Malaria Update

**Another post I wrote in early November**

So, since I’ve learned from Will that my ridiculous bad luck now has his family worried that he’ll get malaria, I’ll give a quick update on my road to recovery. It’s funny because I felt like such a hero saying “I have malaria (gasp!!)” to people, since it’s so far out of the realm of normal for us. When I told Americans, the response was always “omigod are you ok? I can’t believe this is happening! Will you still be able to travel or will you be laid up for days/weeks/months?” When I told Kenyans, it was always, “uh-huh, and what else is new?” Further reinforced that the scary and out of the ordinary for us can be not such a big deal.

Anyhow, malaria makes you feel really really really bad (as I wrote in a feverish text message to Pras all the way off in Uganda). But miraculously, I started my coartem, got a bit worse, then within 3 days was feeling almost back to normal. I even packed up all my stuff, got on my plane to Nairobi to meet up with my Mom and was on a 6 hour bus to Tanzania on Saturday when I’d only been diagnosed on Thursday. Wasn’t feeling the best I’d ever felt, but really by Sunday I was almost all better. It was just too bad that I got sick for my last couple days at FACES, since I didn’t get a chance to say good-bye to everyone as I would’ve liked.

I was thinking though, if I hadn’t gotten my smear and my coartem in Kenya, but instead went back to the US and got sick then it would have been a nightmare. I mean, there’s no coartem in the US, it probably would have taken days to get diagnosed, involved an absurd hospital admission, lots of unnecessary testing, definitely an ID consult and IV meds. So glad to have avoided that! I guess the moral of the story is, run of the mill, uncomplicated malaria really isn’t all that bad as long as it doesn’t happen in San Francisco.

Reflections on Medicine and FACES

** I wrote this in early November, but wasn't able to post anything while I was travelling**

Since I came to Africa to work in HIV medicine (among many other less altruistic sounding motives), I was a bit surprised looking back at what I’ve written about to see how little I’ve actually posted about my medical experiences here other than those where I was the patient. In many ways I’ve hesitated to write about medicine as I’ve seen it in Kisumu. As a doctor practicing in a new place with very different resources and very different problems, it can be very easy to talk about what seems to be lacking, or things that aren’t done the way we’d do it back home (often with the implication that different = bad, or worse than we would do it).

I have seen things that have shocked and surprised and saddened me, but I’m really not sure how useful it is for me to write about them here, either for myself or anyone left who might be reading this. I mean, it’s no big secret that Kenya is a developing country and that there is a lot less money and a lot less capacity to pay for medical treatment than we see in the US. Then again, how often do I rant and rave against an injustice that has been done to one of my primary care patients at SFGH, or am I horrified by the fact that I have had to do things that are below the “standard of care” because we lack the political will to make that standard of care available to everyone in the US?

In reflecting back on FACES, the feeling I am left with most strongly is amazement at how much this small organization is able to accomplish for their patients. Yes, there is NGO money behind it, but I feel as though so much of what is being done has come to be through the sheer force of will of every single person working there. It’s not like there’s one, Paul Farmer-like individual who through the cult of personality has been able to accomplish great things. Instead there are many, many Kenyan people at every level of the organization who say, “this is what is right, this is what our clients deserve,” and then find a way to make it happen. It’s a wonderful sight to see.

The pace of medicine moves differently at FACES; things we would admit someone to the hospital for, run a million tests to work up, give some expensive treatment for, with the goal of finding an answer within a week don’t really occur. But problems - HIV-related or not - present, minds come together and a work up is undertaken that may take months and be lacking all the latest technological bells and whistles but is really often enough. Sometimes an answer is not found and one of the empiric treatments that was tried works and we assume we know the diagnosis. And sometimes the things we tried don’t work and the patient doesn’t do well. But don’t we see that all the time?

When I first got here, the second patient I saw walked into clinic incredibly sick: febrile to 40, tachy to 130, CD4 around 80, with a headache for a few days, cough for a few weeks, and abdominal pain. Oh and by the way she was 34 weeks pregnant, too. I looked at her and felt completely useless – take me away from the tertiary care center, strip away the 8 billion lab tests and scans and consults that she would get from our ED and I felt like I couldn’t do a single thing despite having the end of my residency looming not far away. We even entertained a brief discussion of whether or not she really needed to be admitted, since she didn’t have any money. But so quickly it became normal when we saw a sick person to figure out what we could and couldn’t do diagnostically, make a plan to treat the one or two things that seemed most likely, and send them off with the hope that those tests would happen and that when we saw them again in a couple days we would have more info from tests and treatment response to go on.

