Galapagos Adventure Video!

The Nemo Nemo Galapagos Video has been released!

Disclaimer: Young Whan edited this video (and did a fab job) and i was only a consultant, so i am not responsible for the bizarre footage of the marine sophy and the sleepy sophy.

drama penguin

The funniest 5 seconds in the Galapagos!

Galapagos Photos & Slideshow!

Click on the link below to check out the photo album from the Galapagos Islands or watch the slideshow here. It's crazy how close you can get to the animals there. They haven't evolved to run away from humans... yet.

Galapagos - Nemo 1 Adventure - July 2007

Galapagos Adventure

The Galapagos Top Five [Cool Things]:
1. The scariest looking animal was the vegan, salt-spitting marine iguana. 2. The biggest oldest land animals were the vegan land tortoises.
3. Swimming with penguins at the equator. So Galapagos.
4. Baby sea lions. So Cute. So Kawai.
5. Batfish. The Tammy Faye Bakker of the marine world. This creature has big thick black eyelashes, blood-red lips, little legs it scuttled around on, and a winged body. And it praises Jesus in a world where Darwinism rules. See the photo below.


Honorary Cool Things:
-surviving 8 days on a boat only slightly sedated and confused on scopolamine... but not barfing a single day!
-best animal name: nudibranch.
-that the clumsy, careless blue-footed boobie has survived natural selection to this day. i guess Mother Nature has compassion too and endowed the Galapagos with next to no predators.

-Victor's AWEsome multi-course feasts for us on the boat - none of the meals on the 8 days was exactly the same. He even accounted for my lactose-intolerant pescaderian-vegetarian diet. And fresh jugos every morning! Victor was our boat chef.
-Mauricio's AWEsome dry-erase marker drawings of our itinerary and elaborate, articulate, knowledgeable explanations of the zany place that is the Galapagos. Mauricio was our naturalist guide.
-Mauricio's way of radio-ing for the "Nemo Nemo" crew to come pick us up on the islands.
-Jonathan's amazing ability to clean our tiny, salty, smelly submarine rooms into pristine, neat homes away from home. Jonathan was our super-nice, super-charming helper-outer.

-fun folks from Ecuador, Holland, Germany (via Argentina), Italy, Israel, Florida, Utah and good ol' California.

Ecuador Mainland adventures

Ecuador Mainland Top Five [Crazy Things]:
1. The Ecuadorian national delicacy is guinea pig ("cuy" en espanol). Young Whan ate it. i even tried a bite. It came deep fried with its head, eyeballs and little contracted claws intact. Yes, we ate a rodent.

2. Banos: the whole entire town of Banos came to the Le Virgen Hot Springs (heated by volcanic activity)! It was a whole-town hot tub fiesta! i have never been to a hot springs pool where there were more bodies than water, as many children as adults. Even toddlers were soaking in the hot hot water. i tried not to think about pool-pee.

3. Otovalo: despite the mounds and mounds of yarn at the Otovalo market, i could not find a single vendor who sold natural wool (sheep, alpaca, llama) instead of synthetic acrylics. In a country that prides itself with textiles, this made me sad! Finally on the way to the bus station, i spotted a sheep's wool warehouse - a real wool wonderland. Needless to say, i had a bit of a shopping spree, buying yarn by the kilo.

4. Tourism: everywhere we went, 75% of the tourists seemed to come not just from the US but specifically from California. Man, quit following us around, people...

5. Politics: the new Ecuadorian president Correa is a progressive economist, elected with the blessings of the indigenous community and pissing off the wealthy community - we naturally became fans by default. Apparently he is proposing a project to avoid destroying biodiverse rainforest and indigenous land for petroleum drilling and development. He is asking the global community as well as Ecuadorians to donate enough (roughly $350 million a year) to make up for some of the losses Ecuador will take for not selling the petrol. Consider Gore's proposals to do carbon-swapping. Interesting...

Check out our photos from Ecuador Mainland! Click on the link to the Picasa album directly below or watch the mini slide-show from this site further below:

ecuador photos to share

Kenya: video documentary

[You can play a short, 6 min, version of the FACES documentary here. Viva YouTube!]


It feels good to be doing creative work again. I’m excited to spend my time brainstorming about sequences, soundtracks, what clips to take out of the 10 hours of raw footage I have to work with. The process is amazing in itself: to be able to ask people probing questions about why they do the difficult work they do, to discover the intricacies of the community in which we work, to have a large group of children climbing over you to see what your filming, to climb the rocks of an island and battle thick swarms of lake flies to take footage no one else has. People are also generally excited to be filmed; it helps them feel appreciated and important for the work they do. Then I get to take all of this and turn it into a narrative that tells a story, constructed to emote what I want.


