|faces of FACES|
Monday, April 30, 2007
Sunday, April 29, 2007
[FACES Kid's Club - older kids posin on the staircase]
It is astounding how much HIV clinical care has expanded in
You can read an article about the AMPATH program in Eldoret here: http://alumni.indiana.edu/magazine/kenya.shtml
Imagine providing HIV management and treatment in a place without roads, electricity or clean water. It is still like that in many places. But now these places are remarkably better staffed, better resourced and are seeing 10 to 20 times the number of patients. The Kenyan government has trained young medical officers in ARV management, and now Kenyan 20-somethings are running HIV clinics with 10-20 staff and managing huge public health programs. I’ve never witnessed such rapid development and growth in healthcare. And I am fortunate enough to be a part of it.
Back in early 2004, the AMPATH program in Eldoret had only a couple thousand patients involved, and only a small fraction of those on ARVs. We were just beginning to roll out Triomune for free or heavily subsidized rates. Of all the people who needed to be on ARVs due to advanced HIV disease, less than 1% of those people were getting it. Now AMPATH is serving 33,000 patients, runs several children’s programs and innovative farm-based nutritional and micro-enterprise programs. In
I will visit Eldoret and the AMPATH program at a more rural site called Turbo at the end of this week. It’ll be really interesting to see how much it has changed.
FACES (Family AIDS Care and Education Services) is the clinic where I am now working in Kisumu. First, I should note how great it is to work at a place where people are incredibly welcoming and happy that you’re there. It creates a much happier, positive work environment. The staff at FACES seems to naturally create a constructive work community. Similar to AMPATH, FACES started with a partnership between a Kenyan medical site in Kisumu, and a US-based institution. In this case, it was the CDC and UCSF Ob-Gyn program. They had started with PMTCT (prevention of mother to child transmission of HIV) and microbicide projects, and then expanded their clinical care to include one of the biggest glaring health needs: HIV clinical care for adults. This is where the UCSF ASPIRE and internal medicine residents (like me) step in. We can actually be helpful in training folks here to manage complicated adult HIV cases.
Their family-based model is great in involving whole families and encouraging everyone in the family to be tested and treated as needed. It is much more holistic than dividing families up into internal medicine, pediatrics, and ob-gyn. It also includes home-based, hospital-based visits by staff, nutritional supplementation and counseling, as well as programs such as “Kids Club” and “Family Empowerment” workshops. [I attended the most recent Kids Club yesterday and got some really great photos and video of the kids. It’s not hard to get great pictures of kids- they love the camera. I’ll post some up.] FACES also has an integrated lab and pharmacy, so patients can get all these services on site, rather than having to trek around town to get blood drawn and their medications. The approach is so much more comprehensive than most of our out-patient clinics in the
The FACES clinic in Kisumu started out in September 2004 with just a few hundred patients and now sees over 4,000 patients, most of who are on ARVs, including children. It is truly inspiring to see how far HIV care in
I’ve seen patients for three clinical days during my first week at FACES, and already I’ve initiated (alongside a clinical officer) several people on ARVs, diagnosed ten or more smear-positive malaria cases, managed people with extrapulmonary TB on ARVs. I’ve seen with Liz and Everia (a Kenyan FACES clinical officer) a young man stumble into clinic with left-sided pain and weakness and treated him for presumptive toxoplasmosis, a parasite that can create masses in the brain causing focal neurological deficits. I see about 20 patients a day… and I’m relatively slow! It’s a very very busy clinic. And amazingly, despite my newness to this clinical site, I feel helpful: seeing patients and helping clinical officers think about the differential diagnosis and treatment options, assisting with paperwork and getting the patients the treatment or investigations (labs and studies) they need.
