Pemba!

The aroma of Zanzibar spices and fresh vegetables is filling our dining area as May prepares our curry meal for dinner. She’s one of my classmates from Australia who has, through her offer to cook dinner, become even more popular this evening – each of us has peeked into the kitchen one-by-one to half-sincerely offer to help, but more so to check in to ensure our spot at her dinner table. Tonight is the first night we have had a long rain, providing a calm evening for our hostel to dine together and catch up.

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Malaria was the major theme of the second week. Our main professor practiced as an Infectious Disease physician and studied Malaria for over four decades. He retired just three weeks prior to joining us for his week of lectures. Most fascinating, he was part of studying the malaria vaccine. It was particularly eye opening to hear him, the academic, the expert, point first to the importance of access to basic healthcare, existing medicines, and public health infrastructure, before more advanced studies on new treatments or vaccines that are either too expensive to be rolled out any time soon or not even very effective.

The middle of the week, instead of exploring three cases in-depth, we rounded rapid fire on about 8 cases within 2 hours.  Case 1: Tuberculosis. Poorly treated the first time, and concern for a multi-drug resistant case, perhaps with an overlying cancer. Case 2: Lymphoma, but we could not investigate further due to lack of pathologist. And even then, there is no access to even basic chemotherapy here at this regional referral hospital. Or an Oncologist. Case 3: Acute onset lower extremity neuropathic symptoms. No MRI machine. No X-rays completed yet due to cost.

You get the idea. It can be gut-wrenching and it’s simply not fair.

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Today was a full day of presentations, hearing about each small group’s one-week (week 3) rural placement. One group studied palliative care and end-of-life beliefs amongst Maasai villagers, another studied malaria rapid diagnostic test use amongst physicians and traditional healers, and another focused on battling malnutrition.

My group traveled to Pemba, the northern of the two major islands that make up Zanzibar. We spent the opening weekend at the apparently infamous “Biederman’s Farm.” The farm excursion was a 2.5-hour bumpy dirt ride from Tanga, and came with fresh cold milk and cheese that we think was properly pasteurized. Mr. Biederman has lived there for 50 years, following an initial placement on the Tanzanian coast by his engineering firm. His property is dotted with barrels of mosquito larva-eating fish that Dr. Albert Schweitzer reportedly introduced to him (?) and swore by as protection from malaria. We spent hours swimming in the incredible warm water of the Indian Ocean, where the stressors of real life back home finally washed away. Some take a few days to really relax on vacation; I took about 12 days to be fully on board here.

The following day we flew to Pemba on a 14-seat plane. A couple cold beers at the airport treated the pre-flight anxiety. The safety demonstration was two sentences. The 20-minute flight ended safely and we were eventually delivered to our destination – the Public Health Laboratory (PHL) guesthouse. Zanzibar is largely Islamic as evidenced by the more conservatively dressed women and the 0445 calls to prayer.

The PHL was originally started by an Italian NGO but is now well integrated into the Zanzibar Ministry of Health (MOH) and its public health campaigns. Zanzibar is actually its own “country,” depending on who you speak to, and is part of the United Republic of Tanzania, but its Ministry of Health functions autonomously.

Health spending in Zanzibar reaches $13 per person per year, versus $3600 and $8600 in the UK and US respectively. Stop and think about that. I didn’t accidentally add or omit zeros.

Our hosts provided lectures on schistosomiasis, water quality, the Zanzibar health system structure, and sanitation, and then we set out on field trips to see some water quality measurements and latrine construction in action. In the evening, we ate our home-cooked meal, played Mafia, and watched the British TV favorites of The Inbetweeners and Fawlty Towers. I had forgotten about Mafia, played when I was younger, but when 11 physicians from different countries are put in a dry guesthouse with little else nearby to do, Mafia proves quite entertaining.

Thursday evening ended with a lavish thank you dinner for our hosts at a nice hotel. We mixed with another group of consultants and funders in town from the UK and US here to assess the Millennium Village on Pemba. Our hosts were actually key leaders in the implementation of the village, selected as one of the poorest in the world. Some of our hosts sat at the consultant table for political purposes while others chose to sit with us to avoid the formal chat. 2015 will be the final year of the Millennium Villages Project and it is when the Millennium Development Goals will essentially “expire.” The Pemba village appears to be on track and the funders seemed pleased with the results in this penultimate year.

And then came Friday night. Friday we flew another short flight across to Unguja (the main island of Zanzibar) to join forces with two of the other small groups. After completing our write up of our project on shistosomiasis, and traveling hours longer than expected, we arrived after dark at the guesthouses on the beach of northeast Unguja. We threw down our bags and walked 10 minutes down the beach to join the others at happy hour – and you would have thought we were heroes returned from battle! Clapping, hugs, kisses, high-fives! I think we surprised ourselves by how happy we all were to be reunited.

It has always struck me how quickly people can become close and build relationships. During times of stress, people seem to need each other. And when the group starts off with baseline commonalities, they start from an advanced position due to an existing high level of trust. Fraternity pledgeship. Residency training. Summer camp. Whatever the experience, it’s a powerful pull that is difficult to put into words and it’s exhilarating to be in the middle of it.

We spent the final night on the beach taking in the clear view of the stars and rising moon celebrating our classmate’s birthday. After blowing out her candles on the dry chocolate birthday cake, she wondered aloud: “I wondered today if this might be the best birthday I’ve ever had. And I think it is.”

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Dinner is ready. Thankfully, I’ve contributed some wine and a chocolate bar for dessert.