As a medical resident here for a month, one can’t really hope to do or accomplish much. It would be an incredible arrogance to assume that my brief presence could make a significant impact. I was really here for my own learning, to see a new system, to learn new ways of thinking and to become inspired by the amazing individuals I met at FACES. Hopefully some of that will have a positive impact on what I do and how I treat patients in the future. I really hope that one or two things I may have done while I was here were at least slightly useful, so that I will have contributed just a little bit with my presence instead of only gaining myself.

Malaria

(Not my smear, it got thrown away before I could see it - I wanted the souvenir!)

Well, my exciting news of the day is that I have malaria. So much for doxycycline prophylaxis & using a bed net! Although I was looking at my doxy bottle this morning thinking there were maybe too many pills left, so maybe I wasn’t the best prophylactee.

I was feeling lousy 2 weeks ago – really tired and feverish – but figured I was just getting too much sun and it was really hot out. I was going to check for malaria then, but I got better so I never did. Last night after getting home from dinner I started to feel horrible – really feverish, terrible headache, nauseated. I barely slept because I was having crazy dreams and was so hot. This morning I still felt really wiped out, so I went and got a malaria smear. Much to my shock and amazement, it was positive.








So I started my Coartem (not available in the US, so that’s kind of exciting), and am expecting to feel better momentarily. The whole thing is kind of funny, actually – I mean, how many Americans can say they’ve had malaria? Definitely rounds out the whole African experience. Now all I need is TB…




It’s really interesting, malaria is so common here that it’s often treated for empirically without even checking a smear, or we’ll treat anyway even if the smear is negative. If someone presents with headache, fatigue and “hotness of the body,” we’ll frequently just treat them. It makes me think about my clinic patients at home, who when they present with those vague symptoms I often tell them to rest a bit, try Tylenol and figure it will likely just go away. Malaria doesn’t usually cross my mind.

When I was an intern I took care of a really sick patient who had been airlifted from Africa after having really bad malaria that was treated in the hospital there, but he was now intubated and close to death. We ordered malaria smears, and had to call in the heme path resident and attending in the middle of the night to read them. They couldn’t really tell if they were positive, so we decided to treat anyway because the patient was so sick. But in the US it’s hard to get IV quinine, so we tried to get quinidine but the hospital didn’t have any in stock so we had to try to get it from SFGH across town. It was a crazy, comical production. And in the end the quinidine never came and he didn’t even have malaria anymore after all.

But here it’s just an everyday thing – when I asked someone a couple weeks ago what it feels like to have malaria, she laughed and couldn’t believe I’d never had it. Everyone here has had malaria at least a couple times. Today, I just got a fingerstick, rubbed some blood on a slide and 45 minutes later had my diagnosis. No attending called in from home involved. The good part, as several people have told me, is that next time I come I’ll at least have partial resistance. And not a bad story to tell.

Anonymous

Once a week the COs visit any FACES patients who have been hospitalized, and I’ve now been to the provincial hospital (aka “Russia” because it was built by the Russians) twice with them. I’ve talked with other residents who have rotated in Africa, and was expecting the crowded, open wards often with 2 patients to a bed, someone with active TB coughing on their neighbor with advanced HIV. I wasn’t surprised by the family members at the bedside who provide much of the nursing care, making sure the patient gets food and is able to get up to the bathroom. It’s hard to see, but I was expecting it. What I wasn’t expecting was the degree of anonymity that patients experience there.

In the US, medical teams are structured to have a group of 3-5 residents, interns and medical students following up to around 20 patients. They are supervised by an attending physician who is responsible for overseeing the care of these 20 patients. We tell med students that their goal on the rotation is to be the experts on their patients – to know more about her patient and her medical history than anyone else on the team. As a senior resident is can be disconcerting how little time you actually spend with the patients – your day is spent thinking about them and teaching the rest of the team about them, carrying out tasks in order to provide them with good care and help them get well – but you often miss the intense experience that you had as an intern and medical student of getting to know your patients as individuals (not that it never happens anymore, just less than before).

When we arrive on the ward at Russia, usually there are no medical staff there. We search out the nurses or the interns and ask them about the patients on our list. Frequently they have no idea who we are talking about, with some prompting about the circumstances of the hospitalization and some chart review they can give us a few details. Then we go into the ward to find the patients, and we often have to yell out their names to find them, because again, no one is exactly sure who they are. The information about the patient’s course is often confusing and obtained piecemeal – we check whatever med might be hanging when we get there and surmise he is being treated for malaria. We ask the patient if she’s had a transfusion yet – the reason for her referral 2 days before was a hgb of 5 (severe anemia). The answer is no.