You can read more about FACES at their website:
I also have a number of projects that I created for myself and have been assigned to do by the rotation. Because the clinic is so busy, it feels a little crazy to add so many things on top of the clinical work. However, it is the diversity of my work that keeps me engaged. I think I would go crazier if I saw patients from to every day without other work projects going on. This is not news, but I am once again confirming that I need a wide variety of creative, clinical and program/systems-level projects to keep me happily and actively engaged with work. Here’s my current list of projects, in rough order of what I personally think is most important. Pole, sorry, it's like showing you my to-do list, but at least you get an idea of what I'm doing here. You’ll hear more about them as they develop:
1. video documentary on capacity building and training at FACES (my own gigantic project)
2. the faces of FACES staff photo book (my own project)
3. CME (continuing medical education) session on HIV and pulmonary (lung) diseases
4. mentoring clinical officers and nurses
5. organizing the rotation for future UCSF residents with proper orientation materials and resources so that they are useful and get the most out of being here
6. less formal educational workshops for clinical officers; i will do one on a subject they choose
7. journal club (not my favorite thing to do because it is highly entrenched in academia, but it has become part of the rotation)
8. developing sections in the clinical officer handbook; i will likely tackle sections on HIV and pulmonary disease, diarrheal disease (my personal fave!)
Somewhere lodged into this list is the clinical work of seeing patients. I can’t decide how to prioritize that because it always becomes a priority once I commit to seeing patients on certain days. I’ve decided to see patients for at least 3 days a week and spend one full day and some half-days on my other projects.
Yikes! It’s a lot to get done in the next 3 ½ weeks. Time here always goes so quickly.
[photo: me, baby Shawn, and mom Triza, who is also the pediatrics medical officer at the Nyanza Provincial Hospital]
*adjusting to life in Kisumu
I intended to have a restful first weekend in Kisumu. I was finally able to chill out after my long journey and busy tourism in
But it was poa (cool) because I was able to meet up with my friend Kibachio, who happened to be in town for a Kenyan Medical Association meeting. He now is a Medical Officer in the provincial
I spent the next few days incredibly jetlagged, probably the worst I’ve ever been coming to
*Kisumu is big and diverse
Kisumu is a big city. Way bigger than I remember Eldoret being. The largest market in western
If Liz wasn’t here for my first week in Kisumu, I would have gotten totally lost going to and coming from work every day. There is so much construction and craziness downtown that it makes it all the more difficult for a directionless person such as myself to get her bearings.
We walk 3.7 km each way to the FACES clinic. I know because I took a taxi home one day and watched the odometer. Amazingly, the whole way is paved with nice asphalt. I really feel like I’m in a big city because of this. The walk would not be so bad, and in fact is mostly pleasant and allows us great exercise, except for the fact that you have to cross (unprotected) an undivided highway to Nairobi and walk on rocky dirt patches in order to avoid being hit by a swerving boda boda (see below) or a speeding matatu (privately-operated “public” transport vans). The roads are quite busy here. You have to share it with a wild medley of transport forms: people, carts carrying huge loads of petrol, carts carrying huge loads of chickens or furniture, boda bodas, bikes, matatus, tuk tuks (three-wheeled gas-powered covered vehicles for hire as a cheaper alternative to taxis), taxis, large buses, construction tractors, trucks crammed full of people in the back, trucks crammed full of various other goods, and oh yeah- cars. And of course there are no real traffic signals.
I’ve seen few mzungus here, relatively speaking. I see them mostly at the fancier stores and at the CDC. It’s nice not to be in a heavily tourist city. I even met a crew of four young men from
There is a huge South Asian population here, and the cottage I am staying at is in the upper-class neighborhood of Kisumu, called Milimani. Most of the families here seem to be very wealthy black Kenyans as well as wealthy South Asians (South Asians here tend to be merchants and owning class). Despite the obvious class schism, it is nice to have different cultures represented strongly here. Plus, it allows me to go out and get lots of yummy South Asian food ingredients, and buy delicious samosas, dal and dhosas for lunch.
As Kisumu is quite cosmopolitan, it also has a bigger diversity of tribes represented here. Despite the large Luo majority, the businesses and NGOs here have attracted folks from tribes all over
*boda boda phenomenon
There is a new mode of “public transportation” in
My pimples are gone, my color has returned, I walk 4 miles a day at 1130 meters, swim 20 laps every day, take most of my weekends off, work almost normal hours at clinic, and cook almost every meal. It’s amazing what a more relaxed culture and work environment will do for you.