From the base of Kilimanjaro

Energized by the 2.5-hour church service at the Anglican Church here in Moshi this morning, I figured it was time to check in. I arrived in Moshi (Tanzania) last weekend, but my delayed checked bag stayed behind a few nights in Nairobi at the international airport. Following some local advocacy by our course administrator, a handful of patient phone calls to London, Nairobi, and Dar es Salaam, and a few clean shirt changes thanks to our course director, my bag arrived at Kilimanjaro International Airport for pick-up Tuesday evening.

We are now one week into the East African Diploma inTropical Medicine and Hygiene put on by the London School of Hygiene andTropical Medicine (LSHTM). 58 physicians are attending the three-month course. Roughly one-third are from the UK, 8 are from Australia, and the rest represent places such as Ireland, Botswana, Scotland, Austria, Denmark, Canada, Portugal, Uganda, Tanzania, with yours truly being the sole American representative.

Our course began Monday morning with brief introductions, registration, the passing out of our heavy textbook, Principles of Medicine in Africa, distribution of some bicycle helmets (in case we decide to hop on the back of a motorcycle as transportation instead of a taxi), and safety warnings. The first week focused on Epidemiology, where we reviewed the basics of epidemiological study design, had a review of biostatistics, and went in depth into the original outbreak of Ebola in the DRC. A timely topic, we thought... Our lecturer was a well-known epidemiologist and Infectious Disease (ID) specialist from LSHTM. She made a potentially dry topic interesting, and is (like many of our lecturers), an author of chapters in our reference textbook.

The mornings were spent in lecture, and the afternoons were spent in group Swahili lessons and clinical rounds. I rounded at Kilimanjaro Christian Medical Center (KCMC, our home-base in Moshi), with our small group of seven. Our Attending was an ID specialist from Cape Town who conducted bedside rounds. First, we saw a case of an HIV-positive woman with a Co-trimoxazole (Bactrim) induced dermatologic drug reaction. Unfortunately this could have been avoided as at the time she started the medication for PCP prophylaxis, it was not yet indicated. Our second patient was battling chronic schistosomiasis with resulting splenomegaly and esophageal varices. These patients end up severely anemic from GI bleeds and have a fairly poor prognosis. Lastly, we saw a patient with a history of TB, currently struggling with an exacerbation of chronic interstitial lung disease from his years of work in the tanzanite mines. My second day of rounds, we went off site to a smaller district hospital, where we saw four pediatric patients with viral gastroenteritis, rickets, tonsillitis and severe malaria respectively. Our Attending this day, was a local Moshi-based physician who claims he has an allergic reaction any time he travels too far out of the Moshi area.

In these settings, there is very limited access to laboratory tests or imaging, so most of our diagnosis was based on clinical examination and physical signs. Even though this is a tertiary referral hospital, there is no pathologist on site most of the year to read biopsies. There is a CT scanner, but it has been broken for three years. The machine to do a complete blood count is broken – and there is no back-up. These local Attendings are unbelievably impressive with what they can deduce from just a physical exam, whereas in the States we have come to rely on more costly measures to nail down a diagnosis in nearly every case.

Socially, or what our course director affectionately calls the “Hidden Curriculum,” things are ticking along quite nicely. Most of my classmates are in the middle of their specialty training and many have a wide variety of experience. A common thread however, is that they have almost all had an “elective” experience working in a developing area, and are currently taking, or have already taken, a year off in the middle of their post-graduate training to travel and learn more about healthcare in different settings. That’s in stark contrast to American docs who are in such a hurry to complete residency training for a variety of reasons. More on that later. I have enjoyed getting to know my classmates and lecturers, slowly adding in one or two at a time, hearing about their travels, their training, and their feelings on the system within which they work.

Our lodging is decent, and Thursday night we had a meal cooked at our hostel (our group is staying in one of four places around town) for $5 per person. A few from the other hostels came by, and half the group hung around on my hostel’s terrace ("Terrace Thursdays" we've dubbed it) for a few Kilimanjaros (beer) and some Konyagi (the local spirit). 

Most of the group went on safari or to stay a night at the Ngorongoro crater this weekend, but Micah, my new Irish friend, and I went out to Honey Badger Lodge for some relaxation poolside. An Epidemiology professor associated with the LSHTM based here in Moshi owns the Lodge.

We are now preparing our reading for next week’s topic – Malaria. The end of next week we will travel in six small groups to our one-week rural placements to learn about different community-level health services or projects. I’ll be headed out to Pemba, the northern island of the Zanzibar region, and most of us are eagerly anticipating the week away.

The first week was busy, but it is about to end with our hostel’s cook serving a homemade meal. What a blessing to be here – when your Sunday evening sunset looks like this, it’s easy to be reassured you are exactly where you should be.

Kwaherini!

4 months. 1 bag.

In Defense of Backpacking: Is free WiFi killing the backpacking experience?

“So where y’all from?”  That one simple phrase is the only thing necessary to spark an instant friendship under the hostel roof.  Backpackers share many of the same traits – the spirit for adventure, a desire to see new parts of the world, simple travel needs, being trusting enough to share quarters with complete strangers, and the goal to do so in a cost conscious manner.  Sharing a bathroom with a friend or a sibling is hard enough for most.  Sharing a bathroom with someone who doesn’t speak your language is a completely different experience. 

After a couple solo trips around the end of my time at university, there were so many elements of backpacking to which I’d become addicted.  Traveling solo had a certain air of freedom that, combined with cheap hostel rates, allowed for versatile travel plans.  Thus far, my whole life had been meticulously planned from my educational and career path to my tennis training.  Traveling with only my backpack was freeing, and began my desire for a new plan to have no plan.

