Rafting and ward rounds…

Only one intern turns up for the ward round. The others are going to be in a sticky situation…  As predicted, consultant Dr Chapi returns the following day from his annual leave, and we are in for a shock – 5 hours in and still standing. Truly a feat of endurance – ankles swell, dry throats shrivel, eyes count frantically ahead to check number of mothers left (larger and easier to count than kids)…dismayingly there are 9… will I make it to the end without falling over?. Happily I am excluded from grilling, but everyone else gets it in the neck re protocol, proper (in his defense he is obviously a very kind man, and a very good doctor too). 11 o’clock is bread time for the mothers, and the tea bucket comes round too (sadly this passes us by); 1 o’clock is visiting time, and there is always a big queue of people waiting at the main gate – they are scanned in by the security guard (not sure he’s really necessary as most of them are only carrying rice and bananas - the only time he really comes into play is when a matatu arrives carrying prisoners to be seen in clinic. All in stripy pyjamas, and dresses for the women).

Lewis is a patient with severe malnutrition – so listless and sad, and he’s in a shocking state – completely skeletal. This is marasmus- severe wasting due to total calorific deprivation, as opposed to Kwashiorkor (which is protein deficiency – here the baby is usually oedematous, which can confuse the diagnosis). Another mother brings in her baby with measles – he was never immunized as she wasn’t able to read the record card. A few cases of rickets – soft fontanelles and widened ribs. All things that I would never see in the UK. It’s so difficult – the medicine is completely sound, but so often compromises have to be made  due to frustrating circumstances - poor quality xrays, lack of proper nutritional support, multi-drug resistant cases, missing lab results, mothers unable to pay for treatment. One girl is admitted to the acute room with a new murmur – she is pretty poorly and in heart failure. I thought there was an ECG machine here, but she will have to go to Nairobi for this. Dr Chapi rocks up and summons us to a departmental meeting (I have the feeling this has a lot to do with the ward round) - this time I am asked for my opinion, too… It is the end of my time on the paediatric ward, and I am sorry to finish.

I go on a home visit with the palliative care team – there are 6 of us in total, including a pastor and 2 nurses. Palliative care is mostly free in Kenya (unless patients are able to give a little for the more expensive drugs) and should be given ‘regardless of race, gender, tribe or religion’. The team’s caseload consists primarily of cancers, heart diseases and HIV. We drive out towards Meru in the back of a small van – during the ride the pastor ‘amuses’ us with the story of a patient he followed, who had a curse put on him by a women claiming he had stolen her chicken. (An ultimatum of 6 days was given for the chicken’s safe return, but since no bird was forthcoming the man mysteriously dropped down dead.) Wey! Sinister indeed. The son of the lady we are going to see waves us down on the road and leads us up the track – it is very green here with many shambas and steaming charcoal mounds, which are kept burning continuously for several days. The house is a simple wooden shack under a mango tree, and we sit outside under a bower of bourgainvilleas next to the fire place- it is very smoky. Joy Betty is the patient’s name, and she has a squamous cell carcinoma of her right cheek, which is extremely unpleasant for her, and painful (she first noticed the pain when chewing sugar cane, and has since been given radiotherapy and a blood transfusion without being told of the diagnosis – understandably this has been very upsetting, and expensive too). She is only 53, but has aged considerably – Summi the son (who is her primary and only carer) shows us the family photo album, and she is almost unrecognizable. The team are excellent and we spend nearly 3 hours with her providing counseling, cleaning the wound and prescribing drugs and adequate pain relief, before the pastor and Joy both say prayers and we leave. The team will return on Monday with a mosquito net.

Early morning sight of Mt Kenya on my run, wow. I do a ton of laundry outside, bucket style, and watch moles in the garden (at least, I can see the top of the soil moving and hear them snuffling – as soon as they realize it’s me they reverse down the hole, gutted.) We are having very heavy rain at the moment, with long evening powercuts (the hospital does have a generator which can back up the whole system for 24 hours, fortunately!). Phyllis and Easter arrive and tell me about the earth tremor this morning at 5am (4.6 on the Ricter scale, apparently!) – not that it made much impression on me at the time… I’m still learning Swahili, and inflict morning practice on the night watchman (he lives just below the house in a shack which he has built himself) – ‘habari yako’ – he replies ‘nzuri sana’ (‘sana’ is an affirmative, like ‘very’).  Sawa sawa. (Incidentally, the wise monkey’s name ‘Rafiki’ from the Lion King means ‘friend’).

