Sunday, May 20, 2007

Kenya: the islands of Suba

I spent a week in Suba District, the district of Nyanza Province in western Kenya with the highest HIV prevalence of Kenya (35-40%) and where FACES is training HIV providers. There is nothing that I can write that would capture the feeling of being there. It was astounding in every way: the beauty, the rawness, the poverty, the illness, the calm despite the storm.

I lived in a house-shed without electricity or running water or clean water with three guys on Mfangano Island. I was thankful that Boit, the island clinical officer, gave up his room and gave me a bed to sleep on. We spent the days taking wooden boats out to mobile clinic and Ministry of Health public clinic sites, seeing and treating patients with HIV medications who otherwise would have no contact with healthcare providers. We took care of children named Steven Biko and Fidel Castro. We ate freshly-caught tilapia fried in metal woks over open flames. We walked home on dirt paths, trying not to inhale the swarms of lakeflies which would coat our bodies. We bathed and swam in Lake Victoria. I watched the guys take water from the very polluted Lake Victoria, put “water guard” into it, and drink it. We spent the evenings talking world politics by kerosene lamp. I went to sleep to the sound of rain pelting down on corrugated tin roofs and woke to the sound of roosters and insects in chorus.

Kenya: is beautiful. Kakamega Forest

My one safari in Kenya – purely for fun – was my trip to Kakamega Forest. It’s one of my favorite places in the world. It is the only rainforest in Kenya, and it’s barely protected by the government. The Kenyans have formed an NGO: KEEP- Kenya Environmental Education Project, to help do some of the preservation and education in the forest.

Kakamega Forest is very close to Kisumu – only a 45-60 minute matatu ride away. It’s in between Eldoret and Kisumu, so it was perfect for me to stay in the forest when returning from my trip to Eldoret.

Once you’re in the forest, you can hire a forest guide for 300 ksh per person per hike/walk. Joe Mamlin goes to Kakamega all the time and always goes with a guide named Ben. I went with a guide from KEEP named Gabriel, who runs the KEEP Education Program in 100 local schools on a volunteer basis. His only income comes from leading these guided walks through the forest. I tipped him handsomely in part for that reason, in part because he led me on a great hike up to the bat cave and Rondo Point. At 2,000 meters, climbing the hill as fast as Gabriel definitely gave me a challenging work-out. It was well worth it: the view from Rondo Point is spectacular. You can see all of Kakamega Forest, as far as Kericho and Kisumu. The bat cave was also very cool. I got to see baby bats. There also something very peaceful (though initially scary) about being in a dark cave with small bats gently flying around you.

Rondo is a beautiful place, and well worth the extra expense. It’s peaceful, has its own self-contained beautiful walks through the forest. The food is amazing and fresh. They will accommodate special diets too. It was so peaceful that I didn’t even mind all the missionaries there. In some ways, we are doing similar work. It was definitely the kind of reflective getaway I needed.

Kenya: AMPATH visit & Turbo Clinic

[at left: Dr. Joe Mamlin, lead clinician in the AMPATH program and me in his garden, Eldoret]

AMPATH is its own organism. It’s grown from the 2,000 patients in 2004, when I was last in Eldoret, and just starting a few clinics outside of the main referral center clinic. It now sees over 40,000 patients in almost 40 clinical sites, a few of which are in tented sites along areas of tribal conflict. Like FACES, AMPATH is acting like a consultant with Kenyan Ministry of Health (MOH) sites – existing clinic sites with infrastructure already built. Unlike FACES, AMPATH has a huge independent endowment and is the darling of Indiana University’s philanthropic efforts. With more funding and more institutional support, AMPATH can grow and build clinical sites much faster and better than FACES can. Why hasn’t UCSF stepped up to building FACES in the same way?

Joe Mamlin, one of the founders and the clinical guru of AMPATH, was nominated for the Nobel Peace Prize this year. I am not surprised and am proud and very respectful of all his work. It is unfair and probably impossible to compare people’s dedication to this work, but if asked, I’d say that he is among the most dedicated clinicians I’ve ever met – one of the top three. Of the other two, one also works with AMPATH: Jane Carter, the Rhode Island TB controller, the TB person at AMPATH, and my first mentor in medicine. The third is Dr. Dan Wlodarczyk, my mentor in HIV primary care back at San Francisco General.

Thinking about this list of mentors, I feel extremely fortunate to have these folks in my life. They show me what is possible in medicine. They show me what is right. Despite the fact that Joe and Sarah Ellen (his wife and partner in humanitarian adventures) are devout Christians, along with Indiana University, I realize that most of our principles match. Basic human rights and principles generally span across most world religions. It’s when you add power and dogma that I find that organizations get into trouble and provide less-than-ideal services.