Arriving at the hostel dorm is the best part.  After a brief check-in, I throw my bag on my assigned bed and start introducing myself around.  “So, where y’all from?”  In the hostel, we are all on the same team – traveling solo or in small groups, far from home, eager to explore, and celebrating life on a budget.  You know that you and your dorm-mates already have many things in common, so after the simple “where y’all from?” you can skip right to “what’s the plan for tonight?!”

The common area of the hostel is a place for sharing a cheap beer in the evening, hearing stories from the day’s sightseeing, and formulating the plan for dinner and dancing that night.   

“So, where you from?”  To be able to get this icebreaker off your lips, there must be someone ready to receive it.  This takes eye contact.  The hostel of 2013 however has unintentionally put a barrier in place to prevent this:  Free WiFi. 

Is WiFi killing the backpacking experience?  And is it eroding the ability for people to interact in the simplest yet most meaningful way possible - face-to-face conversation? 

Last month, I stayed in a giant hostel in Budapest I affectionately called the Disney World of hostels.  They’d literally thought of everything.  It was clearly built by backpackers.  The entire hostel was cleaned twice daily.  A hot breakfast was included.  They even had a small shelf on the wall near the head of each bunk bed with an outlet to set down your watch and charge your phone!  Most importantly there was a bar downstairs that was lively every evening complete with a pool table, Palinka tastings, beer deals, and a free drink on the evening you checked in.  I also stayed in a hostel in Istanbul a few days later that was a dump comparatively, yet still sufficient.  And both places had the same thing in common:  Free WiFi.  Both places I dropped my bag down, settled in, and came down to the lobby to find my new hostel-mates in the lobby glued to their iPads and iPhones, ear buds in.  There was even one Australian Face-timing loudly with someone back home on his laptop.  No one looked up to acknowledge their new arrival – me.  So I sat, opened my bottle of wine, read my book and hung out.  Everyone else read news, sifted through Facebook posts, and listened to music from their devices - everything they could have done back home.  They were so focused on their electronic task that there was no looking up to appreciate the current moment, take in the scenery, or make a new friend.

Rewind 9 years.  It’s 2003 and I’m backpacking for the first time ever, in Fiji.  I stayed in hostels in the Colo-i-Suva National Park and on Beachcomber Island, the latter a backpacker’s paradise where the dorm had 100 bunk beds under one roof, wide open to the ocean breeze entering freely on all sides.  Each evening after exploring during the day, I’d clean up in the dorm and go settle in the lobby or main bar area for a drink, and I’d do the only thing left to do – meet the rest of the folks staying there for the night.  There was no WiFi.  Both of these places didn’t even have Internet access.  Placing a call back home required a pre-paid calling card.  Thus, there were numerous steps (read barriers) necessary to connect back to the “real world.”  Instead I was forced to participate in the present.  Thank God for that.  I met two generous Swedish couples.  I watched some rowdy South Africans fail miserably at limbo.  And I took in one of the best evenings of my life – a Christmas Eve complete with free boxed Chardonnay and a game of musical chairs with 11 strangers. 

Six months later I found myself hopping through Europe over 5 weeks.  I visited with friends I met in Fiji and crashed in hostels when I was without a host.  To use Internet then I could walk to the Internet café, but that cost me a few Euros, which was a tough decision when that could have been put towards a cold beer instead.  The fact that energy was required to go find an Internet café was a barrier to my decision to connect and I only e-mailed my family and friends as much as was essential to let them know I was alive and well.  I was aware of my surroundings.  And my blessings.  And I was immersed in the moment.

Now we find ourselves in the age of 24-hour news outlets and second-by-second Twitter updates.  We in the States have slowly become comfortable with constant stimulation, whether that is by TV, music, Facebook, or text messaging, and we almost can’t live without it.  I see so much anxiety and attention deficit disorder and I have to think our constant need for connectedness, and our inability to occasionally “check out” from the stressors of daily life, is playing a role in this.  For if you are used to constant visual or auditory stimulation and then all of a sudden you have none, and are stuck with a still view of the ocean or find yourself seated in a somewhat quiet lobby or restaurant or bar, what would your natural reflex be?  To worry?  To reach back for your standard level of stimulation?

This is precisely why I am choosing to make a concerted effort to resist the new norm.  And, at the risk of sounding like (or posing as) a backpacking elder, I am calling all backpackers to do the same.  Whether you’re away for a year or a week, old or young, beginner or veteran, let’s return backpacking to its roots and keep the spirit alive.  Do it for your health, or your sanity.  But most importantly, do it in the spirit of building new connections around the world.

My home life is very well planned, with a fairly steady routine that relies greatly on the Internet and electronics.  But when I travel, I travel to get away.  To escape my daily routine.  To experience something new and meet new people.  To rest my brain, take a deep breath, pray, and reflect on how blessed I am and my current position in life. 

If I am constantly being told what’s happening on my iPhone I fear I won’t be able to see for myself what is going on right in front of me.  So it takes a conscious effort to stay off the iPhone, put it deep away in my bag and only use it for essential communication.  But it’s going to take a community effort to renew our vows to each other to travel for the original reason we were intrigued by the journey in the first place.  Perhaps you wanted to take in a kava ceremony in Fiji.  Maybe you wanted to reach the top of the Eiffel Tower.  You likely wanted to meet someone from a different culture and hopefully share a meal with your new mate.  Maybe this is another vacation away from your daily work or a necessary venture far from your comfort zone.  Whatever your inspiration for crossing international borders or flying across oceans, your iPhone or iPad will not be necessary for you to accomplish your end goal.  And they’ll be waiting for you back home – trust me.

