My US colleague and I have just spent a very productive week with our Kenyan hosts and German leaders focused on the Nehemiah International ministry.  We have spent our days this past week, including today Sunday 3 May developing a long range sustainable plan for the future of Nehemiah Kenya.  The communication has been very good and a lot of cultural understanding has been accomplished.  Greg and I will bring this information back to the US board of Nehemiah and determine what projects and endeavors we can support in addition to our continued support of students.  The German team will, as God provides, support several primary and secondary level students with school fees, uniforms, shoes, supplies and transportation.  The US team will continue support of now 5 students in University training degrees of various stages.  It has been wonderful re-connecting with the students an hearing their hopes and frustrations, as well as their visions for the future.  Greg Livdahl and I will leave the farm tomorrow and thereafter be with Dr. Omoto until we return home - both of us just in time for Mother's Day!

While there is a chance I may do some more teaching on trauma topics, it appears our time may be filled looking at children's feet to determine the efficacy of the Jigger elimination project we helped fund back in December 2014.  We are set to visit 4 schools and take a close look at many feet!!  

The Jigger is a flea which once pregnant completes a part of its life cycle by burrowing into exposed toes (or fingers).  There the larva mature by feeding on our blood and oxygen, to erupt and find again dirty floors with moisture and debris, where they mature into adult fleas, whom for once mating has been accomplished  find their way back into our toes (the females anyway).  The project resurfaced concrete floors that had become dirt and dust, applied within the concrete an insecticide, and at the same time undertook resurfacing of the children's floors at home with a fresh smear of cow dung! and insecticide as well.  To provide shoes to the 40-60% of children without them is only temporary as the shoes will be outgrown, lost, worn out or simply not used.  We hope to find some evidence of eradication this week.

Beyond that, my 53 day journey from home is to end in 6 days.  I have been able to re-work my book, write new material and do further editing.  Hopefully have injected even more heart and soul into the book.  I will be sending a few sections off to my editor in 2 weeks.  Will see what happens - anything from a total re-write to further editing (fully expected) is possible.  But it has been an enjoyable process!  Hopefully I have begun to reflect the character of my wife in this new material, and shared more of the personal struggles we both endured.  Other voices and eyes will have to judge that.  I pray I can respond accordingly.  Writing has been not so much a cathartic or healing process for me, but perhaps of discovering more of who I am and of what my wife and family mean to me.  Hopefully that comes through in my writing.

All for now from south of the Equator and this side of the pond.

Blessings, and thanks for reading -

Ernie

After that also teaching at Sagam Hospital to family practice residents on similar trauma topics.

There is so so much more to be done. Fortunately it appears I will have time to do more teaching when I head back to Kenya in just over a week.  The official goal of the second trip is to work with the staff at Nehemiah International in order to develop a long range sustainable plan - for both the farm and for the 20 students we are supporting.

By May 9th I should be homeward bound.  I shall shortly report on the state of RTA's (road traffic accidents) in Kenya.  All in all, it has me thinking of going back to school for a masters in global medicine…. but first, to finish editing my book.  And that is why I now find myself in Split, Croatia. 

The good news, then some really sad news to report and a tribute.

Kenya 2014 - Yes before the Ebola scare I traveled to Kenya in February of this year to look at several potential projects in support of Dr. Omoto as well as to visit Nehemiah International, the farm in Miwani.  I traveled with Greg Livdahl our Chairman of the Board (his first time ever to Europe and Africa!).  We had a fabulous time; visiting many clinics and hospitals to look at their challenges.  Teaching on Emergency Medicine trauma topics (primarily motorcycle trauma); and a great visit to the farm.  The students we support are doing well, as we were able to meet several of them.  The farm itself is seeking outside support as our funding (shrinking) is directed more to the students and to the medical work of the Nehemiah clinic and Dr. Omoto.

The Book - I did finish my first rough draft in December of 2013.  Editing has been slow - - very slow.  Excuses, excuses, well YES!  Kenya, life, bicycling (I did reach again over 2000 miles on the road - now my second year in a row), intensive care for our Bernese Mountain Dog from January til August (at which point, sadly, he needed to be put down), and within a week of that, and most vitally important, my dear mother was diagnosed with stage 4 Endometrial cancer (Uterine).  

She elected, after surgery, to have Hospice care only, and declined chemotherapy. Fortunately she suffered minimal pain and distress, did get to say her goodbyes to everyone, and thanks to incredible support was able to remain at home throughout it all.  Sadly she has left us - free of this life as of October 31, 2014.  I am grieving, and yet filled with the memory and spirit of her.  The Obituary I wrote, a tribute, to follow.....

June 12, 1932 – October 31, 2014

Esther Yonan Franz was born in Chicago 1932 as the second of 4 children raised by her Middle-Eastern immigrant parents who continued a family owned Oriental carpet business begun in 1906. Yonan Carpet and flooring is still family operated and thriving to this day.  She was a brave and beautiful Assyrian girl who was game for anything from playing baseball (even into her 70's after having grown up in the shadows of Wrigley Field) to driving a red Galaxy 500 convertible in the 1960's (something a pastor's wife was just not to do in that era) .  While in college in the early 1950's she ran for Prom queen as an independent solely because she was fed up with the status quo; there she beat out the popular sorority favorites and the reign of Queen Esther began.  In 1952 she met Faris Franz, a dashing McCormick Theological seminary student while they worked together at an inner city home for displaced and troubled youth.  They married in 1954.  Together they formed an effective ministry team; Faris the intellectual scholarly pastor, Esther performed the emotional and relational field work.  They produced four boys.  The oldest of who was gravely disabled and ultimately could not live at home.  This profound sorrow was overcome by Esther's deepening faith, love and sincere interest for her family; characteristics that were extended to all she met at her husband's five Presbyterian Church assignments.  Throughout her 38 year career as a pastor's wife she established a loyal network of friends from Indiana, Florida and Illinois; and in "retirement" on Bainbridge Island since 1997.  She always had a special inclination towards those who found themselves as a minority, whether by race, religion or other preference; especially working to see that African-Americans were treated with the full respect they deserved, even in the late 1960's to 1970's as she and her husband continued to serve despite threats of harm in Florida.

Esther remained active in volunteer work her entire life wherever she resided.  She sought out all those in difficulty, suffering or with disabilities in order to share her love, bright eyes, listening ears and encouragement.  Her five grandchildren loved being with her as she helped grow their talents, teaching them cooking, sewing and home-making; not to mention how to live simply and remain content in this life despite the inevitable losses, hardships and disappointments that will come.  Esther had experienced more than her share of these in the death of her oldest son at age 16, and especially in the sudden loss of her husband Faris aged 63; after 39 years of marriage and just into his first year of retirement shortly after the two of them had built, much by themselves, their dream log cabin home in New Harmony, Indiana.

She brought much wisdom, peace and love to those fortunate enough to know her.  Her presence is deeply missed, yet her spirit and love for all of mankind will live on in each of us blessed to have called her mom, sister, grandmother, aunt, or friend.

She is survived by her sister Ruth Yonan Iyengar (spouse Hal), brother David Yonan (spouse Karen), and sister-in-law Nancy Yonan; her three remaining boys Ernie (spouse Gwen), Andy (significant other Brigitte) and Steve; and her five grandchildren Evan, Daniel, Heidi, Helen and Faith.  As well as several nieces and nephews.

A celebration of life and memorial service is planned for Saturday November 22 @ 3pm at Rolling Bay Presbyterian Church.  In lieu of flowers, the family requests you consider a donation to Esther's favorite charities:  Heifer International or Habitat for Humanity. 

First the bad.  In December I fell on our stairs over our 105 lb. Bernese Mountain dog.  I had stepped on his tail and slid, falling backwards actually but forcibly flexing and rotating my right knee underneath me.  After lying on the landing for perhaps 5 minutes waiting for the tone and general spasms to dissipate, I got up to find my knee was none too stable.  To cut through weeks of uncertainty and a few more falls in the meantime, basically I shredded what little cartilage was remaining in my right knee.  The joint space filled with debris and floaters, which cause either knee locking (stuck in partial flexion, unable to flex or extend further) or sudden collapse (thus a fall again down the stairs just when I thought all was well with the world).  Many phone calls, exams and consultations later - we decided the best course was Physical Therapy.  Failing that, a surgical flushing out; despite the fact the plain films and the MRI looked as though a total knee was in order!  The good news - no pain at all (since I have almost no sensation below the waist), and even better yet, PT again worked wonders!  Time heals - well that and PT, and prayer and a knee brace and perhaps even Wobenzyme (a German developed combination of anti-inflammatory enzymes).