Alas, my GI tract has become immunologically oversensitive and wimpy from being in
Needless to say, on Kenya Day Six, I started having bad intestinal cramps and gas. Lovely, especially during clinic. The loose stool started on Thursday, Day Seven. I am proud at least to state that my GI system is at least strong enough that I didn’t develop the full traveler’s diarrhea of awful cramps and 10 stools a day. However, I was hoping to stave off the antibiotics and condition my GI tract more (don’t want to contribute to fluoroquinolone resistance!) but after three days of cramps, gas and gnarly loose stool, I decided that it was time to break out the cipro. Sure enough, twelve hours after taking the first dose, I am gas, cramp and loose stool-free. Yay!
Sunday, April 22, 2007
I had a very typical foreigner-in-Kenya entrance to
My taxi driver, Francis, was a very interesting young man. In addition to driving his (licensed) taxi, he works for a Kenyan pharmaceutical company which was apparently doing trials on an HIV immune modulator. He spoke about wanting to go back to school in order to go to medical school and eventually become a doctor.
I then embarked on another very Kenyan experience (though middle-class Kenyan, as it was quite safe): a hot, dirty, bumpy nine-hour Easy Coach ride from Nairobi to Kisumu on very broken roads. It felt a little crazy doing this after an eight-hour overnight flight from
I arrived in Kenyan time at the Kisumu Easy Coach terminal: two hours late. I had scared Vero, our wonderful Kisumu-based UCSF/UBC liaison, earlier when I didn’t call her till I reached Nakuru. She was afraid that something would happen to the lone foreign female traveling by bus from
Happily Vero and Liz helped me with my luggage into the clinic van, and drove me straight to the cottage that I am staying at for the next five weeks. It’s gorgeous. It’s tropical. It’s perfect. The woman who runs the cottage compound, Mrs. Pabari is a Turkish landscape designer. You can tell. She has an immaculately maintained tropical garden with plentiful flower and vegetable patches, koi ponds, frog ponds and a naturally heated lap pool. Not only am I in this lush natural setting, I also have a home with hot water, plumbing that works, electricity, and –get this- speedy internet access with an ethernet connection.
The only thing tough about this place is 1) the bugs, including mosquitoes and 2) the immense racket that the nighttime animals make. The random outbreaks of hornbills, bullfrogs, dog barks and howling contests keep this jet-lagged insomniac wide awake at night.
What’s gross? Ants one-inch long invading your home.
What’s grosser than gross? Killing a large ant and finding a swarm of smaller ants eating and liquefying its body within 5 minutes.
Friday, April 20, 2007
Thursday, April 19, 2007
(photo: Hyde Park's Diana Princess of Wales Memorial Walk)
Last night I met my new roommates: two graduate students from Brasil, one in a film program in
I spent the day not rushing to get into subway trains. I made it to the Camden Market, the Inverness Market and the Camden Lock Market, which are all in the same neighborhood. It was huge. And it was hugely repetitive, sort of like the markets in
I went to Harrod’s next. I felt like it was necessary to visit the world’s largest department store. This was a dubious honor, but I was curious, and had not been inside of any of
Today my luggage went through a multitude of transformations, from the moment I got up and dragged it all down the 3 flights to the Ace Hotel lobby and devised a way to use my laptop cable to lock my documentary studio (i.e. my laptops and video camera and equipment) to the soda vending machine. I returned from the above described last-day journeys and found… whew… everything still there, untouched. Although I must say that traveling with my most expensive possessions (my laptop) has made me think about how I would feel about losing everything. Mad at myself, but fine otherwise. Being mad at myself is definitely the worst. I had been dreading dragging everything to the Underground Station again at
Now I am flying over the
Wednesday, April 18, 2007
(photo: Omygod! They're REAL mummies! - British Museum)
I was attacked by an Underground train today. I got off the verrrry loooong escalator at
But that was nothing compared to my next scare: loose stool!! Aiiieeee! And at the
Aside from those happenings, today was primarily a Squeeze-as-many-interesting-museums-u-can-see-in Day. I took full advantage of my all-day Underground pass and went to the:
-Tate Modern: the best part of this museum was getting dismantled in the massive Hogarth room: a gigantic steel spiral tube slide for adults made by an artist whose name I can’t remember. I almost made it through the museum, when they closed off what turns out to be the best part of the museum: Guerilla Grrrls and a few people of color artists (!!). I was so museumed-out at that point that I did not have the patience to meditate on the colour fields of yet another Rothko painting.