So, disconnect.  Turn off.  Be present and soak in the moment.  And the next evening you’re in the hostel lobby or bar, decline the free WiFi and look up.  Our eyes will be able to meet and my friendly Texan face will be smiling to greet you: 

“So, where you from?”  And we’re already friends.

Kili and Me

When two men arm wrestle, they do so to prove themselves to a woman.  When a man does pull-ups, he does them to prove himself to another man.  I travel solo to prove myself to myself.

Despite the “are you SURE you want to do this?!” questions from family and friends, I’d been brought to Moshi, one of two towns at the base of Mount Kilimanjaro, encouraged along by Michael Crichton’s autobiography “Travels.”  The descent into Kilimanjaro International Airport ended with the sight of the equatorial snow-capped mountain I’d read so much about and that stunned stomach feeling:  Will I stand up there?  Can I do this?  I was sick of talking about it;  the prep, the planning, the hype.  I was ready to do it.  My backpack was a confusing mix of my North Face jacket and wool socks at the bottom, with t-shirts, shorts, and sunscreen at the top to prepare for the mixture of climates on Kilimanjaro.

Zara Tours’ warm hospitality got me from the airport to the hotel, and I’d arrived at the briefing that afternoon.  Our guide talked us through the six-day trek.  I’d been introduced to Meghan, the American I’d been partnered up with for the hike – a fortuitous meeting given our similar interests of health policy and public health in developing countries. Going up Kilimanjaro alone has its risks, and going up with a partner allows for splitting the guides’, porters’, and cooks’ tips.  My pairing with Meghan proved in many ways that God was surely driving.  The staff kept telling me I would meet “him” and that “he” would be at the briefing, but sure enough Meghan’s gender was simply lost in translation – she was a she.  Our guide went by many names, but his buddies called him Sikuu.  With his broken English yet calm demeanor he confidently talked us through our plan for the next five days, assuring us of his Kilimanjaro experience. 

That night, Meghan and I became acquainted over dinner and our conversation attracted a Dutch gentleman, just off the mountain.  He handed off his left-over Paracetamol (Tylenol) to be used as needed for pain.  “You can do it!,” he encouraged us.

I slept well, awoke with excitement, and took pictures of the white peak from the bottom from the last time.  We ate a big breakfast and I gathered my rented pants and gear – in true med student fashion, I’d arrived with only scrub pants.  We then made several stops - grabbing one-liter bottled waters and chocolate, both trek essentials - along the way to the entrance gate.

The Trek

Our arrival at the front gate was pretty unimpressive to the hired crew.  We had Sikuu (our guide), his assistant guide, six porters, and two cooks - all for the two of us.  They set off ahead of us carrying stacks of plastic chairs, tents, and other heavy gear.  Their shoes were torn; some went without socks.  “Pole sana.”  Or “I’m sorry for your work,” we’d mumble as they took off ahead of us.  We stuck with Sikuu.  “Pole, pole.”  Slowly, slowly.  “Acclimatize,” Sikuu would say, explaining our slow steady pace. 

At the end of Day 1, we set up camp with about 40 others.  Even though we had told Sikuu that we’d be willing to share a tent, the crew brought us each our own.  I suited up with my cold weather gear - hat, coat, gloves.  The father-son duo from Colorado who passed the football around in shorts and t-shirts had a hell of a laugh at this.  It was only night one, and I was preparing for hibernation.  Sikuu brought us boiled drinking water, and the dining tent was prepared for dinner.  Every night included tea and chocolate to mix with our boiled drinking water and options ranging from chicken (usually) to some form of boiled egg or fruit, and bread with jam.  The Nestle hot chocolate mix was my dessert.

Days 2 - 4 took us from dirt terrain to a more lush, green, and humid environment.  We were under large trees, mysterious giant plants, as we walked over rocky terrain and across trickling streams pulled downhill.  Sikuu kept our pace steady, stopping only for him to smoke and for us to pee.  Michael Crichton summited when he was smoking a half-pack per day, so surely Sikuu could handle it!  The higher altitudes have lower partial pressure of oxygen and the body’s increased respiratory rate requires increased hydration.  The combination of the necessary 4 – 5 liters of drinking water per day plus the acetazolamide diuretic that we took to prevent altitude sickness contributed to our frequent bathroom stops.

Each night I took flak for my added winter warmth.  On Night #3 however the analysis was from a crew of four girls my age from Seattle.  One was a vet and they were all entertaining at every stop.  Our socializing was interrupted that particular evening by the sight of guards who were armed with semiautomatic weapons supposedly in place to fend off any large animals that walked around at this altitude.  Soon, we would be too high up for any animal life.

On Night #4, we arrived at base camp - Barafu Huts – about 15,000 feet above sea level.  We signed in, just as we had each evening at camp, but this time, excitement filled the air.  Exiting the sign-in hut, we looked out at the blue sky above the clouds.  This was our last stop before the attempted summit.

I still had no symptoms from the altitude (I got this!).  Sikuu laid out the plan, and we tried to get some sleep before our nighttime summit.  Each day brought about 5 hours of walking, and at the end of each day I would ask Sikuu:  “Hey Sikuu?”  “Ndiyo Bwana?” (Yes, my friend?) “Was today harder than the Summit Day?”  “Not,” he would reply.  I’d heard plenty about the summit day; soon it would be go time.  I dozed off early, comforted by the hum of the porters, relaxing and sharing stories during card games played by the dim light that emerged from the door-flaps of their tents.