Gradually, by March, I could begin cycling indoors for up to 10 minutes!  But quickly due to my improvement the 10 minutes became 30, then an hour, then pushing personal records on a Compu-Trainer.  Soon it was outdoors, and since sometime in April I have managed to get in about 1400 miles on the road!  Lots of knee clunking and popping, but no collapses nor locking.  My weight back below 170 and a hope for further improvement.  Still a scope and a wash out are likely on the horizon, but who knows.  Time will tell.

Africa, book writing and further updates .....

Mostly our US based board is trying to figure out where we can create the most good with the designated medical support funding we do have.  A trip to Kenya will likely help to clarify that, but is unlikely until possibly December 2013.

Sadly, the changes with the Miwani farm support have mostly to do with one Kenyan individual who has not wanted western (either EU or USA) involvement.  That single person has enough physical power and threatening language within his grasp, that he has successfully brought to a halt our ability to support the ministry and the people involved.  Though we too desire to see a Miwani farm run by, staffed by and managed by Kenyans (just as he does), the way forward with him remaining involved is blocked.  Stay tuned as we work through this.  Pray for those on the ground there.  It has to be difficult.

For years, even shortly post-trauma, I have thought about writing a book of my experiences and lessons learned.  The past 18 months have seen me get more organized in that regard.  I now have close to 50,000 words written and hope to soon (in the next month or so) get that off to some readers and an editor.  My goal is to have something in print by the 10th anniversary of my injuries - August 23, 2014.

On the family side of things, our youngest - Heidi - graduated from Bainbridge HS this past June.  She will attend Seattle University beginning next month with intentions of pursuing photography or photo-journalism.  Daniel in the meantime will begin his final year at Seattle Pacific University in computer science.  Evan is working at a great job in Portland doing commercial sewing at Spooltown.  Just when you thought Gwen and I may be empty nesters, no - that is mostly not happening!  Gwen herself is heading back to finish her doctorate in music at the University of WA combining classical viola studies with jazz.  So I should be able to find the time to focus on completing this book project.  In the meantime I will be continuing my volunteer work at the University of WA school of medicine with first and second year medical students in Introduction to Clinical Medicine and also teaching physical exam skills.

Thanks for reading!

So here are my final impressions of the trip.

Our team along with people from NI and local community health workers (CHW’s) surveyed 157 households in the Miwani area over 3 days from July 3-5.  We covered Karunga, Keyo, Chebrir, Kaleng, Obino, small sections of Kibos and Miwani, and a few other areas.     We were well received, though asked on occasion if we had the Miwani area chief’s permission to conduct such a survey; which had been obtained in the form of a “required payment” of 3000 KSH to the chief himself.

In order to validate the survey tool, as well as to compare and contrast the Miwani population with another population group, our team also surveyed households in the Mundeku/Khwisero area near where Dr. Omoto resides (about 2 hours northwest of Miwani).  There our team was joined by CHW’s who already serve the population of these areas, as well as one NI staff member and two nurses from Siaya District Hospital. The survey was undertaken from July 10-14 and gathered data from 357 households.

This data, combined with additional data (roughly 700 additional households in Miwani) gathered by the BHS team, will be analyzed via the help of Dr. Omoto and someone he has hired in Kenya.

The results have just in the past few days been made available to me, and my assessment of those is to follow.

Teaching – Dr. Omoto asked me to lecture to “medical students” at Siaya.  I was not certain which group of students this would eventually involve, yet I did prepare my talks for that level of education.  As it turned out, I spoke to roughly 25-30 graduate nursing students over 2 full days.  Topics included:  Motorcycle crashes in Kenya, statistics, laws and current trends; Head Injuries; Lower Extremity fractures; General Trauma care; Diabetic Emergencies; Chest Pain; and lessons learned from my own personal story and how to better connect with patients to deliver empathetic care. 

Much of the material was presented in a traditional lecture format, while other sessions involved using a small group interactive approach with some homework between days 1 and 2.

This material seemed well received with the class voicing their deep appreciation at the conclusion, even choosing to provide a blessing to me and prayer for how God might continue to use my life.   

Emergency Services @ Siaya District Hospital – Most patients are routed to clinics for their acute care needs, such that over two days of intermittent visits I did not see anyone actually treated in the A&E.   Given that the four physicians serving the hospital are a general surgeon, an OB/GYN, an internist and a pediatrician, there seems to be no one to fully appreciate the lack of preparation and organization of the A&E.  The department appears ill prepared to handle a crisis or true emergency due to both lack of necessary equipment and disorganization of supplies. 

The 220-bed hospital has no EKG machine and no cardiac defibrillator.  These are not broken, merely non-existent.  There are apparently two cardiac monitors in use in the operating theaters, but none for use anywhere else in the hospital.  Approximately 95% of the supplies in the A&E are locked behind cabinets, all which have separate keys, and no labeling system for either keys or supplies.  The “mobile crash box” is quite immovable and fixed to the floor.  Any given cabinet, once opened, revealed a random supply of gauze dressings, syringes of epinephrine, rubber boots, bottles of IV fluid, and medications from anti-hypertensives to glucose tossed loosely in piles or mislabeled boxes.

Beyond the addition of a cardiac monitor, EKG machine and defibrillator for the A&E they clearly need an extensive re-organization of medications, supplies and equipment to begin to be able to respond to crises both in the A&E, but also within the hospital itself.  I was told this area was staffed continuously and that theft had not been a problem which further had me thinking a few days of re-organization and the addition of some key equipment may indeed save lives at the hospital.

Of course given this system no one needs to know CPR!  There is simply no reason for CPR; nothing to correct or change.  If your hear stops, you are done.  DRT as we say in Emergency Medicine - Dead Right There.

NIHS Dispensary – Nurse Esther and Lab Tech Ken are doing the best they can with little to no supervision, and limited resources.  They appear always willing to open the dispensary doors whenever a patient presents to NIHS, even when scheduled to be closed.  It was difficult for me to actually observe patient care being delivered.  I did request text messages for when someone ill presented to the clinic, but that did not happen.  Other times of direct on-site supervision saw them evaluating either simple rechecks or minor problems.  My sense is that most care delivered is via consultation only, meaning taking a history and deciding what course to follow.  I saw very little physical examination ever take place either in Siaya District Hospital or at NIHS dispensary.

There does seem to be a strong intention of requiring people to pay for their medications received.  Not so much for actual care delivery, but at least for the cost of medications themselves.  I did obtain an excel spreadsheet of current mediations in use and the cost to NIHS.  I have yet to complete that evaluation, but from what I saw medications were far less expensive than I had expected – even IV medications such as Ceftriaxone 1.0 gram cost roughly 85 cents per dose.

Final Conclusions:

There is much to be done!!  Admittedly at times I felt the extent of the need was so great, there was little chance of success.   But what is success?  It is not re-creating even a portion of the (rather flawed) American health care system in Kenya.  I think it is bringing some measure of health and hope to the people of Miwani and Siaya through our efforts of education, equipment and the provision of and access to healthcare that is otherwise non-existent.  IF NIHS is to grow it will need an energetic and creative nurse manager who can work closely with CHW’s to create an effective program that encompasses the following: continued treatment of people at the NI dispensary; establishing an HIV/AIDS program; offering expanded immunization and de-worming programs to even more schools in our area; educating those in the villages in regard to water treatment, common illnesses, and family planning; and possibly the development of a response system whereby we can transport ill patients to the dispensary or to the hospital depending upon their condition.  I envision obtaining a dedicated all-road vehicle which can respond to cell phone calls from Community Health Care Workers to transport those to ill to make the up to 6 mile walk to NIHS.  All of this will require ongoing financial support and careful management.

13 July 2012 

More interesting survey details today.  Lots of ups and downs for terrain, side hill and more rugged balance challenges.  One Muslim older woman said if you urinate into a ground fissure or dried earthen crack while on your menses, then cover the fissure with earth, your uterus too will be sealed.  Another when asked about birth control methods stated that she and her husband sleep in separate beds and in different rooms, that this works for them.  However when asked to list the side effects of this method, she stated that it led to more quarreling and discontent in the home directed toward her from her husband.   We had a woman whose husband works in Nairobi, she has very high BP, which she says is due to a witch or night runner that attacks her house all night long when her husband is away.  Throwing rocks on the roof, hitting the walls, sticking fingers over the walls, between roof and walls, and running naked thru the brush when she opens the door to get a glimpse of him.  Her husband supports this story.  This, “the reason for her hypertension”.  They had 5 children, 4 have died, the one remaining lives and works elsewhere.

Another said pills work well for family planning, but when you do have a child after pills, they will be born with 10 heads.  And again a story of pills swallowed go directly (this time) to your tubes, where they remain and must surgically be removed.  Last Depo injections can “cause your heart to come out of its cage and move” to another area of your body, in this case the woman claimed her lower abdomen.  One day while coughing and pushing there, it “moved back to its cage”.