Working with Joe is great. He has spunk and charisma when interacting with staff and patients. It’s not difficult to see why he, like Paul Farmer, has a cult of personality. At this stage in his career and life, he’s not afraid of calling all his own shots. It allows him to act independent of stupid rules and regulations which often get in the way of providing the best care for patients. “I will lie, cheat and steal in order to get the best care possible for sick Kenyans,” Joe told me. And we all trust him and his judgment well enough that we know that he would be doing all of those things in the right way.

He’ll use what fund he has available to get viral loads on patients so clinicians can more accurately judge when someone is failing their antiretroviral medications. He has a humanitarian fund so that AMPATH can pay for a patient’s hospital bill so they can be released. The humanitarian fund also pays for patient transport, CT scans, other radiology that the patients would otherwise have to pay for themselves but won’t get because they don’t have the money. Or are not willing to spend their entire savings for a weeks’ worth of medications. Some clinicians complain that patients are getting a free ride in life, but if you believe, like I do, that there should be universal, accessible health care everywhere in the world, then there is nothing to complain about. Basic health care is a human right.

At Turbo (is that a great name for a Kenyan village or what??), AMPATH is building a new, larger clinic to see TB and HIV infected patients. The patient load has gotten too high for its small, existing MOH building. They are also digging for clean water for the patients.

That day, two completely unresponsive patients were dumped into our outpatient clinic. I say dumped because they were literally dumped. One was an elderly woman whom Joe knew had TB. She had been abandoned by all her children and other family members. She was left to her own sick self at home, and had probably stopped taking her TB and HIV medications. She was brought in by neighbors on a stretcher, completely unresponsive, with a very stiff neck, and Cheynes-Stokes breathing (a bad clinical sign of severe brain disease). The neighbors jetted as soon as she was dropped, so we had no further information. The other person was a young man, maybe in his early 20s, who was also dumped at the clinic by neighbors who jetted. He was also completely unresponsive, with barely a pulse or blood pressure. No one knew anything about him. He wasn’t known to the staff as a patient at the clinic. I think the neighbors, afraid but trying to do the right thing, thought that no matter what, Joe and AMPATH would take care of these people.

It’s not far off.

However these patients should have been brought directly to the intensive care unit at the referral hospital – not the outpatient clinic!! We had no ability to do anything useful for these patients in the outpatient clinic: no IVs, no ventilators, no bag-mask, no IV drugs. The sad part is that when Joe called an ambulance to transport them to the referral hospital’s ICU stat, the ambulance left without the patients and spent three hours getting petrol, even though they were promised good money to bring the patients there quickly. By the time we realized that they hadn’t done the transport, the patients were nearly dead. They were nearly dead to begin with, but now they were even more nearly dead. Joe called another AMAPTH driver to put the patients in an SUV and transport them instead. Three hours late. Even AMPATH can’t repair some of the fundamental problems of the Kenyan health system.

Joe acknowledges that we, including AMPATH, are getting way too far behind in the HIV epidemic. “We are failing miserably at controlling this pandemic, Sophy,” Joe told me. One of the only reasons the pandemic appears to be stabilizing in Sub-Saharan Africa is that so many people have died from HIV that the prevalence rate is stable simply because people die and thus are not counted. Joe has a project coming up that he’s very excited about to address the deficiencies in HIV care. He was very secretive about it and set up a separate time the next morning to meet with me to talk about it. Since I promised not to leak information about the project before it is started, I will leave it at that. Pole – sorry!

Kenya: FACES Home Visit

Home visits represent to me the quintessential experience of being a doctor. I get an amazing diversity of background and information about a patient from observing them in their home environment rather than in the clinic. I get the privilege of seeing how they eat, how the sleep, what they do during the day, how they interact with their family, roommates, neighbors. I can assess their sanitation and safety. It much more adequately satisfies the part of doctoring that is a bit of an anthropologist … but goes much further than the anthropologist by synthesizing the information into an intervention that is best suited for that particular patient / subject / person.

The downside of home visits is that often you uncover complicated and difficult issues that you can’t solve. We as doctors are trained all the time to solve problems and “fix” people. This of course is very difficult and a stressful expectation, in any setting – be it clinic, the hospital, or the home. If you go by yourself to do the home visit, which is what I do in the US, you then have to figure out how to address the psychosocial and financial problems that you don’t have time or skills or resources to deal with. The nice part about doing home visits in Kenya is that you automatically go with a team. In fact, usually the community health workers often go by themselves, so they especially appreciate it when a clinician goes with them to help with management issues. It makes a world of difference to have a team. You feel so much better supported and able to focus on the issues that we are trained to deal with: medical and psychiatric management.