The Assault

We awoke about midnight and layered up - two t-shirts, two long-sleeve t-shirts, one wind/water-proof fleece, my thick North Face jacket, two pairs of wool socks, and one digital camera tucked inside a couple of layers in hopes it wouldn’t freeze before the peak shot.  We began our assault, led only by our headlamps and Sikuu’s voice.  After about an hour, Sikuu stopped off to vomit.  Our assistant guide took over.  Sikuu caught back up, announcing his return with a term we’d learned on the trek:  “Puke and rally!”  Meghan started to feel her head hurt and a little nausea, but we kept plugging.  One foot in front of the other.  Pole, pole.  My weight was increasingly on my walking sticks, from my grip down to the ground, transferred away from my legs.  I walked without thinking.

We reached Stella Point.  We had walked 4 hours.  The world was still pitch black, and the wind was whipping.  I began to wonder if I could even accomplish this bathroom break with the multiple layers and temperatures surely approaching zero.  Sikuu handed us each a Dairy Milk chocolate bar that hit the spot, and we pounded more water.  We prolonged our break, as we were beating the sunrise. 

We pressed upward.  We had another hour of walking, but only 300 meters in altitude, left.  My weight almost entirely landed on my arms and walking poles, my gait had turned to a slow methodical shuffle, brushing the ash ground with a slow rhythm.  “Giant steps are what you take walking on the moon,” Sting and The Police began to sing in my head.  We came across two headlamps, one seated, one standing.  The trekker vomited, I think, and his guide comforted him.  I think that if I had sat then, I wouldn’t have made it.  We shuffled on, and a bit of light broke over the horizon to the left.  The hill became slightly more steep and curved up to the right and I saw Sikuu bolt up a little faster.  “Kuche Kuche!  We don’t need no trouble!  No more trouble!”  He shouted.  “Huh?!”  I wasn’t thinking straight, but I knew what it meant:  We were here.  We did it.  To compare my feeling to a hangover would glorify the day after drinking.  The vice-grip headache affected me, but the emptiness of mind didn’t allow me to acknowledge the pain.  A few tears rolled down my cheek.  I’m not sure how, but Meghan and I withdrew our cameras and got solo and team shots in front of the sign at the summit.  The sun illuminated our surroundings.  A giant glacier reflected the entire color spectrum of the sunlight to our right.  A giant canyon revealed to the left.  A glacier!  On the Equator!

Then the Seattle girls arrived.  I had a brief burst of energy.  “Hey Seattle!  How’s it going?!”  Blank stares all around.  One may have cracked a smile.  “Just another warm summer day in Seattle huh?!”  No response.  “Was it worth it?!”  Their looks said it all.  It was an unbelievable accomplishment on Day #5 of this adventure, and we had done it.

Meghan and I were trekkers number three and four to reach the summit, 19,340 feet above sea level, on December 19, 2007.

The Celebration

After about 20 minutes at the peak, we headed down.  We walked past the seated trekker, still vomiting, and then slid down the scree as if on skis, racing past single-file lines of hikers still focused on the summit.  Our arrival back at base camp was welcomed by my favorite porter: “Congratulation,” he said with a big hug.  After a quick snack and change of clothes we packed up to head down the mountain.  It was only 06:45 in the morning after all.  The camp for the last night was just three hours from the bottom, and with showers calling our name, we made the decision to reach the bottom that night.  On our final hour of walking, it began to pour down rain.  And after a dry five days, and seven solid hours of pounding on my knees, rainwater had never felt better.

Twelve hours of sleep, one big dinner, and a full day of shopping in Moshi had us all ready the next evening for the celebration night out.  Sikuu and our assistant guide joined the two of us for a night on the town.  Our main drink for the night?  Whiskey and Coca-Cola.  We had, after all, conquered the Machame Route, dubbed the “Coca-Cola Route,” and we were now familiar with Kili. 

Kenya: Gone on Safari

Work's finished and it's time for safari!  Please take in the last official post of our trip.

The last few days were spent finishing up at the hospital and the clinic in the village.  Rounds, treating malaria in the clinic, and watching the clinic's new reception being built were the main events of note.  We even had dinner last night at Brenda's, prepared by her two sisters and mother - boy was it amazing.  Daniela, Brenda's 2 year-old daughter, even has her English up to speed.  We'd ask her "How are you?"  She responds, "I'm fine."  (Those are the most commonly known phrases by the kids here.)  We've definitely explored Kenyan and Indian food to the fullest, and I actually look forward to some Indian food when I return home.  Never thought I'd say that.

It is difficult to capture all the appreciation we have for your support and prayers throughout this trip.  Through your donations we purchased and gave out all our children's multivitamins, handed out toothpaste and toothbrushes to those who needed them, re-stocked about 18 different medications (antibiotics, phenergan suspension for nausea/vomiting, children's tylenol, etc.), handed out glasses and gave reading glasses to the Tenwek hospital crew, left a number of medications from home for emergency use only, gave coloring books, crayons, workbooks, pens and lollipops to roughly 150 kids, and even purchased cooking supplies for one of Brendas' mothers.  Their smiles showed their appreciation, but from us we say "thank you" for your open hearts.  We truly cannot thank you enough - what an honor and a blessing.

This has been an invaluable learning opportunity for me, as a repeat trip to a developing country, challenging my patience and shaping my attitudes.  There are so many projects here, intended to serve the population in poverty, where the ball is actually being dropped:  there is still a huge need for reliable transportation (well-maintained vehicles and smooth roads), the effective distribution of bed nets to those who truly need them, closer access to clean drinking water, and an increased emphasis on the prevention of the spread of HIV.  For the failures, there are plenty of successes as well:  motorbikes now fill the roads getting citizens to and from their destinations quicker, internet access has exploded keeping people better informed on current events and public health measures, anti-retroviral medications are available to those mothers who deliver in the hospital to try to prevent vertical transmission of HIV, and more community health workers are devoting their work-week to improving the health of Kenyans.  There are plenty to build on.  One of the most valuable lessons revolves around respecting what you don't know.  We don't know everything.  Especially when we don't live in the community we're serving.  And a clear and open mind with respect to this can bring one closer to success.