Sad case of the day was a young early 20’s woman with epilepsy, on no meds, with 3 children.  In April she seized and fell into the fire.  Her left knee still with open wounds and scarring and oozing, and difficult to walk or put any weight on it.  Her children very thin, the 8 year old girl was 16 kg and 120cm tall.  Giving a BMI in my head of 11; so sad, I shed a few tears right there for their situation.  The WHO says anything under 16 is extreme thinness.  Did not see a husband.  Nearly empty home still under construction.

Last, I had fun with Carlton, an 18month old kid.  His mom said I was the first Mzungu he has ever seen in his life.  We kicked a soccer ball (old plastic bags rolled into a ball) around for a bit.  He would take a running start to kick the ball, very funny to watch.  He is a talented kid!  Well I am tired, falling asleep now while trying to type.  One half day of surveying left. 

14 July 2012

At breakfast Dr. Omoto asked me to preach for 40 minutes Sunday!  Oh boy, a bit of panic – but how can I refuse?  So prepping for that as I can.  Last ½ day of surveying went fine, hitting over 355 households in total for the 4.5 days.   Dinner had the usual amazing layout of foods.  Again, the staff washed our clothes, ironed them, folded; shoes all scrubbed and washed to an amazing level of cleanliness.  My Keens done 3 times for extreme mud; but they take their job seriously and work on anything. 

15 July 2012

Preached on Psalm 133:1 and 2 Corinthians 4.  Community.  Tied in Dietrich Bonhoeffer’s words from the Service chapter of Life Together.  Spoke to our efforts to establish community in Khwisero and Miwani areas, with the challenges of sharing the gospel and scripture and praying for those in our communities.  By surveying their health and beliefs and lives, we have had a glimpse into the life of those who are suffering and who, like us, as jars of clay – fragile vessels, may find ourselves suffering at any moment.  However this drives us to God who gives us hope, if of nothing else, of eternal life when we are released from this life.  In the meantime we can be of service to those in our community who are broken and in despair.

Omoto’s church was nice, great singing and perhaps Pentecostal?  At the end of nearly every song they all moved into spoken prayers – since I cannot understand the language it sounds like fervent prayer offered in tongues, but could be a mix of Swahili, Luo and Luhya.  Gradually these prayers would fade and another song begun. 

Again a wonderful meal at Omoto’s.  Photos taken.  Goodbyes said.

Sylvester drove us back home to Nehemiah in just under 2 hours.  Looking forward to going home which will begin tomorrow,  16 July 2012!

11 July 2012

Matt had a rough night, staying back today.  He was better by the afternoon, and even better tonight. 

Survey went well.  Lilian (one of the head nurses from Siaya District Hospital), a Community Health Worker (CHW) also named Helen, and myself tagging along.  In Khwisero, the town of Ebushybungo, with nice people and yet quite poor.  We are now at 127 households done in 2 days.  Welcomed nicely throughout.  Most with mud walls, floors and tin roofs.  None with electricity, a few with car batteries to operate radios.  Some elderly.  A few with hypertension.  Lots of missing teeth, some TNTC (too numerous to count) – or better yet to count those present – as in the case of the 86 yo man with 4 teeth present.  We did roughly 16 homes.  One woman worried if you cough hard you might dislodge your IUD and have it move to your heart. 

Lexi on a roll tonight with her language and stories.  She had one wedding proposal today, as noted, to be his first wife!  How kind, and such an honor.  At dinner she had Omoto and his staff in stitches sometimes with her mix of Luhya or Luo or Swahili.  Later a huge bug flew into dinner, after it passed over all of us, Lexi calmly swatted it from the air, and picked it up barehanded from the ground to show us the very large dung beetle.  Matt, scared of all insects, was impressed as Lexi strode out the room to toss it back outside.  Omoto quite impressed too, he could hardly believe a Mzungu would take on a dung beetle in such a manner. 

Times like these, and you think no problem, I could come back and jump into the efforts here.  Then other times like this past Monday thinking, What am I doing here! What was I thinking?!  It will be nice to be home!  So some major ups and downs – but today was very very good.  Ended with prayer and singing – after an amazing meal of rice, green grams, avocado, greens, ugali.  The avocado the best I have ever tasted, by far!!  Texture and flavor – WOW.  And the price in Kenya is typically 5 to 15 shillings at most (that is roughly 7 to 22 cents).   

12 July 2012

Survey day.  Matt much better!  He slept solid.  All is well mostly, the imminent feeling of impending malaria fading a bit.  Somehow during the night I spilled some urine out of the urinal onto myself, my shirt and bedding.  Argh!  Thinking I would shower off in the morning, but no power and just as I am wondering what to do, the gentle knock on the door of “warm water at your door.”   Amazing.  Finishing up my morning routine, 40 minutes went by before I would access the warm water.  No wash cloth, decided to strip and pour some over me with a 3 liter water pitcher.  Mistake.  The water was intensely hot!  Still, now 10 hours later my skin is burning, but no sign of burns.  It hurts though.  On top of that the cracked toilet seat (yes, even at Dr. Omoto's guest quarters) managed to inflict a 2-3 inch long superficial laceration to my thigh this morning; no pain as I have little to no sensation there, but still not good to get up from the seat and find a bloody surface.  Oh well, the ups and downs continue.

Surveying went smoothly, though I bonked for some of it – needing food and/or water.  Made it till 4 pm.  Some interesting cases though.   One lady 170/120 for BP.  Stopped her Nifedipine 3 months ago due to the cost of 250 KSH ($3 USD) every 2 weeks.  No money to afford it.  She has been having chest pain and palpitations recently.   The next home we visited had an 18 year old with a history of seizures.  No sooner had we entered than she went into a classic grand mal seizure.  Her mother restraining her through the tonic-clonic phase then released her to be postictal.  About 15 minutes of slowly becoming more arousable, and she was soon up.  The mom said they had tried phenobarbital and what I later discovered was Dilantin, both without success.  So they gave up.  Not even sure she ever hit therapeutic doses of each.  She is quite talented with crochet, having knit many items quite precisely – a table runner, pillow covers and decorative items.  She apparently seizes 6-10 times per day.  I wrote out a list of other possible medications to try (Tegretol, Neurontin, Lamictal, Depakote) and we encouraged them to pursue care again.  Next we had a 22 year old with what first looked like a dense cataract (in the dark of her home), but outside it was actually a corneal scar near the central visual axis that she had for 5 years.  Perhaps scaring from infection, an ulcer or trauma?  It was only about 4 mm in diameter and solid white. 

Traditions.  Learning lots of these, and myths too, or perhaps "urban myths, or legends".  Many Kenyan women, who are close to getting married, have their lower front 6 teeth broken out?!  This as a sign of a marital commitment.  No numbing, just trauma to break them out as proof “she is tough enough to be an adult woman”.  Fortunately this practice may be declining as we saw this more commonly in women over 40, but not usually in the yonger.  Birth planning, and complications of contraception were always interesting parts of the survey.  IUD’s can apparently travel to the heart, where they are a cause of persistent coughing as one tries to bring it up.  Depo is preferred by many women, as their husband cannot detect that they have had a shot and then not be upset.  Apparently many who use pills have to argue with their husbands who can see they are trying to not have children.  Another said she did not like taking pills because they will go to the uterus when swallowed and cause it to be blocked, once enough pills are taken, and you will need surgery to remove the blockage.  One other felt a part of a condom would be left inside the vagina, and this too will block later attempts to get pregnant.  One man commented he does not like the IUD because during sexual intercourse he feels it and it hurts him.    Another woman, whose husband’s testicles never descended, had been unable to get pregnant, so she had a child by another man.  But in the meantime her husband learned the cause of his impotence, and he knows the child is not his.  He was furious.  Beyond this we have two unusual practices.  Wife-inheritance and polygamy – both common.  If a husband dies, his wife is inherited by his brother next in-line, if he wants her.  If he does not, the option goes to the net male in line.  If she is not chosen, then she is considered “shamed”, and is to stay out of public view as much as possible (not going to market, or even to be seen outdoors in the garden is bad luck to other men who might cast eyes upon her). And beyond that, polygamy is common, especially if the woman cannot bear a husband a son.  We saw several cases of the man and his wives all living in the same compound, just not under the same roof.  One of them commented for birth control he “just senses when one wife is ripe for conception”, so he “runs” to the other wife’s home during those times.  I cannot believe the women put up with this!  Soon, though not soon enough, perhaps they will stand up for their rights and things will begin to change.  When both polygamy and wife inheritance are gone it will impact HIV/AIDS transmission; but even beyond that, women need to be more respected, given a voice and an ability to generate their own livelihood/income.

