November 2007

Lena: Really settling in

So I know it's been a long time since I've written. There are two reasons for this. First internet in Migori is notoriously unreliable... the only internet cafes here connect through the cell phone network and so even when they are working, the connection is quite slow. My second excuse is that being here in Kenya is not as remarkable as it has been in the past. That's not to say I'm not enjoying myself - in fact, in many ways I am enjoying myself more this visit than I have on my previous visits...

This is the first time that I have truly felt comfortable here. The first time I came to Kenya, as a college junior on a study abroad program, I was determined to accept (as best I could) anything and everything that came my way. I really wanted to be open-minded, and I result I wasn't critically evaluating what was going on around me. On my trip last summer to Tanzania, I was equally determined to figure out whether I could live long term in a developing country. I think I may have been overly critical.

On this trip, I feel very comfortable and at ease. I realized upon returning that there are many things that I missed about this place when I am away. In a way, it is like coming home. I feel a sense of contentment and joy. The livestock along the side of the road, the pit toilets, and the children pointing and screaming mzungu, are all expected.

Lena: Images

Fishing boats on Lake Victoria:

Nakumat (the equivalent of Walmart smack dab in the middle of Kisumu):

Maasai in Nakumat (an interesting juxtaposition):

Look familiar? It should to anyone who has ever seen Paul Farmer speak (this is one of his patients):

Thanksgiving dinner (mashed potatoes and all):

Lena: Settling In

I know many of you were worried that I'd wind up spending my birthday alone having ramen noodles for dinner (or maybe that was just me). Anyway, in spite of my fears, I went out with the mzungu team to dinner at the finest (and pretty much only) restaurant in town. Having several vegetarians in the group, they tried to request a chapatti with egg and kale inside - something of a breakfast burrito. I was surprised that by the time the waiter made it around the table to me, everyone in the group had ordered this odd entree. I went for some good ole fried goat. I also had some avocado and pineapple juice, which was unexpectedly delicious. Overall, a nice way to celebrate my birthday!

I've finally moved into the place where I will be staying for the rest of my time here. Each day after our arrival in Migori, there was some reason that we couldn't move in. First there was no gas, then there were not enough beds, then it was too dirty to move in. I began to worry that they were just trying to avoid having to show it to me until the last possible moment. Turns out the place is pretty nice and very close to where I've been staying the past several days. Still it was nice to be able to finally unpack. I'd been repacking my stuff every morning, so that I would be prepared to move whenever it became necessary.

Home sweet home (for the next month).

Olivia, my flat-mate, and I made a makeshift living room setup so we could hangout outside our bedrooms.

We cooked plain white rice to celebrate being in our new flat.

Lena: My Research Progress

Some of you may at this point be wonder how my research is going, as that has been conspicuously absent from my posts. To be honest, I’ve been wondering the same thing. I was really ready to hit the ground running because my ultimate amount of time in country was not as long as I had initially hoped it would be. Unfortunately, and as expected, I’m the only one who seems to feel this sense of urgency. I’ve been trying to be patient and remember that laying a solid groundwork is essential to the success of future endeavors. For the past week, I have been introducing myself to healthcare providers at the facilities where I will be conducting my interviews. I call this building social capital and I guess we will see if it pays off next week, when I am scheduled to actually start interviewing people. ...

I pre-tested my interview guide and questionnaire with a nurse who works at the district hospital on Friday. I was pleased with how it went. It took approximately 50 minutes and seemed to get at most of the issues in which I was interested. Still I found a few areas that may require clarification and I was glad to identify them ahead of time.

Lena: Hospitals in Migori

On Monday morning, we visited our first of the 12 sites involved in the study in Migori. We went to Karungu, a sub-district hospital, on Lake Victoria. It was almost a 2 hour drive from Migori, where we are staying. A 2 hour drive is in itself not short, but when you are in a double cab truck with 7 other people on extremely rough roads (if you can even call them that), it becomes interminable. Now I understand why only 4 of the 12 sites are currently distributing antiretroviral therapy (ART). I had been told it was partially because we didn’t have enough vehicles. When we went to visit the site we brought a host of ART drugs with us as well as TB drugs. In addition, we brought clinical staff with us capable of administering and distributing these drugs. We visit a different site each day (Monday through Thursday) in this way and hence, 4 sites are currently active. When we have another vehicle, theoretically 4 more sites could be activated. I don’t want to oversimplify here, because there are other criteria that must be satisfied as well; for example, they must have at least 50 people who have tested positive for HIV. ...
Karungu subdistrict hospital:

On Tuesday, we visited Muhuru, another sub-district hospital. As on the previous day, I helped monitor the patient records, a talent I developed during my year off when I worked on a phase III clinical trial as well as during my time as a coordinator for the Arbor Free Clinic. It essentially consists of ensuring that information is complete and consistent within both the patient forms and the register that lists all the patients seen. I also helped Janet pre-test some of her questionnaires that she will be using to interview pregnant and post-partum women regarding AIDS stigma. I served as a notetaker/Kiswahili translator. It was quite interesting, sometimes surprising, and a bit depressing. It seems that there is not nearly as much stigma surrounding HIV as I had remembered from 2003. It’s unclear at this point whether this is a trend in the right direction, a difference based on location, or simply a coincidence. Many of the women reported some degree of depression either during their pregnancy or after, and every single women (all seven) reported having been at the very least verbally abused and many were physically abused as well by their partners during their pregnancy.
Muhuru Subdistrict hospital:

On Wednesday, we went to Rongo, which is supposedly the most accessible site because it is located along the main road. This means that we can take public transportation, e.g. a matatu. So we crammed our usual 16 or 17 people in the vehicle and then along the way picked up a few more. At one point, we pulled over and a surprisingly large number of people alighted (as they say here). I noticed that the tout (the money collector and conductor) was actually giving these people additional money back – something I’ve never seen before. I put the pieces together a few moments later, when I was instructed to buckle my seatbelt, another event I’ve never witnessed before. We were approaching a police checkpoint. About 5 years ago the new president at the time had instated limits on the number of people to be carried in matatus and had additionally required that matatus be outfitted with enough seatbelts for every passenger. When I returned, I assumed that these rules were simply being ignored. In fact, rather than simply being ignored, these rules were being circumvented. Matatus had learned where the checkpoints were and made certain to appear as if they had been following the rules. Shortly after passing the checkpoint, we again began picking up passengers and filling the van far beyond its legal capacity.
Rongo district hospital:

We also met with the District Manager of Health (DMOH) for Rongo, which is a newly designated district. He expressed during his satisfaction with the work that FACES has been doing, but also that he would prefer programs that address the whole health of a person, rather than just focusing on one illness, such as HIV in our case. I guess the issue of horizontal versus vertical programs isn’t some topic we just debate about in classrooms. He cited an instance in which a child is prevented from acquiring HIV from his mother who is HIV positive, only to die of malaria before the age of five. Unfortunately, this stems from the realities of funding agencies, which often award grants based on proposals to address specific diseases. On a brighter note, we are in the process of rolling out a ‘food as medication’ program as studies have definitively and repeatedly shown that adequate nutrition is essential to good health – sometimes you have to wonder if research was really necessary to show this – I mean all I can say is duh.

Lena: Update from Kisumu

So I’ve been in Kenya for a week now. I guess it’s time for an update. My first day in Kisumu, there was a team-building event for all of the FACES staff from Kisumu. I wasn’t really sure if I should attend or not, but for lack of anything else to do I decided to tag along. We all piled into a matatu (minibus/van made to seat fifteen people, but usually crammed with at least eighteen people) at the clinic and headed to a place slightly outside of town and upon arriving, we began playing all kinds of games and singing songs that I couldn’t even pretend to know. Many of them involved singling out a specific person to, for example, dance in the middle of the circle. Luckily, I hadn’t been there long enough that anyone knew my name. After several more matatus full of staff arrived, we began the planned activities (I hadn’t realized these weren’t the official team-building activities). We were divided into groups had to do a variety of classic team-building activities ranging from ‘crossing a river’ to a trust circle and untying a human knot. Our last activity of the day was a blindfolded relay race. The first step in the race was to go bobbing for apples and then completely eat the apple, skin and all. For those of you who have traveled abroad, I’m sure you know that this is a cardinal sin: you must drink bottled water and you must peel all fruit and vegetables. I attempted to explain my dilemma to the organizers, but no exemption was given. I didn’t want to let my team down on my first day during a team-building activity, no less. So I decided to take one for the team, literally. Overall, it was a great opportunity to get to know some of the many FACES employees. ...