Often the clinical officers haven’t met the patient before, and they get a bit of background from notes taken during the clinical meeting where very brief case presentations are given (so and so referred for admission for PCP). Because I don’t speak Swahili, I also don’t get all the info they glean during the brief conversations with the hospital staff and when we leave I am left with many, many questions. Why is the patient in the hospital at all if they’re not being treated for TB or getting IV antibiotics? What’s the working diagnosis at this point? What more will be done before the patient is discharged? Who really is following up on the patient and making management decisions, if the intern assigned to the ward doesn’t have the answers?
One of the Medical Officers at FACES was telling me that during his internship at times he was expected to cover up to 80 patients with only one other intern (and as an intern I’d feel sorry for myself when our service was busy and I had 8 patients!). It’s not unexpected then, that no one can take the time to get to know these people, to learn their stories or get a glimpse of their lives aside from being sick. I just wish there was some way that when we were there we could make the patient feel like someone actually knew them and was aware of what was actually going on, to make the experience of being in the hospital just a little more personal. And maybe we do – at least we come, we know their name if not their face, we ask what’s going on and how they’re feeling. We bring them their medicines and tell them to come to the clinic once they get out, we'll do what we can to help them out.

Expat Life

The neighborhood where I live here in Kisumu is called Milimani, which I am told means up on a hill in Swahili. I live on the edge of the district, but as you venture further in you see it is a neighborhood of huge, ornate mansions and gated compounds complete with 24hr guards. The people who live here are Kenyan Indians, who are often local business and hotel owners, and Europeans and Americans many of whom work for NGOs, aid organizations or various foreign government affiliated enterprises. Very few Kenyans live here; there is no pretense that this is a “mixed” neighborhood, with wealthy African families scattered amongst these non-Africans who clearly have the deepest pockets in town.

It’s an odd experience being here for 5 short weeks; you want to set up a life for yourself because really, who wants to sit alone at night watching the bad Mexican telenovelas translated into English that pass as prime time TV in Kenya? But on the other, with such a short time you can’t really begin to understand the social and cultural context in which you find yourself. The expat community is used to transients who come and go, and as a foreigner in a new place it can be easy to slip into a social scene that is welcoming and easy, but remarkable for lack of actual Kenyans.

Many expats live a life here that is luxurious to a degree that most couldn’t imagine living in their home countries. Servants, guards at the gate, cars with drivers – who could live like that at home? And yet the salaries that many expats earn here can support that lifestyle. The ironic part, to me, is that there are a lot of these expats who live in these fancy places, who have the means to go out for a fancy dinner then out to party every night of the week if they want to, are here in affiliation with some kind of foreign aid organization or governmental entity. How does it happen that people come here with good-hearted aims of helping people and improving people’s lives and yet away from work they live this life that would be out of the question if they weren’t in a developing country? Now, this is not to say that everyone who is here working in an aid capacity lives this double life, far from it. It just strikes me as so odd that this scene exists as it does at all. I guess it's normal when you're away from home to crave the familiar and to try to re-create elements of your life at home, but sometimes parts of that life are so strikingly different from where you are that it feels weird to try to make them happen.

Oranges and Bananas

Election season is here in Kenya, and the scene is really heating up. The presidential elections come around every 5 years, and in recent past have been really contentious, at times violent. In its 40+ year history of independent governance, there have only been 3 Kenyan presidents: Kenyatta, Moi and the current one, Kibaki. For every election, each party with a major candidate chooses a party symbol that is listed on the ballot, I’m assuming to assist those voters who can’t read. 5 years ago it was the oranges vs the bananas in a fight for the finish, and the bananas won. Now the oranges feel it’s their turn.

Politics in Kenya is passionate; much of the fervor with which candidates are followed stems from tribal affiliation. There are about 40 tribes in Kenya, but of the 3 presidents, 2 have been from the same Central Kenyan tribe (Kikuyu) and the other from the Kalenjin (also from Central Kenya). Kisumu is a very Luo town, and this year there is so much hope and excitement for one of the candidates – Raila Odinga – a Luo. The Luo are the second largest tribe in Kenya (though I’ve seen some sources say third largest), but there is a strong feeling of alienation from the political machine. Many complain that after independence, the government was set up in a way to favor certain tribes like the Kikuyu, while disenfranchising others like the Luo. Of course, I heard all this from the Luo perspective, so it’d be interesting to hear how the Central Kenyans describe the whole situation.