We went to visit Margaret (pseudonym), a 22 year old with a rapidly falling CD4 count (from 500 to 200 in 3 months) and failure to thrive. She had also been pregnant and miscarried at 7 months at home – one month before our visit. The clinicians had been concerned about her weight loss and falling CD4 count, so they initiated her on HIV antiretrovirals and TB medications. She stopped coming to her clinic visits and the staff were concerned that her family was not supportive, so we decided to make a home visit together.

It started out very strangely. I sat back and let Kendi, the clinical officer, Elija, the community health worker, and Nicolas, the nurse, take charge of the visit. I also wanted to observe how they ran it. The home was small but very neat. Margaret’s older sister kept the two-room home very clean: swept, laundry done daily, food on the table for Margaret. Her sister greeted us at the door and sat with us during the interview. She seemed supportive. Margaret, on the other hand, was lying on a couch, barely moving, with an imperceptive voice. Her face was completely flat. She expressed no emotion, except later, when I sat next to her and asked some more questions. For the first 20 minutes, the clinic staff sat on the other side of the room, bombarding Margaret and her sister with questions, many of which sounded accusatory.

“Why aren’t you eating?”

“Have you been taking all your medications? Show us what you’re taking?”

“Why haven’t you picked your TB medications?”

No one shook her hand, sat next to her, examined her. They mostly spoke with the sister. After the 20 minutes had past, my assessment was that Margaret was suffering from untreated severe major depression, almost a state we call catatonic depression- where the patient is so depressed that they don’t move or speak. She barely spoke, in a whisper, and gave simple one-word responses. When I sat next to her, shook her hand, and spoke with her with much softer tone, she started to cry. She shed tears in the near-catatonic state: no change in her flat expression but now she had tears and mucus running down her face. After she started to wet her much-too-big t-shirt, she grabbed her kanga, which she was wearing as a skirt, and wiped her face. She told me that she was unable to walk, unable to motivate to eat, and lay on that couch all day, not speaking to anyone, not doing anything. She just cried when I mentioned the miscarriage. She didn’t say anything about it. But at least I addressed the elephant in the room.

She had no cough, nothing focal except for muscular back pains. She looked very very wasted: her skin clung to her bones except where it was stretched out for her recent pregnancy. Her eyes looked ghostly and glowing white in the darkness of her home, which has no electricity or windows. I held her skeletal hands while she tried to stand up during my neurological exam. She was very weak and her muscles contracted, stiff and thin.

In retrospect, I suspect that her CD4 drop was in large part due to her pregnancy (it was checked during the start of her third trimester) and that she probably doesn’t have TB, though in a person who was not as severely depressed as her, I would definitely think more seriously of treating for it empirically. I think that she has severe untreated depression, and while the clinicians in Kenya are often reluctant to acknowledge and treat psychiatric conditions, I pushed the issue and hopefully she has started on her antidepressants. And hopefully the staff sees the importance of acknowledging, treating and counseling people on depression – not in the accusatory way, but in a supportive holistic way.

Saturday, May 12, 2007

Kenya: poverty & health

[photo at left: Traditional Birth Attendants being trained to do PMTCT for HIV+ pregnant women in Turbo Village. They represent an important piece of task-shifting to community-based members. They also represent a large cadre of people who are not trained in traditional university settings but who are doing great public health work. They reach women in their homes, saving them the cost of going to far-away clinics.]

Poverty and Health

Sickness and Wealth

Poverty and health status are inexorably linked. That goes without saying. We wrestle with this fact every day in clinic. You can’t ignore the blatant poverty that our patients struggle with, even if you tried to. It keeps you from doing your work as a health care provider. On the other hand, you can also see it as part of your work. I like to think of being a good health care provider as being an anti-poverty worker. You treat people so that they are healthy enough to work and take care of themselves. The problem lies in when people are too poor to pay for the treatment they need.

Chicken or egg? Chicken AND egg.

During my first week here, a 60 year old mama came in with a deep foot wound, one week old. The wound happened when she was digging through the dirt of her family farm and cut her foot on a piece of jagged glass in the ground (these types of traumas are common here, as there is lots of broken glass and metal in the earth). She came from a rural village about an hour away by matatu. She was widowed, not just once but twice – by her first husband and then by her husband’s brother (she was inherited as part of Luo tradition); they likely died from HIV and passed it along to her. She had to pay 100 shillings one-way to get to our clinic, which is the equivalent to her entire day’s income from selling milk from her small herd of cows. It took her two weeks to save enough money to cover the roundtrip to and from clinic. She didn’t come in when the wound occurred because she couldn’t afford it, so instead she went to a local tribal healer and got some herbs to make a poultice for it.