9 July 2012

Siaya, and needing to vent a little bit.  All is mostly well, at least thankfully I am doing okay. 

Admittedly some fear since Matt developed malaria while taking Doxycycline.  He is sure he has been faithful about it, perhaps one dose  taken 10 hours late.  Anyway about 40 hours ago he developed teeth chattering chills, sweats and fever, with nausea and extreme weakness.  Wiped out, awful feeling.  No appetite.  Decided to start him on the Coartem that I had bought on my last trip here.   So far all is well, he is doing much better.  A fast response to the meds.

Though I am fearful of what is to perhaps come for the rest of us.  All others also on Doxycycline 100 mg once per day.  So a bit disappointed to see it may not be the 99% effective drug I thought it was.  That and now 48 hours ago I got at least 15 bites while watching Sherlock Holmes with the gang in the coach house.  Feeling like the more bites I get, the more at risk I am – which is quite true.

NOTE: I did later happen upon a meta-analysis which stated Doxy is 92-96% effective; still is that per person or per single bite?

The lectures today to the “medical students” went well, though honestly the students were actually the equivalent of graduate level nursing students.  So needed to flex a bit to talk at a slightly lower level, nonetheless all seemed to be well received.  One more day of lectures, then onto Mundeko and Khwisero to work with the survey in that area.  The 3 girls will start there tomorrow, after they spent the day observing at Siaya District Hospital.

My hotel room is pretty funky.   Not quite as pictured on the internet!  Two light bulbs, one of which is out often – that is, when we have power to notice it is out.  Power out today for a while after a thunderstorm.  No internet.  No mirror anywhere, so hard to shave or groom.  Sink does not work at all.   Unable to wash except in the shower.  The previously used sink “soaps” are actually broken chunks of the deodorizing blocks of crystals they toss into the base of urinals.  Toilet leaks onto the floor.  Shower basin does not drain at all, unless the water gets high enough (as the drain is the well established high point of the shower floor itself), even so leaving 1-2 inches of water in the basin.   My mosquito net seems effective thank goodness, though barely reaches to the edge of the mattress.  My pillow stuffed with bubble wrap for firm support!  Toilet seat badly cracked with chunks of plastic missing, it threatens to completely come apart every time I sit down.  Just a few of the challenges for me!!  Lord grant me patience, a sense humor and continued health measured with gratitude for what I have.

Tired and off to bed, hoping that no chills and fever await.  My headache through the day was helped for a brief time by a Tusker beer, but quickly returned and again in the night with Tylenol 1.0 gram just taking a tiny edge off.  I think this is a caffeine withdrawal headache – no coffee or caffeine since Sunday morning, it is now 36 hours later.  Wow, it is bad – I am really surprised and annoyed at how bad it is.  Were I home, besides getting shots of espresso, I would be in bed.   But this is Siaya, and there are lectures to give shortly.

  10 July 2012

For breakfast at the Mwisho went for freeze dried Nescafe (my Dad’s old standby!).  Two packets in a ½ cup of hot water and I began to feel some life infusing back into my veins.  Two more, and even a bit more life and the incessant headache began to fade!  This was the medicine I needed.  So again once more, 2 more packets before lecturing and I was running on nearly four cylinders.  Shortly thereafter the headache gone – and still gone, Hallelujah! 

Observed the Physiotherapy department and took several photos.  They have so little equipment, very battered and falling apart at the seams (literally, the medicine balls were splitting apart at the stitched seams).  They could use Pilate’s balls, my Body-Blade, any hand exercises, weights, almost anything.  They are hoping for a massager, a TENS unit and more.  To fix their exercise bicycle they need a new seat, clamp assembly and quick release lever for seatpost adjustment.

Still the ER has no monitor, no EKG machine, no defibrillator.  And this, a 220 bed hospital.  In fact, no defibrillator for the entire hospital, ER, OR nor anywhere!

The beautiful African Clinical Officer (CO) who was evaluating children did not examine them, or barely so.  Hannah described her as “modeling gorgeous”, and Matt as “the most beautiful African he has seen anywhere, anytime”.  She was mostly taking a brief history and reviewing some lab tests for malaria.  Sometimes would look at the conjunctiva as she reached across the desk, but no stethoscope and generally “hands off”.  Otherwise asking the mother a few questions and even with the Electronic Medical Record (EMR), minimal documentation.  That, and she, was working for free!  Finished with school, she cannot get a job apparently that pays, so just volunteers and sees 150-200 patients per day.  My favorite new chief complaint by mothers for their children?  HOB = “Hotness of Body”.   Reserving “fever” for documented temperature elevation.

Lectures today went so much better!  Mostly because I was not too hot, and the headache was gone!!  The students seemed quite attentive, and had worked on their learning objectives as well regarding some DKA treatment.  My last lecture was on the trauma I experienced and a changed life.  For some reason I struggled through it emotionally in several spots; which really surprised me.  When finished they were really gracious and kind with comments.  I heard a few sniffles too.  The elder stateswoman nurse for them pronounced a wonderful blessing over me, and said we can see you are a Christian, that God has spared you for His purpose and work, and we pray a blessing upon you and your efforts.  The kind words washed over me and were amazing, all making it worth any effort I had put forth.  Then she asked one of the other Sisters to pray for me, they all stood and insisted I sit down and the prayer in Luo or Luhya was emphatically prayed.  Several were very sweet.

After observing the aforementioned striking CO Helen, we went to Dr. Omoto’s home where they have been without power for 24 hours.  Shortly thereafter hit with a prolonged thunderstorm, we discussed the day over Chai tea with Matt feeling worse by the minute.  Finally in darkness the girls returned.  More Chai and then a great dinner of cabbage, chicken, rice, chipati, and broth.  Matt off to bed with no dinner accompanied by shaking chills, and yet only one dose away from completing his malaria meds.  Walked back the 300 yards from Omoto’s to our room with thick red clay stuck to my Keens, so much that walking became very difficult.  Only then to find Matt soon having prolonged vomiting and diarrhea and thankfully he could use my headlamp to aim both!  So in the dark, he was wretching, bundled up with shaking chills and V&D.  Ugh!  Hopefully he will make a quick turnaround tomorrow.

So highs and lows both.  Such is life.  Glad I could share my life and information with the graduate nursing students; yet feeling bad for Matt and praying for a quick recovery.  Tonight not feeling so anxious about impending malaria, but will see what the new day brings tomorrow, hopefully power for a start!

The preliminary survey in the Miwani area covered a total of 3 days, and in total we saw 157 households.  We were kindly received and all went well.  Many surprises, and some concerns for certain.  We will all know more once the numbers are analyzed.  Though I participated in day one of the survey, the other areas our teams covered were too far a distance for me to cover on foot (some were close to 10 miles roundtrip).  For the most part everyone walked, yet there were a few instances of hitching a ride in a passing truck or hiring piki-piki's (motorcycles - despite prior agreement not to do so from those I am responsible to "supervise").  Thankfully - all went well.

Saturday July 7 saw the 4 Mzungu's hike to Nandi rock and into Nandi itself.  They were gone all day and tired that eve, but not too much so to still watch Sherlock Holmes.  With my impaired sensation I managed to get 15 mosquito bites during the movie, not feeling them attacking my exposed flesh.  Still I figured I was "covered" by my Doxycycline, or so I thought....   more on that thought soon.

Sunday July 8 and we will as a team be headed to Siaya and Siaya District Hospital.  Two days of teaching at the hospital, and observing their Emergency Department before we head off to survey the Khwisero area with Community Health Workers.  Overall I have been feeling very good, many days thinking I could do this long term and without difficulty - other than my usual accommodations. 

So the survey is a combination of suggestions of the US team and of Dr. Omoto and his staff from Siaya.  It is 6 pages in length and has roughly 45 questions of demographic data and also some "test" questions to determine the knowledge of families we are surveying in regard to basic health issues.  It includes questions on hand washing, latrines, dish rack use, mosquito nets, personal and family income, number of people living in the household and immunizations and the timing of them.  Also covered are family planning, contraception and HIV, as well as pregnancy risks.  We then measure BMI (by height, weight and age if less than 20), visual acuity, blood pressure for those over 20, and perform a dental check for missing teeth/cavities.

We met this morning at Nehemiah and split into 3 teams.  Generally one community health worker, one person from Nehemiah and a Mzungu (one of us).  We went out on foot to Karunga, Kaleng and an area close to Kibos.  We surveyed huts/homes from 9am till 5pm.  Amazingly for day one, we covered actually 59 huts/homes!  Beyond that several other children to gather BMI information as well.  We found we were welcomed into huts and offered seating.  Most seemed to answer questions without hesitation, though we all seemed to hit resistance on income and most could not identify the timing of immunizations.  

