There’s Hope in Them Buckets

On my solo tour of sub-Saharan Africa in 2001, I heard one message over and over again from the locals and expats I met in each country I passed through—an entire generation was about to be wiped out by AIDS. Many country’s leaders openly questioned whether HIV was real, the only medical education campaigns I saw were focused on an abstinence-only solution (that would have been hilarious in its incompetence and lack of understanding about local culture if the consequences hadn’t been so damn sad), and it was considered hopelessly naïve to think that the antiretrovirals that were quickly gaining momentum in America would ever be inexpensive enough to be dispensed in Africa.

Well, while a glance at Meg’s last post will show you that there are no shortages of problems in the local healthcare systems, and my four days in one corner of Kenya doesn’t qualify me to be an expert on the African AIDS problem, I’m here to tell you, in a town a couple hours away from our President's father’s birthplace, where people all around you claim that Obama is their cousin, uncle, or even “niece”, there is a little bit of hope here.

I spent Tuesday at a rural clinic with Meg, checking in on patients from the local villages. One man with six kids and two wives eagerly nodded YES! when Meg asked if he’d like to be prescribed more condoms along with his medications. Another woman who had walked three hours to get to the clinic beamed when Meg explained to her that her T-cell count had increased significantly due to the antiretrovirals she had started taking a few months earlier. When we walked home yesterday, we passed a police station where a police car with a huge megaphone attached to the roof began to roll by us and the six cops inside grinned at me, shouted through the megaphone “Hey John, how are you, are you feeling fine?” and then started singing together at ear-shattering volume at the top of their lungs to encourage the entire town to come to a free HIV education and training session.

Meg and her many UCSF and FACES colleagues are far better qualified to discuss why things may be starting to change here—activist pressure to allow generic medications to bring the price of ARVs down, financial and logistical support from governments and foundations, increased vigilance from local people as they watch the people they love die. And, god knows, there’s a lot left to be done. Mothers with HIV still often don’t bring their children in to be tested, afraid of knowing the results. Husband don't tell their wives that they're positive. Plenty of people tell doctors like Meg that they’ll use condoms but don’t. There still isn’t nearly enough funding or doctors or education or drugs to reach the people here that need them. 22 million people in sub-Saharan Africa have HIV (2/3 of the world’s total cases), and while in many countries that number is starting to stabilize, one look at San Francisco will tell you that as ARVs start to save more lives, people will often start to become complacent about transmission, and rates will increase again.

But amidst the tragic stories, you’ve gotta find those signs of change when you can. A couple days ago, Meg and I were sitting in the back of a truck coming back from one of the clinics out by Lake Victoria. In Kenya, there’s been a major adult male circumcision campaign, in direct opposition to the growing anti-circumcision movement in America, due to studies that have shown that HIV transmission rates are lower among circumcised males. We stopped at another clinic, and some men got in carrying two large purple buckets. They were clearly being careful to put the lids on tight and keep the buckets on a flat surface. So, we asked them, “Jambo, what’s in the buckets?” They smiled, paused for a second and said, “foreskins”. We couldn’t tell for sure if they were joking, but for the next two hours, on the bumpy ride home, as the truck careened over rocks and tilted at a forty-five degree angle on the shoulder of the dirt road, I have to admit, I liked thinking “Here I am, 8 years after my journey alone through an AIDS-raved Africa, sitting in the back of a truck in Kenya, with my passionate save-the-world doctor wife who works at a local HIV clinic on one side, and two buckets of foreskins on the other.” Can we win the battle against AIDS? Yes we can.

--rahul

Ward rounds

Today Reena and I made rounds in Migori District Hospital for the first time. We have been spending our time in the outpatient clinics up until now, as the hospital is staffed by clinicians from the Ministry of Health (MOH), not by the FACES* clinicians with whom we work. We joined one of the FACES doctors and the MOH clinical officer to round on the 10 or so patients on the male ward (nothing against the women: morning rounds on the female ward had already occurred; we plan to join rounds on that side on Wednesday).

Rounds were a sobering and intense experience-- the severity and complexity of the medical problems we encountered in most cases far exceeded the resources and subspecialty expertise available in this rural setting. One young boy with HIV/AIDS had suffered seizures and near-coma as a result of an unidentified infection in his brain. He was being treated empirically for cerebral malaria, cryptococcal meningitis and bacterial meningitis with little response, and he remains without meaningful communication or purposeful movement as his mother watches over him and hopes for a recovery that is unlikely to come.

We examined two young men who had both developed severe leg wounds after relatively minor injuries that should have healed under normal circumstances. Both men were found to have advanced AIDS, which was the cause behind their impaired wound healing. Without advanced wound care such as surgical debridement, an appliance called a “wound vac,” and skin grafting, it seemed their chances of keeping their legs and even their lives were not great.

Some cases provided a bit more room for hope. One young man had severe right upper quadrant abdominal pain concerning for cholecystitis (inflammation of the gallbladder) and needed an ultrasound and possibly surgical intervention. Ultrasound is available in the private hospital in Migori, but the patient would have to pay for it. Fortunately his family could afford the expense, and we are hopeful that the source of his pain will be known and potentially treated when we return to the hospital on Wednesday.

Reena and I struggled with feelings of hopelessness and helplessness, familiar to us from past experiences working in resource-poor settings, where the divide between what our patients need and what is available is so vast. We also found gratification in our ability to be of meaningful service to the patients and the other providers this time around. As third year residents, we were actually the most trained clinicians present in the hospital, and thus we helped to guide the clinical decision-making as we made our way around the ward. After eleven years of higher education, it is a relief to know that we have actually learned a thing or two along the way.