She looked like she was 80, she was so withered and thin. She was WHO Stage 3 for weight loss; we didn’t know her CD4 count yet. With her HIV infection, she is at risk for invasive infection from her wound. This is especially true since she’s been walking on it with little dressing… and only little broken cloth shoes and a rag protecting it. The wound was deep – I was able to see her subdermal layers and muscles sticking out- almost to the bone. Surprisingly, and probably thanks to her herbal poultice, the wound was clean, and I didn’t see anything overtly infected.

When I tried to refer her to the district hospital near her home to get a tetanus shot, dressings and wound care done, she refused. She said that she couldn’t afford their fees. While the public hospitals are supposed to be sliding scale, people won’t do anything for you unless you pay something, which pretty much amounts to a bribe. Public hospitals here are notorious for providing bad, shady care. I worked in one in Eldoret. I hated it. Patients at this hospital got terrible care, and I felt terrible that I couldn’t fix it for them. There were several deaths every day of young people who died of treatable infections. I cried every day from the seeming futility of in-patient work here.

I don’t blame the patients at all. I would avoid the hospitals too.

I couldn’t stand the fact that this mama was not going to get the care she needed because she didn’t have the 200 shillings to bribe someone at the district hospital. I would suture and dress the wound myself, but there were no supplies I could use. I know that this is no long-term solution, but I decided to give her the 200 shillings to cover the expense. So maybe it’ll help prevent her from getting infected and losing a leg.

Because of the poverty, people will defer evaluation and treatment as long as they can, in hopes that they will get better and avoid any additional financial burden. The other phenomenon is that avoid going to the hospital at all cost (pun intended). Our clinics provide free care. So when they are sick, no matter how sick they are, they come to our out-patient clinics, which are not equipped (AT ALL) to deal with such sick patients. Well, the fact is that the hospitals here are also not equipped, but that’s another story. They are supposed to be better equipped than our out-patient clinics. It is not terribly unlike what our uninsured patients do in the US, though in the US we have a safety net… and here, the poverty is far more extreme. The financial problem with the hospitals here is that they charge you for everything, and if you don’t pay, you are held hostage in the hospital until you pay something. The horrible irony is that you stay because you can’t pay, and as you stay your debt burden gets bigger and bigger. One of our FACES patients has been in the hospital for 10 days for simple diabetic control because she couldn’t pay for two days of hospitalization. It should have been just an overnight or few-hour admission.

While I was at the AMPATH Turbo Clinic with Joe Mamlin, two patients were brought in to the clinic completely unresponsive and sick as stink. In the US, they would have been coded and brought to the ICU right away. One was an older woman abandoned by her family and found sick by her neighbors. They called an ambulance to bring her to the clinic rather than the hospital, because they knew she had no money. Joe knows the patient a little and thinks she has TB meningitis. Another young man was brought in by neighbors… they weren’t even sure of his name, so no one could find his chart or figure out his medical history. He wouldn’t respond at all. He was septic- they couldn’t get a blood pressure and barely got a pulse. These are serious medical emergencies. And they were brought into the out-patient HIV clinic. And they had to wait 3 hours before getting transported to the provincial hospital because the “ambulance” which was called decided to take 3 hours to get some petrol (i.e. get sodas and snacks and take their time coming).

A couple of such folks come into FACES each week too. What we often admit to the hospital in the US, we manage as out-patients here in Kenya because people will adamantly refuse to go to the hospital. And for good reason. Amazingly, people will do OK with outpatient management, even with limited resources. This is largely in thanks to the great care that family members and neighbors will give to sick people. For example, in the three weeks I’ve been here, I’ve seen a bunch of patients that we diagnosed with rip-roaring pulmonary or extrapulmonary TB, severe hepatitis or biliary obstruction, bacteremia, toxoplasmosis leading to hemiparesis, severe malaria… all of which we have treated as out-patients, and most of whom have come back for diligent follow-up. If you can breathe, take your oral medications and drink a little, we try to treat you as an out-patient.

It’s great to see how good out-patient and community support can heal you. It’s more affordable, and often, it works.