There is a plethora of projects going on here, and the main need for improvement is in the coordination between them.  Filling in the small holes.  Connecting the dots.  Adding the last few small pieces to the puzzle.  And I hope to help with that. 


The true soldiers and "saints," really, in all this, are Josh, Brenda, and Aduda.  Josh, the Bonyo's Kenya Mission #1 here in Kisumu, who ensures the clinic operates smoothly for those in and around Masara.  Brenda, the social / community health worker who gives her time to educating pregnant mothers and young schoolgirls on STI's among other public health measures.  (And let's not forget her father, "Papa Joshua," the clinical officer who offers his experience and charisma to her endeavors.)  Aduda, the former salesman, who believes so strongly in preventing HIV spread and educating those living with TB and AIDS, that he travels by public transport to the villages for surprise home visits to ensure compliance.  I have learned from their actions, and can only hope to support their work further in the future.

In the end, I've learned that the health of all peoples boils down to education.  If you don't understand that germs are on your hands, even if they don't look soiled, you will not prevent the spread of many diseases, especially diarrheal illness.  If you don't understand proper baby-feeding techniques, then you'll continue to feed fresh cow's milk directly to your newborn which can be harsh on their young gut (yes, this happens).  If you don't understand that forcing baby teeth to fall out with nails (yes, as in "hammer-and-nails" - this happens too), then infections will continue to hurt young children.  Expanding the public health educational efforts, and simply expanding the number of children able to complete secondary school, will drastically improve health in this area. 

Finally, what I take from this particular trip is the desire to use all the many little luxuries I've been blessed with, that built the foundation of my knowledge, to strive with extra effort to reach my full potential.  Most children here can't even focus enough in school due only to hunger.  How can I not take advantage of all I have, to do my absolute best?!  It would be a disgrace. 

In the end, my buddy Dan, the manager of the Milimani Resort Hotel, our home for the last three weeks who says, "We live like lions."  They wander throughout the day, with no intentional direction.  But, when an antelope comes along, they eat.

There is no need for plans.  When the antelope comes, you'll be there.

The finale from Mom:

Hi all!  This will probably be our last post as we leave for the Masai Mara and safari early in the morning.  We said goodbye to all our friends at the clinic after seeing several more patients (all with malaria).  I presented our blessed shell to the social worker, Brenda, and we both got a little teary.  She has been such a wonder for this village bringing lots of programs which I think will have a great impact.  It has been a profound and moving experience to be here and I'm sure this will be with me the rest of my life.  There is such great need here (in my eyes) and I hope to be sharing some of our ideas for continued support of this village.  Each day in the village for most people is about surviving and basic needs.  We've been so warmly welcomed and Josh, our host, has taken good care of us.  I feel blessed to have made this journey and especially to have this bonding time with Travis.  He's a very good traveling partner as you won't be surprised to hear.  He's good at keeping his cool when I'm losing mine and getting frustrated.

Last night we had the honor having dinner with Brenda and her family which included her mom, dad, 2 sisters and 2 yr old daughter.  We had such wonderful Kenya dishes such as beef stew with rice, kale and spinach, roasted potatoes, tomato/red onion/cabbage salad, fried chicken abd chipati bread.  Quite fabulous!  And as if this wasn't enough, Brenda's mom presented me with some gorgeous Aftican fabric of yellow and purple.  I'd worn my new African-made dress with zebras which Brenda had helped me have made so her mom knew how much I love the fabrics here. That was an incredibly generous gift and I was quite moved.

Today, we've been taking care of last minute business and we took Josh to lunch.  He's been such a great resource this whole trip.  Tonight, we're having dinner at Dan (hotel onsite manager) and Stella's and we're very excited about that.  Got lots of packing to do and decisions about what I'll leave behind since I need lots of room for gifts, etc.  Ha! I'm thrilled about the safari and can't wait to see all the many animals there.  I miss you all so much and look forward to seeing you soon. Many thanks again for all of your love and support!

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Asante sana for all  your prayers and support.  We can't wait to share in person when we return.

Kenya: The Kakamega Forest + Democracy Now?

So, apparently almost the entire Arab world has decided in the last few weeks, that after an average of 25 - 30 years of autocratic rule, they want democracy.  Now.  In the three weeks leading up to my first trip to Morocco.  What timing!  How selfish.  With uprisings spreading to Yemen, Jordan, Algeria, and now rumors of Libya and even Nigeria being next, I figured it would be smart to change my vacation plans.  With the help of God (it could only be) and Nikki the kind Delta agent, my flight from Nairobi will now head to Lisbon, and then home after nine days of Portuguese espresso, nightlife, and port.  

But we are still one long week from being done here in Kenya.  My time with Dr. Allibhoy came to an end today, after a busy set of rounds.  We continue to see cases that are only seen in textbooks back home.  Today, a patient with cryptococcal meningitis was readmitted, our patient status post thoracentesis is still improving, and a post-MI patient appears to be doing well on day 1.  Dr. Allibhoy gave an excellent talk today on the latest in Acute STEMI management.  Here in Kisumu there is no cath lab, so no PCI can take place - thus, they use fibrinolytics.  I don't think I've seen fibrinolytics used for MI in my training in the U.S., so it's interesting to see that used here, and safely.  I've only seen it given in suspected embolic stroke.  Dr. Allibhoy does an excellent job of keeping up with the latest in Cardiology, collecting journal articles and attending annual meetings in Europe.  