Rose-colored glasses aside, I also have to deal with the very frustrating aspects of being in Sub-Saharan Africa: the only equipment I have to work with is the stuff I brought with me, on my back. Don’t get me wrong: it’s crazy in itself that I own and carry all of the equipment I need and am producing this documentary, from start to finish by myself and with my own money. I’m proud I can do this (though I wouldn’t mind some help, especially with funding!) Still, I need to deal with some crazy situations, which make the adventure… well, more of an adventure. While on the islands, I had to make sure my batteries didn’t run out (no electricity) and that nothing fell into the water, since we spent 4 hours on leaky wooden boats every day. When the kids climb on me, I need to make sure that the camera doesn’t get dropped or otherwise broken. There is no one but me to fix it. And after digitizing only a small fraction of the clips I think I might use, m hard drive ran out of memory. All 100 gigabyes have been used, which leaves me no room to render or export the sequences I create. So I spend excruciatingly long hours digitizing, then backing up to DVDs, which I run out of. There are no blank DVD-recordable discs to be bought readily in Western Kenya. (Though I bet I can pay some of the guys who pirate DVD movies to get some blank discs… I know where to find them.) Everything has to be planned out just right so that I have the clips I need on the hard drive to make the sequence. All these challenges are time-consuming, but in the end they add to my experience and help me plan for the next time (i.e. bring a damn external hard drive!).


As is inevitable with documentaries involving NGOs and health care workers, people’s speaking skills are highly variable. There is very little of the interviews that looks good or sounds good on screen. I can probably only use 10% of what was filmed, and even then I need to cut out a ton of um’s and stutters and repeated statements. While doing the interviews, which are fun in themselves, you can tell who the good speakers are: Reson gives clear but long and comprehensive narratives; Steve can eloquently describe the touchy-feely philosophy of the organization, and Kwaro, given some time to prep, can give a succinct speech with the stats and facts that you need. All without stuttering. And with a decently loud voice. A few aspects of Kenyan culture don’t mix well with these interviews: people speak with very soft voices and tend to talk in overly formal circles, saying the same thing several times in only slightly different ways. I think that this is why Kenyan meetings are long and boring. And why a lot of my interviews are long and boring. And why Kenyans often complain that amerikans are too loud and direct.


Fortunately, Kenyans like to sing, especially at FACES. So to make up for the soft voices that speak in circular statements, I have some great footage of staff meeting songs and Kids Club chants. Good music, good singing, beautiful scenary, interesting work: this is what is saving the documentary from being ordinary.

Kenya to London to SF: the shock

[left: "Sony Store" of Kisumu, Kenya. Not exactly the Metreon.]

Imagine this: plugging in your laptop at London Heathrow airport (i.e. the upscale mall that also has international flights) while facing HMV and Dixon’s electronics shops, and finding your keyboard filled with dead insect carcasses that you have to clear out before typing. After a shady-scammy taxi ride in a stolen vehicle and a driver without a license (arranged by the FACES staff!), a nauseating small plane flight from Kisumu, a 4 hour layover in Nairobi, and a 9 hour flight from Nairobi to London, I arrived in the opposite place: a completely engineered, artificial land. Looking out of the window, even the trees and grass and flowers are completely engineered and unnatural.

Imagine this: Just one week ago I was in the back of a truck (posing as a matatu) with a Kenyan woman next to me. She was wearing a ratty t-shirt proclaiming some little league team, and a kanga as her skirt. She was clutching a live chicken by its feet in one hand, a baby in the other arm, and a large sack of vegetables were at her feet. She has been carryng it on her head earlier, since her hands were full. She stared at me the whole trip. Now, on the plane from London to San Francisco, I am next to a white woman who is wearing a fleece top, velour bottoms, typing an email into her blackberry, and frantically chewing gum. Her well-dressed obese husband next to her is reading some glossy European business magazine. Side by side, these experiences seem absurd in comparison. But they are both integral parts of my life experience. How do I bridge them?

It’s different from the feeling you have when you are on vacation in a remote place and then travel back to modern, hyper developed life. Because when you are on vacation, you already have a mental separation in your head with these two places. But when you live and work in a community not as a tourist but as a honorary member of the community, you feel the shock more deeply. How I can navigate these worlds without artificially compartmentalizing them remains a challenge. The Buddhist principle of compassion for all helps me approach it, though this too is challenging to do fully.

Kenya: psyche of the global health worker

What makes someone want to come to Kenya? Someone not from here, not black, with no family members nearby, with no connection to the people and community aside from work?

For those of us who struggle with having meaning in life, global health work can feel like an answer. The US (and I imagine most of the developed world) has a work culture that constantly forces you to prove your worth and to compete with many others who have comparable skills. In these settings, it’s hard to feel like you are adding unique value to your community. They are supersaturated with a ridiculous amount of (maldistributed) resources and highly skilled, highly educated people (also maldistributed). The developing world is saturated with people but not with resources and not with education. As a result, there are a lot of people eager to become skilled and educated to do good work but not enough resources or educators to train them. That’s where we can step in and be useful. That’s where I can do good work.

It’s a combination of the Robin Hood principle and a Chinese proverb: take from the rich, give to the poor; if you give a woman a fish, she’ll eat for a day, if you teach a woman to fish, she’ll eat for a lifetime. Cheezy but practical – and real and meaningful.