Most homes were of mud walls and flooring, with generally thatched roofs.  Many had fires burning for cooking inside the home with charcoal.  Prior to coming I was concerned about CO, or Carbon Monoxide poisoning for these people burning charcoal indoors, yet the studies I could find reflected levels of around 30 ppm of CO; whereas 200 ppm is toxic.  It appears they all have such adequate ventilation, that CO poisoning is not an issue.  It was so good to spend the day observing, in our team's case 16 huts, and the life they have.  Corn planted around the huts, some with attached latrines, or perhaps 15 feet away; but many used only the bush and no latrine even in a village area somewhat populated.  Children everywhere, happy in most cases, though my mustache and cane scared a few who began crying.  Lots of great photo opportunities which I will have to upload when home.  Most men and women adults seemed to run about 42-52 kg and roughly 160 - 165 cm tall.  I will begin to work on the calculations tomorrow.

The only real problem encountered was with the team I was with. And even then God's hand was all over that!
Shebby, Victor (our CHW), Lexi and I were approached by two older men who asked in a somewhat gruff manner what we were doing (after we had surveyed about 6 huts), and who had given us authorization. A kind explanation by Shebby did not help and they seemed intent to get rid of us. Shebby explained we had authorization from the chief, they said they had no knowledge of that and had not heard we were coming. Just then Shebby called Ken Olindo who had gotten the authorization - and at that exact moment Ken was with the chief and was interviewing him and his family for the survey! The two men with us (one an associate chief, the other a village elder of the clan) did not accept that, and one called the chief himself the next moment. The chief answered the phone, and whatever he told the assistants, they simply had a change come over their faces and both said "Sawa" and walked away......
So I guess the money was worth spending, especially since all teams will have authorization until even the larger Bainbridge group is done. We have an official signed letter from the chief as well that Ken is photocopying.

In regard to the mentioned funds.  A few days ago we found the "Miwani chief" required payment to "authorize" our survey.  This was to assure safe travels and acceptance in the area, in exchange for 3,000 KSH.  Though several felt this was again corruption at work and an abuse, I felt after all we had been through that this was not that much to pay - if it made a difference (only around $35 USD); so though it was in theory not the right thing to do (after all we are trying to help these people by learning about them and already spending a lot of money to do that), I did go ahead and pay the funds this morning myself.  It now looks like that was the right decision.

All in all everyone is encouraged!  The survey will continue in the Nehemiah/Miwani region over the next 3-4 days.  Mostly on foot, with areas to come beyond my walking strength.  I felt I held up well today, though likely because so many are praying for our team and our health. 

More soon! Thanks for reading.

At 0530 Kenya time I got a text from a new Sikh friend whom I met here in February.  "Respected Bro, wishing you a very happy & blessed b'day. The Lord bestow his blessings on you with happiness. Good health this auspicious day and years to come always. Johnny and family"  Then two hours later a call from him as well.  He and his three daughters are cooking Indian food to bring over to feast with us this evening in further celebration of the day.  

Then after church I seemed to have a line of people waiting to greet me.  Last Sunday was an introduction to many, and making again friendships with others.  This Sunday had several asking me directly for money to pay for their medicines, or healthcare, or food for family, or funds to start a business.  More overwhelmed with the need, and how little so many people have.  One mother with her 2 year old who has had malaria several times, now again with intermittent fever and cough with scleral icterus (jaundice) and dark urine.  All I could do was tell her I would read about this and try to educate myself on what it may be (will do that shortly).  Most seemed to think having met me once or twice, I now would be more sympathetic to their plight and give money.  It is hard to say no when my wallet is basically empty, and my heart is full.

A visiting pastor asked me to please start a medical clinic near his home of Port Victoria, Kenya.  Apparently there is a lack of medical care in his area as well.

Last, another family wanted to greet me in the church afterwards.  Thinking this again might be another financial assistance request, but no.  A widower whom we met this week, teaching pre-school in Miwani who is barely surviving I am certain (whom herself was injured falling from a Piki-Piki in 2009 and walks with a bad limp), had brought me a gift.  A colorful chicken.  A birthday chicken!  The cost for her to give that up for me, likely incalculable.  I thought of the Bible story of the widows coin - giving nearly all she had back to the church.  In this case her thankfulness for our being here and helping with a survey to study the health of the local people.  

So it is barely noon, and I am already overwhelmed by the generosity of those around me.  

More to report.

So a final update on the day's events.  Our entire group had a wonderful Indian dinner with Johnny and his family, including a traditional Kenyan beer they brought for me - Tusker.  Chocolate chip cookies put together from no-standard ingredients and baked by Hannah Berkimer were outstanding.  Overall a restful day spent with friends from the southern and northern hemispheres.

Last, medically - the 2 year old likely has recurrent malaria given the mild jaundice and ongoing illness from mother's report.  I suspect they have no mosquito net, though did ask her that and got a puzzled look only.  According to the CDC malaria website, mild jaundice is common.

Tomorrow we start training for the survey trial with 2 nurses coming from Siaya.  The days following that we will survey mostly on foot around Nehemiah.  All for now.

Our first week has been focused on friendships and re-establishing Kenyan contacts.  I have been in conversation with Dr. Jackton Omoto as often as the internet connection will allow, in regards to the surveys we will undertake in Miwani and Yala.  While our team in the US had established a short form, Dr. Omoto it seems has bigger plans!  The form our team had created focused on BMI (weight, height, age), visual acuity, blood pressure, mosquito net use, dental condition, water and sanitation.  Dr. Omoto's 7 page form incorporates those parameters, but also looks at income, housing conditions (floor, walls, roof), hand washing, family planning, preferred contraception, immunizations received, dish rack use, appliances owned and a few other things.  I must admit, at first I was very skeptical we would be able to obtain this information, yet Dr. Omoto hopes we can be well received by having several Kenyans on our survey team - with more Kenyans than Mzungus (perhaps 2 Kenyans for each American).

Again would say, I don't feel I have any right to ask a Kenyan living in a rural area about how much they earn every month, or other personal questions (such as family planning) - BUT, perhaps with other Kenyans present that may occur.  Also I am reminded, the purpose of our smaller team is to prepare the way for the larger Bainbridge team coming after us - and to trial the survey to see how it actually works.  So in the spirit of adventure and for the sake of learning even more about Kenyans in Miwani and Yala, our team will gear up for the task!  If it does not go over so well in the two areas we are going to survey, then we will look at altering the methods and length of the survey.  Dr. Omoto feels we should due able to get all the questions answered within 30 minutes of time per hut, or housing unit.  The goal is to understand health conditions as well as their living environment/socio-economic status.

Beyond the survey discussions, I am working on my lectures for the medical school in Siaya.  The schedule is a more manageable 2 days of presentations.  I will incorporate a few Problem Based Learning cases from my teaching at the University of Washington school of medicine that will tie in with the topics covered.  Lecture topics will be Motorcycle Accidents in Kenya: statistics and trends; Lower Extremity Trauma, Head Injuries/Trauma (both topics as they relate to motorcycle trauma), Diabetic Emergencies, Chest Pain, and my personal story as it relates to lessons I have learned from being a patient, and how care providers can connect more closely with their patients to meet both their medical needs and their emotional needs.  I am hopeful the Problem Based Learning cases will impart some practical knowledge, and teach a method of thought to craft a differential diagnosis list, a problem list and the manner of thought needed to either rule-in or rule-out a potential diagnosis.  I look forward to seeing how Kenyan medical students work in a small group setting where they come up with learning objectives, and report back to each other the following day on those potential diagnoses.

I will do my best to keep this site updated.  Our internet coverage has been very sketchy, with frequent outages, and literally a small zone (like a 10 foot square area of coverage) of reception.  Once evening hits, the mosquitos become rather active, and since my reception is outside - I am a ripe target!  Possibly a fried electrical part will be replaced this coming week.....

I will be involved in several medical adventures this time; whereas the first trip involved more observation and understanding of the Kenyan care delivery system, this trip will include many more hands-on endeavors from teaching at a medical school near the Siaya District Hospital for nearly a week, to studying the health of two separate populations.  One of these near Siaya, the other close to the Nehemiah International property/farm east of Kisumu.

Dr. Jackton Omoto, chief of staff at Siaya District Hospital, has asked me to speak to medical students and medical officers on various topics of Emergency Medicine.  We are still working through those details, as he initially hoped I would be able to provide 6 hours of lecture per day for 5 consecutive days!  I simply do not have the time to prepare that much material.  Instead I have suggested I would be able to teach over 2-3 days; including several problem based learning cases (an interactive teaching method I have learned as a volunteer at the University of Washington school of medicine the past 6 years).  Additionally I would like to spend a day or two observing emergency care delivery in the Siaya hospital to see if any improvements may be realized - looking at everything from supplies, response to crises, available medications and testing capabilities.