Tomorrow we go on a field visit to one of the smaller satellite clinics, which will make Migori District Hospital look resource-rich by comparison.


* FACES stands for Family AIDS Care and Education Services, and is the organization that we are working with through UCSF

- Meg

Husband. Hair. Haiku.

Husband is here. Yay.
But with a surprise beard. Boo.
Soon to be shorn. Yay.

- Meg

Blurbs from the first fortnight

Highlights from the first two weeks in Kenya . . .
- Eating sweet, juicy mangoes for 30 cents a pop! Ate a whole one tonight for dessert, plan to do the same every day for the rest of my stay in Migori. YUM!!!

- The warm-hearted, big-smiling people of Kisumu and Migori. Such friendly, welcoming communities—a far far cry from the menacing, hectic feel we got in Nairobe last time around. I could stay here a while.

- The kids yelling at the top of their lungs “How aaaare youuuuuu???” and collapsing with shy laughter when we reply.

- Traveling abroad with Obama as my president and not Bush !!! I didn’t realize ahead of time how different it would feel to be PROUD to be an American and to WANT to talk politics rather than feeling ashamed. Countless Kenyans, from Tuk-tuk drivers to doctors, have told me that Obama has given them an optimism they never before dared to have, that they themselves and their children and Kenya as a whole might become something great one day.

- A last-minute trip to Masai Mara, in which despite our lack of advanced planning, organized tour or 4-wheel drive vehicle, we ended up with a fun-loving and able driver whose company we loved, a hawk-eyed Masai park guide who, from the back middle seat of our beat-up Toyota station wagon somehow spotted a family of cheetahs lying under a tree hundreds of yards away. A cheetah with her four baby cubs up close and personal! That and a pride of lions we admired from within 10 feet (and not a single other vehicle around), a crocodile sunning himself next to a big heap of hippos, a herd of elephants that crossed the road right in front of us (with babies!) and much more. All for $40 per person.

- Learning from the clinical officers here who struggle daily to take care of HIV patients with very limited resources, and sharing with them the knowledge we have gained from our own training in the US. More on clinic experiences to come.



Lowlights from the first two weeks in Kenya . . .
- Mosquitos that come with the risk of malaria. I have discovered that I am somewhat paranoid when it comes to this particular disease (don’t worry Mom, I haven’t missed a single prophylaxis pill, I sleep under a mosquito net, and I am rabid when it comes to killing them).

- The fashion and hygiene nightmare that were Reena and Meg after wearing the same jeans that we sweated in for 11 straight days while we waited for British Airways to finally deliver our lost bags. The two of us would have been no match for the stylish Kenyans anyway (the women of Kisumu look like a million bucks every day, in heels, slim skirts and brightly colored fabrics), but we were really slummin’ it in our tan hospital Clarks (Meg) and our hiking boots (Reena) in clinic. Desperate for clean clothing more suited for the 90 degree heat, we hit up a big open market in Kisumu and found some choice items that had made their way to Kenya from Goodwill (H&M reaches the developing world!). Fashion show photos to come when Rahul brings me the camera cable which I went off and left.

- Missing my hubby! Being back in the developing world without my backpacking partner in crime feels just plain wrong. But he’s headed my way in 5 days. Wooooooo!!!

- Day after day seeing patients go without life-saving diagnostic and therapeutic measures that we take for granted back home. Today I saw a patient with headache and neurologic abnormalities concerning for a mass in her brain. Without a head CT to characterize the mass, she will have to be treated empirically for an infection called toxoplasmosis and hope she improves. If she instead has a brain tumor, there is little chance that she will ever be able to get a CT to make the diagnosis, and even less chance that she would be able to receive the specialized treatment it would need.

- Meg

The Volcano Liveth!

After three years lying dormant, without so much as a hiss of steam, the volcano rumbles anew! We are on the move again--me already, and Rahul soon to join me! The scale will be much smaller this go-round—a month in Kenya and Uganda as compared to the whole of 2005 spent circumnavigating the globe—but we’ll take what we can get.

The past three years have been short on adventures overseas and long on adventures on-call (and not of the salacious Grey’s Anatomy variety, unfortunately), and we scarcely recognize the globetrotters that we once were. We blame the neglect we have shown our poor passports on Meg’s residency, as we do all other shortcomings of ours.

The residency years did witness one grand adventure in the life of Meghul . . . our Massive Ass Karaoke Wedding!!! Getting married completely rocked our worlds, leaving all of life’s previous highs in the dust, and shattering any notion we might have had as to how much fun one could possibly have at one time. Our honeymoon in Laos and Vietnam was definitely volcano-worthy, but spending it in internet cafes and not in our luxury hotel rooms was, we agreed, a terrible idea all around.

So, without further ado, we bring to you the resurrection—if brief—of the volcano. Hopefully it will never again lie dormant for years on end, for we will not have residency to blame for all of life’s woes much longer.

Stay tuned for stories of my medical work in HIV clinics in rural Kenya. Internet access here has proved challenging to say the least, and I spent most of my first week here trying—and mostly failing—to get British Airways to deliver my lost luggage. Now that I am finally settled in Migori and no longer wearing the same vile jeans, I'll try to start posting snippets whenever I can get online from clinic!

Off now to do some shopping close to the Tanzanian border!

-Meg