That evening, Janet, my research advisor, arrived and loaned me some clothes, thank goodness. I had by this point been wearing the same clothing for the last 4 days. I bet none of you can say that you have borrowed a pair of underwear from your mentor. I mean I knew I would have a unique experience while here, I just hadn’t guessed how unique. Fortunately, after numerous phone calls, we were able to get in touch with someone in Nairobi who located my bags. We persuaded them to put them on an early afternoon flight and I got them very shortly before leaving for Migori. I can’t tell you how relieved I was.

I got some additional good news on Sunday that KEMRI, the institution we’re working with here in Kenya, finally approved our study, which was under ethical review. Still we don’t have final approval from the CDC, but apparently as long as we aren’t using a funding from the CDC, I can go forward with my research. Another sigh of relief.

Lena: Background

Map of Western Kenya:

Migori town:

The flat in Kisumu and my mattress on the floor in the living room.

Two views from the balcony of our flat.

More details to come later...

Lena: Arrived in Kisumu, Kenya

After more than 24 hours of traveling, I've arrived and all in one piece (for the most part). I even managed to meet up with my Aunt Jill in London during my 9 hour layover. So that's the good news...

The bad news is that my bags didn't make it. I guess this wasn't completely unexpected, but a girl can hope can't she. Apparently, the same happened to another student who arrived earlier this week. Upon arriving in Nairobi and going through immigration and customs, I had to walk across the street to the domestic terminal. Along the way, I picked up a 'guide' who 'showed me' where the terminal was and in return wanted a tip. Luckily, at this point, this is still a novelty that just reminds me of my past experiences here. I good-naturedly explained that I didn't have any Kenyan shillings and he of replied that he accepts pounds and dollars as well. When I got to the appropriate counter, the clerk at my paper ticket with a puzzled expression. Then she walked off with it, much to my dismay.

She returned eventually and explained that they had signed it over to another airline. Instead of flying on Kenya Airways, I would be flying with East African. Apparently, however, I gathered from some conversations in Swahili, there was no room on the flight and there was no way that my bags, which were supposed to be checked through with Kenya Airways, would make it. One of the clerks personally escorted me to the runway where the plane was waiting. As I was entering, I heard a man complaining that there were no more seats. I glanced at my boarding pass for the first time and relieved that my seat number was illegible (yes, it was handwritten). They eventually found me a seat, but my backpack had to be stowed in a different location. Needless to say, I wasn't excited to part with my few remaining possessions, but again what choice did I have.

I was very relieved to find someone (actually 3 people) waiting for me at the Kisumu airport; during the flight I had begun run through the possibilities of what I would do if there weren't someone there waiting or if I couldn't find them. I considered hiring a taxi, but realized I didn't have an address for where I was going. I then came to the realization that I didn't even really know where I need an address for as I had no idea where I was meant to go. Luckily when I arrived I didn't have to start down the line of my contingency plans.

I went to an ATM and got out some arbitrary amount of Kenyan shillings - at this point, I'm only vaguely familiar with the exchange rate and I have even less of an idea what my expenses will be and how much cash I need. Next, they took me over to the the flat where I'll be staying and it seems nice enough, although it looks like I'll be sleeping in the living room on a foam mattress on the floor. The fact that there's a refrigerator and allegedly running water were enough to make me happy. They tried to convince me that I need to rest, but I'm afraid that if I do, it will take longer for me to get adjusted to the time change. On top of that, I don't have any pajamas and with the daylight, the heat, and my nervous excitement, I don't think I'd be able to sleep anyway. My final ulterior motive was that I actually wanted to see the clinic today and meet some of the staff - I didn't want to be forgotten at the flat or have to find my way on my own to the clinic.

Now I'm at the FACES Clinic (http://www.faces-kenya.org/) where I got introduced to at least 25 people, all of whom I've already forgotten. My guide literally took me from room to room (interrupting patient visits) to meet all the staff. The clinic waiting area, which is outdoors, was very crowded. It's definitely a larger scale operation than I expected and seems to be relatively well equipped. They have a wireless internet connection here in the clinic - too bad I won't be living in Kisumu. I don't expect to find the same luxuries in Migori, three hours from here, but then again I don't really know what to expect at all, I guess we'll see.

Aunt Jill and I having lunch in Heathrow airport during my 9 hour layover - much to my surprise we were able to connect without the use of cellphones.

FACES clinic in Kisumu