While in that area, Dr. Omoto has asked that our team survey the health of children and adults.  I have been purchasing equipment to perform a basic health assessment on people for this trip.  This will include BMI (body mass index - which gives a very good sense of nutritional status from age 2 to adult via measuring weight/height/age), hypertension screening in all over age 20, visual acuity, and dental hygiene - looking for obvious cavities.  For villages we hope to obtain population, births and deaths in the past 12 months, mosquito net use, sanitation (garbage and human waste) and water sources.

This will also be undertaken in an area around Nehemiah in an effort to begin to understand the health needs of the community and how we can begin to meet them.  More details below.....

The entire area that the Kenyan Ministry of Health wishes us to cover, or provide services to, is 40 square miles in size.  Though we do not know how many people live in this area, our best guess at this time is 15,000.  We do know from the Global Millennium Project study that the HIV/AIDS incidence is 15% in this region; that infant mortality is 12% by age one, and 22% by age five.  This is most likely due to malaria and unsafe water/diarrheal illnesses.  By getting a sense of the BMI, and some basic screening parameters we hope to impact the mortality and improve health.  Though there is no way to cover this area completely, the more people we can study the better.  The last available data for this area was from a WHO study of BMI in 2003/4 when roughly 1500 women around the Kisumu area were evaluated.

Beyond the above objectives I would like to look at how we are currently using medications at Nehemiah for various illnesses.  Whenever possible using the least expensive effective medication; likely pills.  Though effective, IV meds are expensive; and we are likely to be able to treat many many more people with illness by using oral meds (before we exhaust funding, which depends upon generous donors).

That is all for now.  I have been very busy - but wanted to quickly get an update posted.  I will do my best to keep blogging going while in Kenya.  IF you are looking for a tax deductible donation (Nehemiah is a registered non-profit in the US, and a registered NGO as well) - to help provide medical services to this area of western Kenya, or even to help offset some of my out of pocket expenses for supplies and travel, those donations can be sent to Nehemiah International, PO Box 11791, Bainbridge Island, WA  98110  with a note stating your donation is for medical care.

Next, I plan to share my thoughts on how we can use community health workers to directly impact the health of villages, and how they can alert us at the clinic to a sudden illness that may require transport to either the clinic or local hospital in Kisumu.  Thanks for reading!

Kisumu – two lane roads with no markings, poor shoulders, random speed bumps and potholes that would eat most suspensions and/or car tires and cars, mixed with piki-piki’s, tuk-tuk’s, matatu’s, bicycles and pedestrians. Piki-piki’s are a small 125cc engine motorcycle that carry from 1-4 people (I have heard up to 5). Matatu’s are everywhere and seat 14, but may carry more. They are usually a converted Toyota mini-van, of the bread loaf styling. Tuk-tuk’s are 3 wheeled and carry around 3-4 people. In general people walk everywhere, and carry a lot with them. Mix all this with cows, bulls, goats and the occasional 2 wheeled cart which generally use car tires. Any people moving vehicle may start and stop anywhere, the matatu’s the most erratic of the bunch. Vehicles are right hand drive. People walk everywhere in and amongst the traffic day and night. No traffic lights anywhere. Very little signage. No one anywhere wears bicycle helmets. Only the piki-piki drivers wear helmets, none of the passengers. People ride on the back of bicycles on a small seat, with small bars under the main seat. Some women well dressed ride side saddle and talk on cell phones as they ride.

Nairobi – very rare main roads are 4 or 6 lane. No speed limits posted, rare signage. People walking everywhere along the road side and crossing the roads day and night with very poor visibility and minimal overhead lights. Even these major roads have roundabouts, and u-turn options. Amongst all that are the matatu’s and larger buses. Again on major roads there are speed bumps not marked and the occasional big pothole. Coming back from the aiport to Hampton house at night, the road suddenly went from 6 lanes to 1.5 on each side, became rough and uneven and had big drop-offs on the shoulders, only marked by stones and rebar on the edge. No signage again about the narrowing or construction. Side roads generally very bumpy and some with major potholes and destroyed road surfaces. Very few major roads overall, mostly a network of rambling 2 lane roads all thru the city.

Everywhere the people are kind and smiling. They do have a sweet spirit, as my friend Gary Ames pointed out. They do not seem depressed or downtrodden. Almost all are spiritual in some manner, and most Christian. They are open to discussing prayer and Christ. Hard working, many work long hours to support themselves and family. I am told the average wage is around 200 shillings per day. Mike, our taxi driver says, that once a boy turns 15 generally they are built their own small house on the parent’s property – and move out of the parents home, “they don’t share the same entrance into the home any longer.”  The kids are always smiling, seem to love Mizunguu’s and want their picture taken. They are optimistic, regardless of the setting it seems – from Kibera to the tribal village unit. They do not know any other life, nor have dreams or understanding of what it could be like….. 

School is taken very seriously throughout Kenya. Education valued highly and children strive hard to be the best in class. Uniforms worn. Teachers respected. Visitors very welcome.

Cellphones  

Everywhere, even in very poor regions.   People obtain a phone, then buy coded cards that buy airtime. Calls apparently cheap. Texts are 1 shilling to send, free to receive. Cellphones are used to transfer money between people, generally at M-Pesa booths. No banking as such, but you have funds in your cell account, and in that way can send funds to others via cell phone. I called Frankfurt from Nairobi for 87 shillings, or about $1, for about a 3 minute call.

Food

Mostly a vegetarian diet. Ugali is a corn glob, that is stirred a long time with water over heat. When finished it is about the size of a round loaf of sourdough bread, but completely white and with the consistency of fresh Playdough. Very bland, it becomes your eating utensil to pick up food with your fingers. We had beans, green grams (lentils), and greens (like collared greens).

Fresh chicken at David Isuvi’s which they had killed was pretty tough and muscular due to its running around!! Chipati is a wheat flour flat bread cooked in a skillet with vegetable oils – saturated with fat but quite tasty! Very few utensils used, mostly hands. The tilapia meal in Kisumu was interesting for sure – see my photos (when I can get them up).

Security is big business. It is everywhere and employs a ton of people. Security for NI, hotels, hospitals, grocery stores, malls, homes, businesses. We needed security to walk thru Kibera. Three guards with AK-47’s or Kalashnikov’s escorted us throughout for 5,000 shillings. I am told that if you are caught stealing in some areas it may be punishable by death. One of the locals apparently stole a digital camera from a friend of Bob Wendel’s and he has been in prison for 3 months, still awaiting trial. Police can randomly pull you over, sometimes to extract an illegal fee for “road maintenance”. At major Nairobi roundabouts police are stationed by 5am for any incidents, and work shifts covering the particular roundabout. When things get busy, they may stop traffic to allow flow in one or two directions only. But if you are stopped, you will likely be ascended upon by large groups of individuals selling stuff from world maps to shoes to figurines to trinkets to jewelry and even Masai spears.

Placentas

Still I am baffled.  We have missed something of the significance of the placenta.  In US hospitals it simply disappears, or so it seems.  Not so in Kenya!  Some tribes have traditions with it, such as burying it on your home soil, to more or less stake claim to your family's connectedness to the earth and soil on which you live.  Most have now gotten away from that tradition, but how one disposes of a placenta is still a matter of controversy.  Hurlingham Women's Hospital in Nairobi incinerates them.  Most hospitals we visited though seemed to use an in ground placenta pit, where it is tossed whole.  Others macerate the placenta then put it into a pit.  Some of the outlying clinics do incinerate them, yet the Kenyan inspectors do want to be certain your incineration temperatures are high enough; but some inspectors apparently may still require you to dig a pit.  You may never know, until you are going for inspection.

Regardless, it is a big deal to Kenyans, and does hold a more honored/respected place in their culture than we may ever fully comprehend.

Thank you for reading and traveling along with me!!  It will take me some time to process all this; and I know I am a changed person because of it.  I hope to be able to return to Kenya/Nehemiah International someday soon to find an expanded healthcare center in operation.

Started the day with a visit to the Karunga school and almost 100 kids. No money for any sort of food program or supplements, which means most of the kids go without lunch at all. NIHS does a medical outreach here for de-worming and immunizations. Kids in bright purple uniforms, as usual smiling and giggling. They flood to anywhere a camera is shown! Met the teachers and looked at classrooms NI helped to fund and build. Momma Helen (aka Momma Jeff Krueger) was there to meet. We met Momma Mylka on the way to Karunga.