I pass by Nyambura’s cake shop on the way into town to say hello. She’s got several demos on display – one is a wedding cake in a traditional pot shape (this must never be cut by the bride), another is a basket. The bride would also be given a wooden spoon – all symbols that she will go to the market and cook good meals for her husband. I am earlier than usual at the rescue centre and Lillian is making uji for the boys for when they finish football training (it is the school holidays so sessions happen most days) - she keeps some of it back to ferment for the next day’s mixture. The boys have all lost their spoons so githeri has to be sucked from the plate – too hot to handle. I am sent to the market for onions and sorghum (with one of the boys for protection – this is the big market which happens twice a week, and is very busy!), and manage to get some photos, too. Later, against good advice I attempt to cook omena – these are tiny dried fish similar to anchovies found in Lake Victoria which you can buy cheaply in the market (this should have alerted me) – they are really bitter and I have to pick them ALL out. How disappointing. Mama Whyella (who briefed me on the omena recipe) sells bags of fresh milk from her cow every evening at about 6pm (for about 30p) – this has to be boiled (the skin is very thick) and is very nice.    

 

I would have thought the mzungo joke would be getting old now, but no luck. I pass by and a wave of laughter usually follows. Takes a bit of getting used to!

This weekend I travel to Sagana with Charlotta to go whitewater rafting on the Tana river! The campsite takes all sorts, so it’s funny to be back in the company of mzungos – lots of ex-pats (with African nannies) which is quite interesting! And many English-speaking dogs too. We have our own shed, complete with resident gecko. There are pepper and guava trees (their bark is very smooth), and the river runs alongside, brown and sludgy – beware of the hippos, and crocodile, allegedly (it may just be a very large lizard) – but there is a long swinging rope bridge to take you safely across. A local wedding, traditionally flamboyant with about 30 pink bridesmaids, rocks up with the photographer, and we are both summoned to join their photos. David the cook makes us fishing rods with a stick and length of catgut, and assures us that we are very likely to catch large catfish in the river here (for lunch) – we try for an hour with a combination of old goat (meat) and soap (apparently they like the smell) but no luck. The one that took my bit of soap was HUGE, though. The rafting is INCREDIBLE!! In between HUGE class IV & V rapids with 4 metre drops, giant waterfalls, and rather a lot of action swimming (in so called ‘Devil’s Toilet bowl), we cruise past the most BEAUTIFUL landscape. Giant palm trees are hung with 20 or 30 weaver bird nests (small and incredibly neat bundles with a perfect circular hole at on end at the bottom (rather like an upside down pram – it is the males who make them, and if wife does not approve she drops it into the river, how upsetting), there are black and Egyptian eagles, ‘blueball’ monkeys, white ibis, purple agrets and darters, black fluffy flycatchers. Plus trees with giant woolly roots, river melons, hairy pineapples. Happily no hippos today. Local boys fishing seem to be having more luck than us with our soap. Just amazing.

How many people can you fit in a matatu?

23, it seems, plus a chicken or two, and plenty of plantains. They’re really not that big inside, so this is impressive. .There’s a police presence on the road at the moment, as the main road to Meru is being used by Somalia people travelling across the border. Today I see some sights, with Jackson as my tour guide (a local boy). We climb Kawue (a bizarrely-shaped conical mountain used for radio signaling) – the route passes through farmland and coffee plantations and finishes with  a long steep climb, HOT! – but at the top you can see for miles around, including an impressive cloud formation concealing the summit of Mt Kenya (ah well!). People come to pray here, as it is so quiet. On the way down I meet my first chameleon, he is yellow and black striped, including his eyes. We catch another matatu to a stunning waterfall (and there’s a cave too, full of giant moths). The soil is SO lush here (the redness comes from the ‘laterite’ clay which is heavily enriched with iron and aluminum, due to the rainfalls and intense heat) and we poach a couple of guavas for pudding. Weaver birds make their nests here as circular bundles which hang from the banana trees. Later Jack takes me to his Youth Cimate change meeting, this is a very enthusiastic group who have already set up several local projects, including a plastic bag recycling scheme, and the planting of sukuma.