Still, some people can’t even afford the few hundred shillings for an out-patient course of medications or treatments, like the 60 year old mama with the deep foot wound. We can’t keep on providing piecemeal doses of money to cover costs. Besides, the mzungus are at the clinic only sporadically. AMPATH tries to address this by providing a large network of waived fees subsidized by a large foundation and grants, along with income-generating programs. AMPATH is unique in how well-endowed, comprehensive and wide-ranging it is. FACES is not so. And the rest of Kenya (besides Nairobi) is even less so. Despite how much AMPATH is doing, Joe Mamlin still feels like his program is a failure.

Poverty feels like a gi-normous, insurmountable problem. It is pervasive in everything we do here.

I can’t even imagine agitating for universal health care in Kenya. The government seems too disorganized to entertain the idea. Kenya doesn’t have the leadership, vision or persistence that Cuba has. But it needs it. It needs more leaders who can use its precious few resources in creative, wide-reaching ways.

If you are a good health care provider here, you are an anti-poverty worker.

Kenya: sign-spotting

[photos at left: famous people matatus]

You encounter some wild names when you travel - in part because of cultural differences, in part because of writing in English as a second or third language. Asia has some great sign-spotting, but Kenya can definitely join in the competition. Check it out...


My personal favorite…

-“Retired Slaves”

Some people name their babies after famous people, others name their matatus…

-“Barack Obama”

-“Obama Senator” variation

-“Che Guevara”


Would you get into a matatu named…

-“Nuclear Bomb”

-“Totally Crazy”

-“Lord Help Us”

-“The Struggler”

-“Out of Control” …?

tuk tuks

-“The Gunner Team,” watch out for the nerdiest, cut-throat tuk tuk in town!

boda bodas

-most political: “abortion is a crime”

-most philosophical: “what is?”

-most SF: “i am ganja head”


-“Do the Right Thing: Be Abstinent.” on a clearly pregnant lady

-Grateful Dead tie-dye t-shirt on a dude obviously trying to look cool, bobbing his head to Kenyan rap.

-“Your boyfriend thinks I’m SEXY” hot pink lettering on a black t-shirt, worn by an elderly Kenyan woman.


-“Dolphin Butchery.” i didn’t know they had dolphins in Kenya!

-“Virgin Counter” what do they do to virgins there…?

-“Artist.” i wish i could open up a shop and put up a sign that says “artist” and then wait to see who would come in and what they would ask for…


-“New Miyako Hotel” in Eldoret, Kenya. It’s the name of the fancy Japanese hotel in San Francisco and other big cities. Except this one is clearly not fancy … and not Japanese.

other interesting sightings / a very global experience

-camels on the highway to Eldoret! i’d expect giraffes here, but camels…?

-being asked if i’m from India

-advertisements for karate classes all over Kisumu

-sitting in a defunct Japanese video game shaped like a space rocket while eating a Kenyan banana and canned OJ from Singapore while listening to Britney Spears blasting out of a nearby hair salon as two Swahili women in long burqas stare at me from a bench.

Kenya: name-calling

[photo at left: me addressing the FACES staff crowd during my CME talk on "cough and shortness of breath" in HIV+ clients]

The staff at FACES love it that I have a Chinese name. During the first staff-meeting (when I met everyone) I told them a story about my Chinese name and how people constantly mispronounce it, so now a lot of the staff are making an effort to say my name properly. They do much better than my non-Chinese American colleagues, who mostly don’t bother to try. Often in the mornings I will be greeted at the clinic with a hearty handshake and a “Hello Sophy Shiahua, How was your morning?” The Luo staff do a particularly good job pronouncing my name. Apparently Luo also has a bunch of tones, so speaking with specific intonations come naturally to those who also speak Luo.

The nurses have given me a Kenyan name. The nurse mamas (older women) in Eldoret gave me the Luo name “Akinyi,” when I was last here in 2004, which means “she who was born in the morning.” They just guessed that I was born in the morning, which is correct. However, when the nurses here in Kisumu gave me the name “Achieng,” which means “she who was born in the daylight,” they said that it was more appropriate since I was born around 10 am (i think…) rather than in the dawn hours. I prefer either Akinyi or Achieng over the other nicknames I have been given here, like “Chinese Madam” and “Japan, Japan” and “Wing Chong Ching” which people call me all the time on the street.

Now my full name is (drum roll and deep breath, please)…

Sophia Sophy Shiahua Akinyi Achieng Pokey Resister Wong

Monday, May 7, 2007

Kenya: photo album

This is my online photo album of photos from Kenya. It includes clinic and work photos from Kisumu (FACES), Eldoret and Turbo (AMPATH), daily living, and adventures, such as to Kakamega Forest. I'll keep adding to it during the trip, so please visit the link periodically during May 07!

Kenya, April-May 07