Kenya: rawness of living

[left: pus drained out of a client's lungs by straight IV into the only drainage bag we could find on the island



below: our backyard in Sena: straight up cornfields]

Someone should tell the folks at San Francisco General Hospital that they’re wrong about something. San Francisco General Hospital is not “As Real as It Gets.” Sub-Saharan Africa is.

I wake up to the sound of twittering birds intermixed with roaring diesel engines without mufflers. I walk 4 km to work on a dirt path next to the highway, hopping over sewage, chickens and walking wide paths around cows and goats. In the mornings, I dodge boda bodas, regular bikes, slow pedestrians, tuk tuks, speed-demon matatus that swerve like crazy, giant buses and trucks spewing out black clouds of exhaust into my face. When I get to work, I thank all the higher beings in the world for sparing my life.

My sweat has dried, making the dust and dirt cling onto my skin for the rest of the day. The sun has already darkened my nose; the rest of my body is covered in the usual conservative Kenyan wanna-be Western attire. The blisters of my sandal-clad feet have already turned into calluses.

I then spend the day working with clinical officers and nurses who haven’t been paid for 2 months because their payor in Nairobi is slow, and it take 5-7 days for salary checks to clear at the local bank. I see clients (patients) who had to sell their family goat in order to have enough money to travel from their rural home to our clinic monthly. I see people who have obviously been ill for many years, but they wait till their disease is too advanced for them to handle at home. So there’s the mama who left her deep wound till her next scheduled visit. And the kid who came in with a giant mass in her neck, most likely a lymphoma. And the skeletal man, skin taut over his bony body with deeply sunken cheeks and eye sockets, who got tested only now, and said that he’d been previously “fine.” Somehow I doubted that.

Even the rain here is RAIN. It’s not the mealy half-hearted foggy drizzles that we get in San Francisco. It’s BAM! Late afternoon, and all the hydrogen in the sky collides with all the oxygen in the sky and falls on us. It beats us into submission. The entire insect world comes into your house for shelter, so you are covered in bug carcasses within a half-hour of the rain. And then it’s done. The sun comes back, the water dries up, and the land is ready for another storm the next day.

Life here is raw. There is little protection from the earth, creatures of all types, the dirt of industrialism. There is no shield from the scammers and the neediest in the world. Most non-black folk here in Kenya try to hide from these elements. They buy cars and ridiculously large houses. They hire black Kenyans to do their housework and take care of their children but treat them poorly to further mark the difference (and thus to hide even more). But people who do that aren’t living fully.

It feels good to live more raw. It’s harder in many ways, but so is truly living.

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.

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...

matatus

My personal favorite…

-“Retired Slaves”

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

-“Barack Obama”

-“Obama Senator” variation

-“Che Guevara”

-“Beyonce”

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”

t-shirts

-“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.

shops

-“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…

hotels

-“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

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

Kenya: faces of FACES

Check out a slideshow of the fabulous staff at FACES, taken for a photobook i am putting together:

faces of FACES

Kenya: FACES Clinic & expansion of HIV care

[FACES Kid's Club - older kids posin on the staircase]

It is astounding how much HIV clinical care has expanded in Kenya since I was here in January 2004. At that time, I was in Eldoret, a smaller and more mountainous city about 3 hours by matatu from Kisumu. We were just beginning to roll out antiretrovirals (ARVs), and most patients who were on them had to pay out of pocket for their ARVs. Cipla was producing Triomune 30 and 40, the generic fixed-dose combination pill which includes d4T (stavudine), 3TC (lamivudine), and NVP (nevirapine), and ARV treatment suddenly became more affordable. Part of my project in Eldoret back then was to help link patients diagnosed with HIV in the hospital to be properly referred to the subsidized HIV treatment available at the new AMPATH HIV clinic, which was in the process of being built. That program in Eldoret was also starting to branch out to a few rural and more remote clinical sites.

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 Kenya, roughly 20% of the people with HIV who need ARVs are now getting ARVs. That means 80% still go without, but this is way, way better than more than 99% of people going without treatment. This is a result of a massive influx of attention and resource allocation by the Kenyan government, NGOs and global public health institutions. They’ve built clinics, they’ve provided lab equipment, we’ve trained thousands of clinical staff in HIV care. We’re in the middle of a 20-fold jump in treatment, and there’s still a lot more to do to get it to 100%.

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 US. And they do it with a lot of people-power but not much in material resources.

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 Kenya has come since 2004. They have a lot more to work with than what I had 3 years ago: a full formulary of medications, CD4 counts, HIV qualitative PCR (measuring the presence of the HIV virus), and they used to provide viral loads too. And it’s free for patients. The clinic has a very deliberate patient flow model which allows them to see about 200-250 patients every day. For the number of clinical staff, it is incredibly productive.

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:

http://www.faces-kenya.org/index.php

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 8 am to 6 pm 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.