In any case, Raila is the candidate from ODM, the Orange Democratic Movement. Not really sure what the orange part means, whether it came before or after the ballot symbol, but it gives a good excuse for people to dress in their Halloween best. People here have so much hope that he’s not like the other politicians, that he won’t stand for the corruption and graft that have tainted the government in recent years. To hear them tell it, Raila can do no wrong and will be able to swoop in and make all this better. Of course, as former Minister of Roads, and having recently travelled on some pretty bad ones, I have some doubts about his potential for overall efficacy. And really no one could live up to all the high hopes being built around here.

The political debate is starting to sizzle, with the 3 candidates variously accusing one another of extreme corruption. The first lady, Mrs. Kibaki, has given many mudslinging speeches calling the competition criminal and corrupt and all around bad guys. Interestingly, though, many regular Kenyans say the same about her husband’s government. Many people feel really frustrated with Kibaki because one of his early campaign promises last time around was that he would serve one term and then step away. And yet here we are, he is running again. Another big issue is that the Kenyan constitution has not been changed or updated since independence, and power is densely concentrated with the president, rights of women aren’t well address, and all around people want to make some changes. Kibaki promised in his last campaign that there would be a new constitution within something like 100 days, and yet only recently he refused to sign a newly drafted constitution. Talk about power… So the Luo around here aren’t happy with him for many, many reasons. But Nakuru where we just spent the weekend is a Kibaki town. Our cab driver told us what a great leader he is, how he’s done so much for the country, etc. Having only heard about politics from the Kisumu Luo perspective, I had to bite my tongue to keep from arguing this guys merits, or lack thereof.

In Nakuru there were lots of billboards encouraging people to use their vote (selling of votes has been a big problem in the past). The most interesting one was a billboard telling people to vote by the issues, not by their tribe. It’s great that that sentiment is put out there, though clearly tribal alliances are a huge factor. In Kenya, the Luo are one of the only tribes who do not circumcise their men or their women. Most other tribes have some sort of puberty/initiation ritual that involves circumcision for men, though female genital mutilation is being pressured out on many fronts, though it still exists. Tribal politics are such that people will actually debate whether an uncircumcised man is fit to be president. Crazy. Some have said this is the most contentious campaign ever, and they’re anticipating things will get a lot worse before the December 27th election.

An interesting corollary to all that political chatter is the Barak Obama bit. Barak’s father was Luo, from near Kisumu. So you can imagine how people around here feel about him. When talking politics, the second thing out of people’s mouths (after talking about how Raila will save Kenya) is, “so, do you thing Barak has a chance? Are you for Barak??” His autobiography is sold in the supermarket under African authors, people wear Barak tee-shirts, he is truly a homeland hero. He even came and was publicly HIV tested at the public hospital in Kisumu to encourage Kenyans to be tested and to learn their status. I guess the cult of personality is big in politics everywhere, but in Kenya it definitely dominates which unfortunately all too often ends in crushing disappointment, since these are only regular guys subject to the same pressures and temptations as everyone else.

Lake Nakuru & Menengai Crater

It’s been a while since I’ve written; I got very caught up in preparing my massive HIV dermatology presentation for FACES Continuing Medical Education. It went pretty well, I think, despite several potentially disastrous AV glitches, and despite learning at the 11th hour that my presentation would be given not only to clinical staff, but to all FACES employees, including the data analysts and front office staff. I found the whole idea of me giving a derm talk kind of ironic, since I feel like at home I see a rash in clinic and always think, “hmm, a rash, whatever could that be?” Now I’m getting called in to look at skin several times a day, and I find myself saying “oh, yes, most likely psoriasis…” Hard not to feel a bit like a big fake, but oh well…

In any case, this past weekend I went on a fantastic trip to Lake Nakuru National park with 4 others – Megan, Jolene & Jolene’s non-medical friends Marieline and John Michael. Nakuru is Kenya’s 4th largest city, and is about 4hrs east of here, in the central Rift Valley. Getting there was quite the bone-shaking adventure – the Nakuru road is absolutely horrendous, 4 straight hours of potholes and ruts and other road quality nightmares. And this is the road that leads from Kisumu to Nairobi! Kenyans complain bitterly about the state of their roads, and initially I thought it was one of those reflex complaints (like Americans and taxes), but no, Kenyan roads are really, really bad. I’ll say it again, really, really bad.