Paediatric clinic – usual amount of noise coming from waiting room. Most are here for follow-up, a few are suffering from white-coat syndrome. I cut out the cardboard tickets which are given out for the date of next appointment. Interestingly, rickets has a surprisingly high prevalence in this area of Kenya – research is underway to investigate the cause, as no-one seems to know why… (Also, the risk for a Kenyan of developing a cancer is considerably lower than in the Western world (although prevalence is on the rise, probably as more and more of our culture creeps in) -  this is thought to be due to the diet here which is very low in fat and high in fibre (beans beans beans!) - long may it continue).

I boil arrowroots for lunch – sweet, with a mottle white & purple flecked inside, to be dunked in chai (as with many things!). You can also eat them with fermented milk, or ‘mala’ – this is a bit like sour yoghurt and is thought to be incredibly good for you (which it probably is! - probiotic central). The masai make it with cow’s blood and urine and leave it for several days to ‘mature’ in a galabash (gourd). If it works for them… (One can even go the whole hog and ferment the ugi porridge, although Gilbert assures me serving both together would be overkill).

Sofi plaits the top of my hair as an experiment to see if it will hold, she is generally unimpressed as it is far too soft and she has to pull it extremely tight, ow. She also calls me ‘baby face’. I’ll try not to mind.

I am joined for early morning aerobics by Charlotta, a german girl who is spending time at Toto Love. I’m sure I lose half my body water each time – I feel dizzy for the rest of the day. We are a comedy-duo running home, and acquire several co-runners. (‘Hello I am fine’ is standard greeting– bit confused? but friendly at least).

Sunday is church day, and the music and drums start early and go right on through. Everyone is in Sunday best. I walk to town to meet Coach Summi and the Black Cats – today is an away match against Kuayambora FC. No worries, we’re confident. Summi has hired an open-top truck to take the whole team plus supporters – its an hour’s drive and the speed bumps make for a interesting ride! I am the team photographer, but progress is impeded by my welcoming crew – who follow me across the pitch and round about. A mzungo is a good afternoon’s entertainment, although it’s very friendly. Anyway, I’m glad when the match kicks off. Two tense halves, it’s hot and dusty, and the refs aren’t playing fair… Big pep talk needed at half time. BUT: the boys play well, and final score stands 2:1 to Black Cats!  It’s nearly dark as we drive home – this time I sit up front (dunno what’s more unnerving, being able to feel the bumps or see them coming!). We are treated to an incredible view of Mt Kenya (finally, my first!) – it has the most amazing rocky profile, and you can see the twin peaks of Batian and Nelion. A flash of lightening forks right through the sky away from us – the storm will come to Embu later.

PS. I will try and upload some photos of the hospital soon, I’m just biding my time with the camera!

Kangas and 'Passion'

Ward 10 is especially busy as the new interns have started, and there is a rather fierce Medical Officer supervising the round who lectures us on the importance of protocol – luckily I am the only one who does not have a copy of the required text and therefore cannot be expected to know anything…  Plus I am distracted by the sight of a monkey out of the window! My name is so frequently misheard as ‘Joy’ that I am no longer bothering to correct people – it’s quite a nice name, and thoroughly approved of, so that is that. Lots of the usual pneumonias and malnutrition. Owing to the ‘cold’, the children are firmly inserted into thick flannel trousers, with thick woollen jumpers and balaclavas on top (still feels like vest-top weather to me though). There is the usual cocktail of medical abbreviations used by the interns, but they are different from home – for example, ‘hob’ means ‘hotness of the body’, for a febrile patient – easy! Old coke bottles are used to measure out the milk quantities and other medicines - for patients with malnutrition, a formula ‘F75’ or a stronger ‘F100’ is often prescribed – this is a replacement feed consisting of vegetable oil, dried milk powder, sugar and water, made up to a ratio. 

I am getting used to being a general source of amusement, for the mothers at least – most of the small clients take one look at my mzungo face and burst into tears. Definitely not making any friends, especially when I have to take bloods and skin pricks (for malaria). (The blood this morning is not successful – the plastic glove fails massively as a tourniquet, femoral vein empty, patient cries, mother cries = traumatic). The lab here manages to churn out results which is impressive considering what we send them – the malaria screen requires a blood smear on a glass slide (of which you carry several in your pocket, along with a few needles) – this is labeled up with a bit of the omnipresent plaster tape, waved to dry (a lot of blood takes a LONG time), piled up (TOUCHING) with the rest and trotted over for a look under the microscope (if it’s not misplaced on the way). Blood films, as with all other investigations must be paid for (the main price list can be found next to the hospital sign on the main road) – a bed for a child costs 500 Ksh per night, and the mothers must also pay PER cannula and giving set - you pay at the patient cash desk. Receipts kindly have written at the top ‘wishing you quick remedy’, nice. The hospital is a ‘corruption free zone’ (signs to remind everyone of this are dotted everywhere) – there has been a problem in the past with doctors taking money privately (and many doctors here do seem to work 24 hours per day, government paid by day, private by night) but this is changing now.