I'm continually referred to as "Dr. Travis from U.S.," but out in the village I answer to Giles, Charles, Jarvis, or Trevor.  The "Tr" sound doesn't mesh well with native Kiswahili tongues, but I appreciate the efforts.

Yesterday's visit to Kakamega was beautiful and a refreshing break from the polluted air and busy streets of the city.  Mom's details will be below, and will hopefully include the amazing 8 - 10-foot python that had wandered into the local village and was beaten to death by a swarm of villagers, and then taken to be skinned by the Kenyan Wildlife folks.  It was the only snake, dead or alive, we saw yesterday, even though the forest has 27 species of snakes (25? poisonous per the guide).  We saw plenty of red-tail and Colobus monkeys swinging from the trees, and great views of the falls and land surrounding.

I'll leave you with a quick commentary on top of all this pro-Democracy anti-autocratic unrest in northern Africa and the middle East.  The sentiment down here is of course the same as the U.S. - Democracy = good.  No other way about it.  But how about when Democracy elects leaders that will not be friendly to the U.S?  This is what will likely happen in Egypt.  Then what?  Will the country then be unfriendly to tourists from the West?  From what I hear, the Muslim Brotherhood (majority in Egypt) is not similar to the majority of other Muslims around the world, and continue to represent an extremist view.  But they are who will ascend to power in Egypt.  At first, President Obama wanted to have "talks" with Egypt, but now the word from the State Department is for a transition to begin "now."  How is our country's leadership handling this?  Shall we bomb the hell out of northern Sudan to set them straight?  Or hold diplomatic talks with Egypt?  What's the course?  Is President Obama being too weak, or being smart?  In all honesty, the main thing about an Obama presidency that made me hopeful was his anticipated ability to work with international leaders and bolster the view of Americans around the globe.  Is he doing enough right now?  Of course, it depends who you read, and it's fascinating:

You can either read the caution-provoking article about Obama being the one who will be remembered as "the one who lost Turkey, Lebanon and Egypt."   Or, you may want to read support of Obama supporting Democracy, and practicing what he preaches.

  

Oh, and Josh still doesn't have the truck.

The better version from Mom:

Hello all!  Yesterday we took a trek through the Kakamega Forrest.  It's about 1.5 hours each way and our driver, Mark, had to drive like he was on an obstacle course on some of the journey as the pot holes are deep, wide and plentiful.  We made it and boy was it spectacular!  We began our 3.5 hour trek (about 10 miles) with our guide, Rachel, who was wearing sturdy leather-soled flip flops.  Our lst stop was to look at a 10 ft. dead python the villagers were skinning.  OMG!  I could not get close but Trav took a couple of pictures.  As we entered the forest, we saw a troop of blue-tailed, red-tailed, and white-tailed monkeys which was quite exciting.  It's the lst time I've seen monkeys in their natural habitat.  Rachel then told us of all the animals/reptiles there--27 species of snakes, 10 of them being poisonous (I went blank after that--ha).  Thankfully, we didn't see any.  We did see lots of monkeys as well as a breathtaking, beyond words overlook of the whole valley and some waterfalls.  Pictures can't capture the awesome beauty of this part of Kenya. We had the perfect day as it was overcast and nice and cool. There were fewer people around and I noticed that the whole area (forest and villages) was pristine with hardly any litter.  They seemed dedicated to caring for the area which was heartening. The kids were excited to see the mzungus and to have their picture taken.

We returned and boy were our feet tired.  After a lovely dinner of spaghetti and garden salad at the mzungu hangout, the Green Garden, we made our way home via tuk tuk since it was after dark.  Trav then began to try and change his trip plans. Instead of Morocco (with politcal unrest nearby), he will go to Portugal.  The communication system here is archaic and extremely slow.  After about 2 hours of trying to communicate with KLM about his desire to change his flights, the call was disconnected and we were about out of phone time.  So very frustrating to say the least.  We decided to call it a night and try again today.  I'm happy to announce that he was able to work out all the changes! And, we'll be on the same flight to Amsterdam so I'm pleased about that.

Today, I took it easy while Trav did hospital rounds.  I began to talk with Dan, the on-site manager of the hotel about differences in here and the U.S. Here people are very connected to family.  If a brother has a financial need, the family (which is usually large) helps thus making it near impossible to save for the future.  On the other hand, the family is a built-in safety net.  Dan has several other businesses so that he can earn extra.  He has driven us a couple of times into town and has helped Trav get some music CDs (which excites T).

It has rained a little bit and there are thunderclouds in the area so we may get more.  We're heading back to the clinic tomorrow even though the truck is still at the police dept.  I guess Josh will find another vehicle.  We only have 2 more days in Kisumu and are trying to fit in many things.  Sat. we leave for safari.  Awesome.

Love to you all!

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Asante sana.

