni is appreciated for a lot of things. He reigned in a lot of the corrupt local police who would create roadblocks and make folks fork over sums of money that invariably would go straight to their pockets. But Lucas lamented the failure of the education system in Uganda, which is why he spends money sending his kids to better schools in Kampala- teachers in the public school system are not paid well enough. Hmm. I also tactfully asked about how he and his fellow Ugandans perceived the Indian immigrants in the country. While they were thrown out during Amin's "reign of terror" in the late seventies (resulting in near economic collapse), they were repatriated in the mid 80s and now again own many businesses. Lucas, whose first question to me was, "are you Indian?," tactfully replied that in general Indians were well-liked because they often sold items at cheaper rates than Ugandan merchants...putting a lot of Ugandan merchants out of work.

 Lucas stopped at the equator for a picture:

We also passed through a national park and saw zebras and impalas- a mini-safari of sorts. My i-phone would not let me zoom close enough to take great pictures. We arrived in Mbarara by 5:30pm. We first drove to the MGH guest house (as in Mass Gen Hosp), which had a high brick fence, an armed security guard and a lovely garden of fruit trees including avocado, papaya, and mango. We met Pauline, the innkeeper, who took me to a different guest house (as there was no room for the week I am here), which offered reasonably secure premises and simple but clean and spacious rooms. I settled in and went down for a dinner of chappatis, stew, and a coke which I was unable to finish:

I wrote a few emails and retired to my room, falling asleep in front of "Benson" and some Filipino soap dubbed in English. Dave woke me up at around 6am this morning and I was excited to hear his voice and glad he made it safely back to the states and was reunited with Emily. I re-organized and went down to grab some coffee and a banana and then headed out toe explore town. Most of the shops were closed, but there were plenty of people out. I caught glimpses of church goers and heard bits of church music. (There is a sizable Muslim community here as well- Lucas says about 25%- but the country is overwhelmingly Christian, and any little religious tension is largely between the Catholics and Protestants, unlike changing India. I did see a number of women sporting burkas, a conversation for another day.) I only heard one "Mzungu" from a small child- though there is some other word for someone of Asian descent, Lucas said that children cannot distinguish me from any other Mzungu...which had largely been my experience in Kenya.

I spent the remainder of the day planning my trip to Kenya (the flights were harder to come by than I had imagined) and thinking about whether I would want to spend the one "free" day I had in Uganda tracking gorillas in Bwindi or chimpanzees in Kibale...and am leaning towards the latter.  I also did a bit of real work (for the first time in 2 weeks) and caught up on old New Yorkers, notably an article on matchmaking websites in China.

I am just about to eat the chapattis and stew I ordered yesterday for the second time today- I had a portion for lunch earlier today, but was again, strangely, quickly filled. I previously had handwritten about 11 pages on 5x8 college ruled paper of our trip to India, so I may allude to it periodically in this journal. But writing by hand frequently causes the muscle below my thumb (the thenar eminence) to cramp, so I am restarting this blog, as typing is far more comfortable. Will try to include pictures as I go along.