I spend the day at the ‘CCC’ clinic – this is the ‘comprehensive care centre’ for HIV positive patients, who come fairly regularly to have their CD4 counts measured, and to receive vitamins and antiretrovirals. I sit with the nutritionist and we measure each patient’s height, weight and BMI. (There is a horrible cycle of weight loss associated with the disease which lays the patient open to opportunistic infections and reduced immune status – this corresponds to a reduced CD4 count etc, etc…) so it is important that patients can be counseled on the importance of good nutrition  (for the overweight as well as the under!). It is a busy clinic – 52 patients in the morning alone. A US-AID programme provides the means for ‘Feeding by Direct Prescription ’for patients whose BMI is less than 18.5 – this is ‘unga’ (flour, reinforced with vitamins and various cereals), and in especially severe cases, ‘plumpy nut’ (a ‘ready to use’ food recently developed by the owner of ‘Nutella’ which has been very effective in cases of 3^rd world famine – it’s a paste made from peanuts, veg oil and powdered sugar and milk – each packet delivers 500kcal and can be easily taken ,even by children). Sadly, a surprising number refuse to accept the prescription, there is still a huge amount of stigma and many do not disclose their status even to close family members.

Horror of horrors – a mosquito INSIDE my flippin net. He eats me for breakfast, and I can’t find him, squash him or do anything about it. The buzzing enters my dreams… The next night, THE SAME. There is obviously a campsite somewhere. Not cool. My back is MUNCHED.

I am learning to cook African style – Ndengu (a green gram bean stew with milk), Ugali, Mathukoi, Githeri. Phyllis (a competition winning Chapattis maker) and her daughter Easter teach me how to make PROPER chapattis (only problem is the final step requires a cast-iron chapattis pan and a fire, neither of which I will be able to lay my hands on at home). You make the dough with sugar and salt, then the chapattis are twice rolled and recoiled like a snail and left to rise, before dry frying in a stack, and finally refrying with oil. They fall apart in your hand, and should be eaten hot with a cup of Kenyan chai (made with a bag of fresh cow’s milk from the neighbour, and sweetened with sugar, tea masala, and cardamom).

The rainy season has officially started and there are frequent powercuts in the evening. This in combination with the fact that the laptop gives me frequent electric shocks (the ‘q’ key is especially problematic) does not make for peaceful facebooking... Instead I am reading ‘The Flame Trees of Thika’ by Elspeth Huxely – an autobiography of her childhood in Thika which is not far from here – lots of it is familiar! Bats here also squeak in the roof at night which is nice.

I make the mistake of ordering ‘passion’ at Morning Glory cafe (this is passionfruit juice, in case people were wondering!) – halfway down the glass I have a sense of misgiving (actually the misgiving happened quite quickly but I couldn’t be rude). Next day – raging headache and temperature. The hospital beds look pretty inviting, but I make it through the morning without hitting the floor, and all the way back up the hill to bed where I pass out for the next 4 hours. Let that be a lesson!

It is a long hot walk to town, but I stop at the rescue centre, where Lilian feeds me githeri. We shop in the market for Kangas (these are the beautiful African cloths  which can be used for anything – as aprons, skirts, for carrying shopping, children…) The market is fascinating and has a hundred tiny alleyways selling salts, beans, rices, spices and anything else you can think of. It’s good to be with Lilian who seems to know pretty much everyone. We buy avocados and tomato fruits (they are extremely like tomatoes inside!).

Drawing is the name of the game at Toto Love today, but my stethoscope is pretty fun too. The children here have to wake up at 5am to take their antiretrovirals (the side effect profile of these is nasty which is why most have to be taken with food – the problems start when the food is not available…). I meet Scooby the dog who also is resident here – he has nice ginger eyebrows.

Thankfully the tsunamai alert for the Kenyan coastline has been withdrawn – the waves were due at 8pm but no show. A bit frightening!