Kenya: Our visit with Grandma Sarah...on the Equator

Today, we try a different format - Mom goes first:

I know we just blogged yday but it was before our amazing afternoon and I just had to write more.  Josh, our host/driver picked us up about 1 and we headed NW to the equator which is only recognized by a metal marker on the side of the road. It's up in the mtns so a little cooler but not by much.  Afterwards, we asked if we might visit President Obama's Grandma, Sarah Obama, who we understood entertained visitors and we heard was relatively nearby.  After several calls, it was determined that Grandma was home (she's often away doing ambassador-type work) so we headed out and 1.5 hours later, after several stops for directions, we found ourselves outside her compound. There was a Kenyan policeman at the gate and he pointed to a visiting schedule which was M-Sat. with no hrs on Sun.  Josh did a great job of convincing the guard that we'd come all this way and soon a young lady came walking down to greet us.  The guard looked at our passport copies, we signed a guest log (the 2 people who had last visited were from Iceland!) and then we were all led to a shady clearing under some big trees where Grandma was seated visiting with a couple of men from the village.  The men soon left and we had a PRIVATE audience with her. There were many chairs around and she told us through our interpreter that she has many visitors--up to 200 in a day.  She loved talking and shared with us many stories for about 30 minutes.  What a gracious hostess and so welcoming on her day off for which we were most grateful. I expressed my admiration for the President and she was pleased. She'd last seen him when she attended the inauguration.  She ended our conversation asking for prayers for him.  I'm still floating from this awesome experience despite the long, hot drive on many dirt roads.  It was well worth it!

Last night we had dinner at a new Indian restaurant which was quite good and we tried another Indian restaurant for lunch today. We've gotten a little adventurous with our food choices!

This morning began in a wonderful way!  Dr. Allibhoy's wife, Nuni, invited me to a pranic healing meditation group with about 7 other women.  It began and ended with a series of exercises.  The meditation itself was led by a CD with an American teacher, John Coe (not sure I'm spelling this right) with beginning prayers and positive thoughts from Nuni and ending prayers by her as well. I found it very moving and energizing.  Many thanks to Nuni for inviting me to this.  I now feel calm and ready for whatever is next.

Just before lunch, I picked up my tailored outfits, made from fabric purchased at the market.  I can't wait to show them off at home!

Much love to you all. Know that I miss you very much and can't wait to show you all my pictures and tell you many more stories.

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Our truck is still impounded with the police.  Josh has his driver's license back, but he needs to produce the log book of repairs done...to get the truck back...to get it repaired up to par...to pass inspection...to get an inspection sticker so we can finally have our own vehicle again.

No worries.  That couldn't prevent what has thus far been Mom's favorite day in Africa.

Josh managed to rent a smooth-riding four-door sedan to take us to the Equator yesterday afternoon.  The one-hour trip ended with us pulling off on the side of the road.  "We're here!"  Mom was expecting a colorful Tourist Welcome Center, or at least a giant "You're at the Equator" sign, but the modest metal globe-shaped sign with "Equator" painted brightly on the side (under the acknowledgment of the Lions' Club sponsorship) was all that was there.  We stood in both the Northern and Southern hemispheres at the same time, snapped some photos, and decided to head on.

Josh called Philip, who called another friend, who called someone else to confirm She was home.  Standing in the checkout line at the Nakumatt last week we'd heard a woman from Minnesota blab about meeting "Grandma Sarah," and after asking around, we heard she received visitors - frequently numbering over 200 per day.  She indeed was home, so we headed further out.  We found our turn-off, asked for directions, went down a dirt road, asked for more directions, turned, and asked again.  Everyone knew where to point us, and as Josh always assures us, we found our way.

We arrived to find the place fenced in, with an iron gate at the end of the dirt driveway.  The sign said visitors Monday - Saturday only, but after some smooth talking, Josh convinced the one guard to let us disturb her day of rest.  We signed in the log book under a couple from Iceland from the previous day and walked up the dirt path.  We found Grandma Obama sitting with two other gentlemen under a giant tree to shade the circle of about 20 wooden chairs.  The two men left, and Mom, Josh, and I were the only three in her company.  She spoke only Luo/Kiswahili so Josh translated well.  She described how "our President" came from a "bad" background and pointed to the graves (and headstones) of President Obama's father and grandfather about 30 yards to our left outside the circle of chairs.  She joked about her trip to the Inauguration and the giant size of our country.  She described some of her projects, including smart farming and sponsoring about 20 orphans through secondary school.  On the way out, Mom had to / asked to / was honored to use her restroom, before the two-hour ride home.  Ha!

Mom was beaming the entire way home.  What a day.

This morning's rounds with Dr. Allibhoy proceeded as usual.  He's a busy man, taking care of complex tropical medicine cases, patiently describing diagnoses and prognoses to families in multiple languages.  He is assisted by some of the in-house "residents," but his status as an Attending leaves him with much of the work and definitely the responsibility.  Today's interesting cases included 1) a patient with acute renal failure, likely from HIV and not the malaria as originally thought, 2) an intra-cranial hemorrhage in a young woman with left-sided hemiparesis who will need to be transferred to Nairobi for MRI technology and neurosurgical consultation and 3) miliary TB.  The x-ray on the latter isn't something to be learned in "real life" back in the U.S. - it's only in textbooks.  She's on four-drug therapy, clinically stable.

The uprisings and political demonstrations north of us look to be spreading.  First Tunisia, now Egypt, Algeria, and Yemen.  Our local paper today states Egypt blocked Facebook and Twitter, because of their use in spreading the word organizing protests and the crazy ideas of democracy.  But the proxy servers circumvented these blocks.  So they just decided to cut out the entire internet.  Egypt cut off from the rest of the world - unimaginable.  Al Jazeera confirmed a lot of this, saying roughly 90% of people are without internet service now - including schools, hospitals, and banks.  The media company is also having its radio and TV broadcasts blocked at the moment.  A "mega protest" is apparently planned for tomorrow in Cairo.

Libya is apparently next.  And maybe even Syria.  In light of this news, my chances for planned R&R in Morocco next week are starting to look slim.  We're paying close attention to the reports, so we shall see...

Asante sana.