Also briefly toured the thatched roof hut village of Karunga itself. 

Back to Miwani. Packed out. Met nurse John who is quite personal and rides his bicycle once per week to work at NIHS while Esther is out doing immunizations/outreach. He is married to a nurse who also works in a health center. One child, 8 mos old.

He is most interested in preventative disease, and education that goes with that. He seems very interested to work more with NIHS.

Said goodbye to Esther and staff.

501 beds. No waiting for beds from the A&E. You simply go upstairs, and if need be, you get into bed with another patient!! Or 2. Only exception – ICU admits, they are kept in the A&E until a bed opens. 2 exam rooms in the A&E, and one minor theater.

Peds wards (here called the Obama Children’s Hospital) were not too busy, maybe half full – yet several sections for various problems – malnourished section (this one nearly full), communicable diseases, age under 3, age over 3, an oral rehydration observation unit (where if they do not improve, they get admitted with an IV). Areas looked “clean”, compared to what I have seen.

Overall a much better facility than I expected. No MRI, but they do have CT.

Off to the Green Garden Restaurant for pizza and a great virgin lemon juice-Mojito w ground mint leaves (thinking later this was the only potential source of possibly contaminated water/juice I have had – time will tell!!). Then goodbyes and flight to Nairobi. Off to be for an early morning trip to Amsterdam, then Frankfurt, then home Sunday 26 February.

She can help set up training of CHW’s. Most are basic trained in 5 days, but in some regions they do more such as BP recording for Hypertension (HTN) screening, and fasting glucose. She does not think in our region these are problems – Diabetes and HTN. She thinks we need to train roughly 30 or more CHW’s. Additionally we will need a CO/MO position, 3-4 nurses total and a few more exam rooms. Inspections once we are ready to advance to a higher level of care. She feels we are a very important center for care to people from the bridge to the town of Miwani. Overall an encouraging meeting about our future role.

Then to Chebirir Primary School where the headmaster who heard we were coming ran 6km to meet us. Students in green shorts. Some new buildings. Mostly volunteer faculty, and 75 students grades 1-7. We met several faculty. No electricity in the area at all, the nearest electricity is about 4km away. Wondered about hydro-electric power as they have water in a cistern which could be dropped to a lower cistern and generate electricity to charge cell phones, and have some lights.  Or perhaps solar power.  This would be a money maker for them and a huge time savings as they otherwise come to NI and pay 10 shillings to charge their cell phones every third day or so.

Termites are a problem as they eat text books, buildings and attendance/visitor logs and such. NIHS provides vaccines and healthcare to these kids. Vaccine program by coming by piki-piki once per every 2-4 weeks. We met in the headmaster’s office. Also Joyce, a teacher support person/widow took us to her home. Cow dung and mud floor. Using the bushes for bodily functions (no latrine) – roughly 60 meters away.

Back to NI where Momma Mylka had walked her to greet us and me, since she heard we had come to visit her, but she was away at a funeral.

Long nap (finally) and outside with my computer to watch a sunset while I got some work done, sipping an iced latte, and including the writing of this.

At the clinic this morning I spent some time with our staff and future potential staff; getting to know them and their background and experience.

Today we had a case of an elderly fellow (maybe 45-55) who has had intermittent fever, photophobia, headache, weakness. No diarrhea. Esther, our nurse, felt this was c/w either malaria or typhoid. Ken, our lab tech, was able to test for both, and it was typhoid. He received 1.0 gm iv Ceftriaxone. No iv fluids, just slow push of the drug. He is to return daily for 6 more days for additional iv doses.

Cisco is in her early 20’s. Here now briefly on school break. She is in school as a CO – or Clinical Officer. Just finished her first year. She will have 3 years of school, then 1 year of internship, which is sort of the payback time to the government. She can rank her top 3 choices, then will be placed at one of those. The school is state/Kenyan supported and costs 60,000 shillings per year (40,000 tuition + 20,000 living expenses [hostel and food]). She absolutely wants to work here when done with training. They do get basic sciences. Gross anatomy is using cadavers, but with someone dissecting for them. They can touch the cadaver if they wish, but do not have to. Otherwise sounds like PA school a bit; but not as thorough. I asked her about the brachial plexus, and she said that week the professor was not available, so it was discussed but not in that much detail.

The circumcision clinic seems, so far, to not be happening.  Last week a team had arrived to circumcise 6 males, and they were to have follow-up today.  For the procedure I understand they get Tylenol for pain relief!

We, Anneliese and I, headed for Kayo which is a small village near the town of Miwani. We were to visit Momma Mylka who is the grandmother to Jeff Krueger and Anna Schuler. After nearly 1.5 hours of rough road, single lane much of it, we are surrounded by trees and huts – some with thatched roofs, some with tin. Smooth hard dark dirt floors (which I later learned are cow dung and dirt), almost like concrete, mud walls supported with sticks inside. One or two windows per hut.....

The latrine is a 3 sided open structure, almost no privacy, used it appears just for stool; not likely urine.  Shallow hole covered in part by sticks and mud. Located maybe 40-50 feet from the nearest hut. Water for cooking/bathing/possibly drinking from a barely moving stream, which is “boiled” we are told. A nearby well provides most of the drinking water. Small gardens, a few goats or a small cow or two, small dogs and usually no cats.

Kids happy, swarm around me to shake my hand and want their photo taken. Most very happy and yell out “Mizunguu!!” or “How are you?”, especially the latter over and over! They especially wanted to see the photos I had just taken of them. Anna Schuler, almost 4 yo, was here, she ran to greet me and held my hand for the 200 meter walk into the village. One dog was snarling, and not too friendly, we stayed away given the recent rabies in the area.

On the way back we saw a currently closed dispensary in Miwani and the Make Me Smile project of orphan girls in a re-purposed pickle ball court. They have a pond for fish and small garden patches. The house mom appears maybe 20 yo. This house rented and supported by a few young Austrians whose father apparently gave them each some funds and told them to find a 3^rd world project to make a difference in peoples lives.  Around 8 girls living in this pickle ball court, ages roughly 8-20. Might have electricity, but we did no see any evidence of that.  Most homes, like this one, use a charcoal interior fire for cooking.  Usually a small, roughly 16 inches by 16 inches base that holds the burning coals just off the floor, with a pot on that for cooking Ugali or other items.  Yes, this does put out CO, or carbon monoxide.  Apparently the ventilation is good enough, as this is the standard everywhere - even in homes on the farm at NI.

Dinner back at the farm – Ugali and greens. 

My days are filled so far with medical facility evaluations and people meeting; making connections.

First the Nehemiah International Health Services building and staff –

Many photos taken today, and staff met. Esther, our Kenyan nurse, seems content and hard working; also very comfortable doing what she does.   No real sense of burn-out impending.  More on her on the next update.

Esther was thrilled to get her gifts today – new stethoscope, new headlamp – both from Dr. Dan Morris. I brought along some used equipment as well, all joyfully received.  They sure could use an otoscope to go with my tips I brought!

Lots of potential in our current building, just unsure how to use it all yet. Seems we need to get Dr’s. Omoto and Morris and nurse Anneliese – maybe Ken (our lab tech) too on skype and figure it out.

Deliveries, basic healthcare, STI’s, HIV testing, counseling, follow-up, family counseling, TB clinic, HIV support groups, community outreach and healthcare worker follow-up. They follow 436 active HIV/AIDS cases. Natalie estimates HIV is closer to 33%, not the reported 15% - due to all the money that has been poured in here not being used effectively, and that those funding care would withdrawal support if they knew the actual rate was 33%. This she feels is due to many not wanting testing (knowing from symptoms they have it), to factors such as if you only test well people without symptoms – you will miss many cases that would be obviously positive. Many would rather simply die of HIV/AIDS than to know they are +, others avoid testing to prevent family shame, many reasons to skip testing – even transportation.

I wish I had Natalie on film; she has a deeper understanding and knowledge of HIV/AIDS that almost any physician I have ever spoken to; way beyond my awareness – and yet she has no true medical education that I know of. The system and process they have in place is amazing. Testing, verification if +, TB screening, then a week of intense counseling, then ARV’s, then ongoing family counseling, then ongoing follow-up and compliance and blood testing for CD4 counts (cannot treat unless under 300) and LFT’s.

The Kenyan government supplies ARV medications for free, but all the necessary lab testing (such as CD4 counts, liver functions), personal and family counseling, case management, and compliance checks are also to be provided free of charge by healthcare centers. So it can be a huge financial burden for those providing care to follow these patients, yet the benefits great to each individual.

Many times today I was nearly overcome by emotion; just the burden of illness and the task to make a difference creatively with little to no funding and limited resources. 