Matoke & Mangos

My days start at 5.30am with a morning jog down to the Embu town – there is an aerobics class at the ‘gym’ here, Kenyan stylee! A free banana for all after class. I run past eucalyptus (you can smell them for miles) and Embu’s famous Jaracuranda trees, a bit different from my usual route! Definitely harder here too as the air is thinner. There is a swimming pool within walking distance – a bit of a Westerner’s haunt so pretty luxurious and deckchaired-up. I am trying to learn Swahili, and also photograph the yellow Weaver birds in the garden, this has not been a success so far (although the local cat seems to be doing alright at catching them).  The Easter weekend is a public holiday, so no hospital – I don’t know this means for the in-patients, but there’s certainly not going to be any ward work.

I go with Gilbert to visit his mother who is a farmer in the rural highlands –the land here is extremely fertile and is divided into shambas (small-holdings) of coffee, bananas, papayas, and at higher altitudes, tea. Agricultural communities here are primarily from the Kikuyu, Meru and Embu tribes. The road to Meru is beautiful and hilly, with so much lush vegetation and waterfall (and speed bumps! – best to follow the Matatu drivers who know where they are). It has rained so hard this morning that as we turn off the last long stretch of track is almost impassable, but luckily we arrive in our borrowed car! There is a recent burnt patch on the road – here a man was set alight for taking a machete to his wife. She owns 25 hectares of land and is managing to grow aloe vera, tomatoes, and tobacco, as well as the usual banana/coffee set. There is also a cow and some friendly goats, a fish pond, space for developing a paddy field, and several mud ovens for firing the clay bricks pressed in this soil. It’s a fantastic place, and the sun is mysteriously concentrated by the clouds here (maybe it’s the altitude) so it’s extremely hot. There is a small diesel mill (there is no electricity out here) for grinding maize, so other farmers can bring their own flour for a small price (everyone here works the land, and it feels much more remote than Embu). We eat ugali and sukuma and beans, all from the farm, and Gilbert’s younger bro fetches us sugar cane – you chew it and swallow the juice, amazing! More incredible flowers (one tree with white flowers is snapped off and a milky sap literally pours from the stalk – apparently this is a good wound healer); and a giant turquoise butterfly which moves too fast for my camera. In the car boot goes a stem of green bananas; they will ripen within 3-5 days if a teaspoon of salt is pressed onto the cut end. Today is Good Friday so we drive back via her church, where the procession for ‘The Way of the Cross’ has just arrived. Long-drop loo stop. The church is packed today, and we stay for a bit at the back. It is a lovely building, and all the African saints are painted around the walls. The first sermon is in the local language (I’ve got no chance) and lasts 20 minutes; the second is sung and lasts even longer!

The drive back is a bit tense as we are very low on petrol! We stop at Gilbert’s older brother’s house – he is an English teacher, and his 6-month old daughter Lititia is extremely cute and happy to chat. Proper sweet Kenyan chai and mandaazi. A cousin shows me the tea plantation – it’s almost ready for harvest (the top two leaves are picked along with the bud; these are sent locally to be processed). There are also coffee bushes, which are ripe when the berries are red, AND macadamia trees – amazing! Cousin climbs a mango tree and throws them down ‘for the road’ – you peel them with your teeth.

Easter Saturday, and everyone is invited to a local wedding between an Embu man and a girl from Australia. Service due to start at 10am, but TIA (‘this is Africa’) so it’s after 12 when the bridal car arrives. A group of hired women greet the bride and process the last section of road with her, singing and dancing and waving ferns. Great voices! The floor outside the church is strewn with fallen bougainvilleas – instant confetti! The wedding reception takes place in the field of a local college – there are white tents set up, and a catering company manages to feed the whole crowd with a beautiful African feast – Irio, matoke (a green banana stew), chapattis, pilau, and piles of melon. Entertainment comes from the Women’s Institute from Stephen’s (the groom) village, who sing and dance dance dance, pretty awesome. Slightly embarrassing as being white I am assumed to be a honoured guest of the bride and am insisted to sit at a table for shade and special treatment – I did try explaining that I had only met her that morning!

I can hear the drums from the church for Easter Sunday which go on all morning. There is a TV at the house too – hymns are being broadcast by Her Excellency the First Lady’s State House Choir. At the bottom of the hill is an orphanage for HIV positive orphans, called ‘Toto Love’ – there are 19 children at the moment, and the youngest is one. They are absolutely gorgeous kids, and I am properly welcomed and beaten up, my watch goes AWOL. They know a surprising amount of Christmas songs! (and more of the words than I do). Really a top place, gonna go back tomorrow.