I have managed to eat only ethnic minority foods here. My bowels are grateful for sparing them the repetitive fish-n-chips experience. Yesterday night, ramen. Today’s lunch: bi bim bop (that’s right! There was a bi bim bop and kim bop shop next to The British Museum!). Today’s dinner: Maoz Vegetarian falafel sandwich on whole wheat pita and fresh veg toppings. And British chips. It came with the meal. I was only able to finish half of those butt plugs.
I had wandered into Picadilly and Oxford Circus to check out the shopping scene. Not very interesting, considering that the only store I wanted to see: A Bathing Ape (Bape), closed 20 minutes before I showed up. Instead of shopping, I stared at the black and Asian dudes closing up the shop. They stared back with blank faces. They’re really cool. I guess Londoners are not late night shoppers like New Yorkers or East Asians. Shopping all seems to close down by about .
That was OK. It turns out I was pretty pooped. I fell asleep on the Underground ride back to the Ace Hotel, much to the amusement of the British dude in an office suit staring at me from across the way. Ew.
Tuesday, April 17, 2007
(photo: V&A's Uncomfortable Truths exhibit)
I’ve been in
I also need to get accustomed to
After my 11 hour, cramped up uncomfortable flight sitting next to the squirmiest big British man I’ve ever met, it was nice to roam free. I thought I’d have the risk of crashing out, but I guess residency has trained me how to walk around like a zombie and pretend that I’m functional when I’m really not. So in the ten hours after I got to
-Victoria & Albert Museum (now renamed to the hipper acronym of “V&A”): i wanted to check out the Uncomfortable Truths exhibit by artists of the African diaspora to acknowledge the bicentennial of the British abolition of slavery (in the traditional sense, though one can argue that slavery is not really gone, just reconfigured into other forms of racism and economic oppression). Their pieces were cleverly interspersed throughout the colonial and imperial artwork to remind everyone of how slaves have had a huge part in making the lives of the owning class work… and allowed them to own huge treasure troves of stolen artwork. This allowed me to run through a majority of the museum. One of the more direct series was by Lubaina Himid (Naming the Money UK 2004), where she made life-sized painted figures of slaves or servants from history and placed them in the frou frou chi chi bedroom, foyer, dining room, ballroom, etc. setups around the museum. On the back of each figure is how much the person should have been paid for the services s/he rendered. Smart.
-On a whim, I stayed on the Piccadilly Line towards Cockfosters (yes, Cockfosters. The Brits evidently don’t find this funny but you can always spot English-speaking tourists because they giggle every time Cockfosters is announced overhead). I vaguely remembered reading about getting half-priced tickets to see British theatre. Unfortunately, I didn’t remember the details about how to avoid getting scammed, so there I was, in the Leicester Square Underground Terminal, getting scammed. Sigh. I sooo hate getting scammed. Only, this one was pretty convincing- it was an official looking store, with a computer system, lots of seals on the wall proclaiming the outfit to be part of all sorts of accredited theater programs, blah blah. And the guy was pretty convincing. I wanted to see Billy Elliot The Musical (though I wasn’t so keen on the musical part) but he said that the theatre had not released any tickets for that evening. So I asked his opinion, thinking that he was a reputable dude. He told me to see The 39 Steps, an adaptation of Hitchcock’s movie, for 20 quid (that’s US $42, guys. A lot). It wasn’t until 20 minutes later that I spotted the REAL official TKTS office down in the
-The 39 Steps: For all the crap I have written about my overpriced theatre ticket, it was good show. It was a bloody good show. Not a standing O show, cuz Brits don’t do that sort of thing. I imagine that the original movie was captivating with all sorts of smart plots twists, etc. But this adaptation was fkin hilarious. Basically, there were three actors and one actress playing 139 parts. Actually, one dude played the same character throughout, so technically, there were 3 people playing 138 parts. They threw in so much of that slapstick and deadpan British humor that even I, in my post-flight haze, was guffawing in public. There were some slapstick remakes of train chase scenes and little-man-actor-as-elderly-lady cross-dressing scenes that were brilliant.