Also nearly overcome with everything required to move our facility from dispensary to healthcare center – almost too many things to list. Inventory of durable goods and non-durables. Kenyan government criteria which are NOT in any one book or place, so hard to know what to do exactly until the inspector arrives. The required HIV/TB testing, separate rooms, and counseling services. Providing the necessary tests for free, despite the tests costing much. All the while obtaining funding and charging a low fee to those who can pay something. Yet I find encouragement in her spirit and heart.

She urged us to understand our mission, and to stick to that. If a donor wants something else accomplished, then they need to send their money elsewhere; but for her she wanted buildings to be able to move ahead.

Crazy traffic in Kisumu, no bother to paint lines on the roads since everyone drives where they want. Motorcycles, Piki-Piki’s (small 125cc engines – sometimes with 4 people on one bike!!), bicycles, carts pulled by hand, oxen, people, cars, buses, trucks, matatoo’s (Toyota mini-vans which are converted to hold around 14 people inside) many times people just hang outside the open doors! Three wheeled taxis as well.  Also right sided steering controls and speed bumps and potholes everywhere!! I mean everywhere – even on heavy trafficked roads, where they appear randomly and without signage of any sort. That, and police just hanging out to pull you over and collect road duty fees – which is a random act. Rather a strange system! 

Nairobi – 15 February 2012

Wow – it’s late.  The pics will tell the story when I can get them loaded.

Kibera slum today 7x10 km.  1-5 – 2.0 million people.  Vendors, phone cash, food, butchers, sheep, dogs, cows, goats, kids and more kids.  Sewage stench everywhere.

Walked in with Pastor John, Aaron, Jeff, our nurse and myself + 3 soldiers with AK-47’s or Kalishnakov’s.  5000 shillings for the escort – since 3 Muzunguus’ were robbed of all they had  last week.

Amazing – I do not ever want to forget it, nor the kids and somehow this is all they know – the look on their faces and still joy.  Several schools along the way until we hit the WorldComm site with 96 kids ages maybe 3-10 in a one room schoolhouse.  All in uniform, orderly and seated quietly.  They sang, recited scripture, and clapped!!  There were some trinkets there to purchase, made on site – so a few items were bought.

They paid for a car ride out for me with Aaron and a security guard.  Crazy bumpy single lane road – not really a road.

Wow….the red clay and dust and smells stuck with me all day – I could taste it through the dust in my mouth and nostrils – no water safe anywhere.

Then to another school. 270 kids, taught well – some orphans.  High achievers.  Many place in the top regionally when testing to advance.  Sports – soccer, volleyball.  They waited to feed everyone as they knew we were coming.  Orderly serpentine line to feed, youngest to oldest.  Many teachers – grades 1-8.  Teachers volunteer or a small stipend.  All passionate about education, Christ, scripture.  Songs and poems for us as well.  They also kindly served us each a cola w straw!!  It was almost cool, but the taste divine coming from Kibera.

Barely to the airport in time to fly to Kisumu and then the drive to Miwani.  Dinner at 8:20pm.  Windy, stars, clear – yet cane fires on the distant hill.  My first “at risk” mosquito bites this eve.  They are small and appear out of nowhere.

I will re-edit these comments when I have the time, but for now, easier to simply upload my notes and correct them later.

Kenya – Nairobi  14 Feb 2012

Exchange rate info for you -  $1 USD = 83.5 shillings 

Walked maybe a mile to B-fast.  The Java Hut.

1.  Off to Hurlingham Private Women’s Hospital in Nairobi.  61 beds; 61 nurses.  Converted from a hotel to a hospital in 2001.  Generally 90% occupancy. 

Casualty requires first generating a hospital MR #, then pre-paying for your casualty visit, then being seen.  Very kind people all along the way working in this nice private hospital, yet in tight spaces.  Medical records is amazing – crazy piles of charts piled high and rubber banded together.

The IT dept is staffed by 2 people who are surrounded by junked out monitors and towers.  Their goals seem to be more about computer info RE: staffing, laundry and benefits for staff, than about actual MR’s.  No intent to go to an EMR, no intent to put a patient’s labs or x-rays or PMH in the computer.  No intent or plan to connect all 3 of their private hospitals together with one computer system.  Suggested it would be nice to pull up doctor notes, RN notes, patient history, meds, HIV status, last admit, current plan, even current admission – but NONE of this is available; nor any plans to make it available.  Yet they rated their IT system an 8/10 (??? Amazing!!!)

Delivery costs 40,000 shillings and a 2 day stay; C-Section 150,000 shillings and a 3-4 day stay.

[talking to Dr. Omoto over dinner his hospital in Siaya District charges 500 shillings for NSVD and 3,000 shillings for a C-section.]

They do transfer people out who cannot pay to other public hospitals.

They had 1-3 beds for males. 

1 ultrasound machine, 1 x-ray machine.  No back-up.

Lab runs 24/7 with something like 7 people in a small cramped area maybe 200 sq feet.  The lab machines “free”, but they pay for reagent and tubes, etc…..  Blood bank, TnC, HIV, and apparently send out very few things.

Doctor’s offices in bldg.  Generally clean and yet open windows, ventilation.  No AC.  A rare fan or two.  Equipment everywhere looks like it is mostly from the late 60’s – early 70’s.  Yet a lot of pride in what they do and how they do it.

Please read on for more from this same day........2.  Next – Kenyatta National Hospital (KNH)........

2.  Next – Kenyatta National Hospital (KNH).  On a huge campus with medical school.  Between Cairo and Johannesburg, this is the largest hospital.  Something like 2,500 beds.  70,000 inpatient admits per year, 500,000 outpatient visits per year.  Big operation with barbed wire gardens, and fenced areas – unsure why (possibly goats??) 

A&E quite busy,  lines of people waiting to be seen.  No photos allowed at all – only outside.  Proud that patients are seen regardless of ability to pay, and insurance information gathered only after the patient is triaged. 

Waited forever for one elevator, which was then jammed with people – someone had to help push the doors closed, body against body – we are talking very tight!!

Got up to peds – unsupervised kids with central neck lines roaming the halls – ages roughly 3 to 12, some racing all over – others just hanging with other 4-6 y.o. patients.  One maybe 4 year old put her plastic chair on top of a narrow bench over a concrete floor, then tried to sit on the chair!  Zero supervision – not nearly enough staff.  Saw 2 very sick kids, both ~ 1 y.o. lying head to foot in the same small bed.  Many sick kids in one open room, maybe 20, with 20 + adults, and 1 or 2 staff at most.  No apparent monitors – even for some kids not moving much.  NO TV, no entertainment, though walls painted w cartoon characters; and a group was there handing out candy to kids.

NHIF – National Health Insurance costs 200 shillings per month for a family, including kids up to age 20 (25 if in school).  Yet most cannot afford this!  BUT if they have NHIF, then 100% of all medical costs are covered at the KNH and other public hospitals.  A room charge is typically 100 shillings per day, but VIP and private rooms available for between 7,000 – 5,000 shillings per day [VIP most costly].

OB – lots of mom’s hanging out for observation.  Again only a few nurses.  Typically 8 beds to a room.  Maybe one sink.  Some moms waiting for DC to a safe home, they generally stay a few extra days while social work figures out what to do; to find a safe place.  Crowded conditions and low staff.

After peds, our nurse and I were offered a sink to wash hands in.  Soap and water (Unfamiliar soap brand) and no towels.  No towel dispenser, just no towels!  Most just then let their hands air dry.

Radiology does have CT and MRI.  Area outside the A&E for urgent care (tents in photo).  Many lower urgency cases cared for here.

3. Dinner w Drs. Omoto – She, Lana, seemed quite tired.  Has been to the US 4 times or more.  Working w U of Maryland now on HIV/AIDS.

Jackton – kind, thoughtful.  Both have a passion to help Kenyan people at low cost, and a focus on the millennium development goals – malaria, clean water, dehydration/diarrheal illness, HIV/AIDS.  Some MDR TB concerns, and yet a lot of basic health like Diabetes screening, and HTN.  BIG advocate on community units – his term for comm. health workers.  A huge benefit to Kenyans.  Thinks training is key for them – but does not have much hope in them even being able to take a BP reading.  Pulse and temperature yes.  Thinks they can be taught to recognize nearly 80% of common ailments.  These chw’s would live in their own village, community – and periodically report into us. 

Sees a NIHC developing over 5-15 years; and plans for it to be overseen by even someone else in the future.  Sustainability.

Think ED physicians would be a huge help!!  Mostly in teaching others at his government supported hospital in Siaya.  Really interested in what training we could bring – especially when he found out it was not ALL about trauma that we do.  Just anything acute.

A Doppler would be really good, not US.  Yet still thinks a fetalscope is the way to go!

Enough for one day!