On Saturday we set out early for a game drive around Lake Nakuru National Park. Nakuru is quite a bit higher in elevation than Kisumu, and it was actually pretty cold. And it rained all day. But it was cool to see the phenomenal landscape in the mist, and I think the animals may have been out and about more than they would be on a typical scorcher. Nakuru is the only national park in Kenya surrounded by a fence, and that is to protect the rhino population that was reintroduced after poaching pretty much decimated the local rhinos. Now there are a bunch of black rhinos (which aren’t black at all, but have a pointy upper lip & eat bushes, and are notoriously shy) as well as quite a few white rhinos (surprise, surprise, not white either but are distinct from black rhinos because of their flat upper lip, good for munching on grass). The introduction scheme seems to have worked well because we saw white rhinos all over the place, including a really cute baby one (unusual to see said Tim, our guide, because supposedly rhinos only have one offspring in their entire 45 years of existence. Though I don’t really trust that since there’s really no way around extinction if you only replace half the population each generation).

Early on in the day we raced across the park - at Nakuru you can only drive on the roads, no off-roading allowed – in search of some lions. Before long we came across a gorgeous female up in a tree, looking bored & sleepy and only about 30 feet away from the road.

About 100ft back we could see a male eating some kind of carcass, which we could smell better than we could see it. After a bit the female hopped off her tree branch & strolled into the middle of the road right in front of us.

After some paw washing she moseyed away. Then her big male friend came to check out her tree, though he was a bit on the klutzy side hopping up. Soon a second male appeared from the bushes – we waited for some kind of angry man-lion showdown, but they seemed barely curious. The first guy got down on the ground, and the second approached and the 2 brushed heads like friendly cats sometimes will with one another. Of course I missed that photo opp. Eventually we moved on and came across the female now up in yet a different tree. It’s actually quite unusual for lions to climb trees I guess – Nakuru is the only place in Kenya with tree climbing lions, much to the leopard’s chagrin since they are usually safe from lions when up in the trees. We drove past her spot a couple times during the day, and she was always up there, snoozing away, occasionally watching a herd of gazelles not far off but looking very unmotivated to chase anything. The last time we passed we saw that the big male was now sitting about 50ft away from the base of her tree; she was playing hard to get, not really giving him much encouragement, but he eventually moved out into the open and flopped down on the ground like a kitten in a sunspot. Tim thought she was likely a young female in heat, and these 2 males were suitors vying for her attention. A bit unusual for a female to be travelling away from a group of other females, but maybe she was just setting out on her own. We watched a while, wondering if we’d see some lion action, then decided to leave them to their courtship in privacy (actually being closely watched by at least 5 vehicles at all times!)

Next we stopped to watch some funny warthogs, which really are called pumba for all you Lion King fans out there. I giggled a little every time I heard it. Off in the distance we saw a female zebra with 2 half-grown zebras nearby. We were about to move on when Tim said, “oh, yeah there’s her baby trying to stand up for the first time.” Not really sure how we missed her giving birth while we were gazing upon a bunch of warthogs 40 feet away, but we did. Looked through the binoculars and sure enough there was a damp, gangly little guy lying in a heap while mom chowed down on the grass (curiously she didn’t seem particularly concerned about this life she just produced. The little guy tried valiantly to struggle to his feet and eventually managed a wobbly, knock-kneed, wide-legged stance, then fell down when he tried to walk. After many attempts he finally got up and staggered around a bit, trying to figure out how to nurse but seemingly aiming at mom’s tail. Really amazing.

From there we checked out Nakuru’s famous flamingos – often up to hundreds of thousands of them at a time on the shores of the lake (it’s a saline lake and they eat the blue green algae there). I guess the flamingos aren’t as reliably at Nakuru as they used to be since the lake is becoming more polluted and the salinity changing rapidly from water runoff and unpredictable drainage. This day there were a ton, though, and looking down at the lake from several hundred feet up, it looked like part of the lake had a lovely pink sand beach.

The day was rounded off by seeing lots of baboons, who are creepily human and yet not so, so much that you start to feel weird the longer you look at them. Also gazelles and giraffes and buffalo, pelicans and crazy, prehistoric Marabou storks. The one big thing we missed was the leopard, but supposedly there are only 4 in the park and they are nocturnal and quite reclusive, and can be really hard to spot. It was a really nice, breathtaking day in such a lovely place.

The next day before getting several teeth rattled loose on the return matatu ride, we took a taxi up to Menengai Crater, supposedly the second largest land crater in the world. It was really awe-inspiring, so vast and green (which has surprised me a bit, Kenya is overall really green) and semi-deserted. We made it up there before all the curio sellers did, so we were able to take in the view without anyone else around. Such a cool weekend, I’m still just awe-struck by the fact that all these crazy animals are just wandering around, doing their thing. I mean, really, that’s a real live lion just chilling by the side of the road.