The beginning of an end

So it’s finally time for me to write my last blog post. I was avoiding the task all weekend because a) I wanted to spend as much time as possible with the wonderful people I have gotten to know this year and b) I’m not really great with goodbyes and saying bye to the blog was just one other thing to add to the ‘this is the last time…’ list.

The one great thing about transitioning from one adventure to the next is that it encourages me to reflect on the old experience, take note of what I have learned, and figure out how to apply it moving forward. I have tried not to include too many posts on this blog about ‘my feelings’ but I think it’s appropriate to at least recap what I’ve learned and accomplished the past 11 months.

I wrote down a few goals on my first day in Nairobi last August and going back through them made me laugh a bit…

1) Learn what it takes to conduct clinical research in a low-resource setting.

Wow. Could I have been anymore broad? That’s equivalent to ‘Learn how to cook international cuisine’. But anyway, I think it’s amazing that I never realized what constitutes clinical research in the global health arena and how many different ways you can do ‘research’.
At the Fogarty interviews, I explained to my mentor the following: “We have all of this evidence based medicine and guidelines on one side, and on the other we have healthcare workers providing care…I want to work on connecting the two.” She smiled and responded, “well you know…there is a name for that. It’s implementation science or operations research!!” I’m sure my jaw dropped to the floor. I was completely sold.
My projects this year have all focused on implementation and it’s very apparent to me that this is the type of work I want to continue in the future. People take logistical issues for granted and often think “here’s a new guideline…let’s start using it.” It’s not that simple. In order to actually be successful in using the guideline, time needs to be spent to identify and analyze a strategy to implement the new principle in an efficient and sustainable manner. This is particularly crucial in a developing country where resources are limited and clinics are often understaffed.

2) Figure out what field of medicine to pursue that will fit in with my global health interests.

This one was creating a lot of anxiety for me last August. Everyone around me seemed to know exactly what they wanted to do and were passionate to get started with their training. I knew I was interested in global health, but how was I going to get there?
During my first weeks on the wards in Kenya, I saw many patients with complications from preventable and treatable diseases. Children were dying from rheumatic heart disease and malaria. The only thing that I could think of was “why isn’t someone finding the strep throat that led to the rheumatic heart disease in the rural communities?” And that’s when it all came together…I would go into family medicine so that I can focus on primary care, prevention and education. Wooo. I hope that in my lifetime we will triple or quadruple the number of family medicine residency training programs in Africa (currently there are only 5).

3) Become proficient in Swahili.

Eh…my understanding is definitely there, but my speaking skills still need work. I guess this just means that I need to come back asap and work on it. :)

4) Learn the challenges and joys of collaborating with an international counterpart.

As an American, we somehow have this attitude that ‘we know best’, when in reality what we know is simply a small piece of the enormous global puzzle. Working with my Kenyan colleagues has been extremely valuable because I learned how their culture and upbringing influences how and why they work differently then I do. I think that it’s important for both parties to recognize this and be able to laugh about it. Being rigid is not an option, and sometimes it was glorious to have another work style rub off on me. (see chai break)

5) Establish a side project.

I knew that I would be helping out on an ongoing project at first in order to get my feet wet, but my goal was to eventually find an area that I was passionate about and create something that I could leave behind. Only time will tell if the child contact register and child tracker projects will remain functional once I’m back in the states. However, the process of envisioning the project, grant writing, getting IRB approval, and troubleshooting throughout the initial months has been invaluable.

Alright, I think that's enough sharing! Hopefully I didn’t bore you too much.

In summary, I could not have asked for a better year and I’m so grateful for the experience. I am particularly thankful for all of my wonderful Kenyan colleagues/friends and for my amazing hilltop family.

Here are some pictures from the going away festivities this weekend and my final week in Kenya!

This is Nancy - one of the cough monitors from the pmtct TB screening project, currently the child tracker, and a great friend.

My friends from work took me out to an Indian restaurant on Friday...

And they surprised me with my very own Kenyan outfit which they insisted I try on in the middle of the restaurant...haha.

Some of the Tumaini staff making nyama choma (roasted goat) for the going away party.

The hilltop family on my last night doing what we do best...

Astrid, Laura, me, and Rakhi. These wonderful ladies put up with me at my best and worst this year, and I wouldn't have survived some days without them.

Thank you for reading the blog, and I appreciate all of your comments and words of encouragement throughout the year. See you on the other side of the pond! :)

Dr. Heimburger visits!

Last Friday, Dr. Doug Heimburger - the associate director of the Fogarty program support center - came to Eldoret. It was perfect timing as things are winding down, and it was great to show him around and recap my year.

Doug started the day with a lecture on his nutrition and HIV/AIDs work in Zambia. It's always amazing to hear about how other people got into global health and the discoveries they are making along the way.

Then of course back to back meetings with the 'who's who' in AMPATH. This is Joe Mamlin - the man behind AMPATH's creation!

My favorite part was introducing Doug to some of the amazing people I have worked with this year.

Here are some of the cough monitors and TB clinic staff

Since it was one of my last weekends, I decided to join Doug in Kakamega for some hiking and bird watching. It's always nice to spend time with people outside of the work setting!

Only 4 more days left in Eldoret...stay tuned for 1-2 final blog posts!

Running

One of my goals for the year was to start running more. I usually pick other activities over running since distance running for long periods of time was never my thing. I polevaulted in college so my running consisted of sprinting about 80 feet several times in a row. Anyway, I've definitely built a better running base while I've been in Kenya but I still feel like I have a lot more work to do.

One of my motivations to keep at it? The gorgeous scenery!
These fields are about 5-10 minutes away from the compound and it's a nice way to start or finish a day!

Day of the African Child

I bet you didn't know that was actually a day!

Tumaini staff and many of the kids got together today with children from other homes, schools, and centers. We marched through town together to the children's rescue center in Eldoret to celebrate and recognize African children. The kids had a blast and it's so great that people in town could see them in a different light today.

Here are some pictures...

Tumaini girls in the parade

Tumaini boys

Tumaini staff...these are some of the most incredible people I have met in Kenya. Keep up the fantastic work guys!

Tree planting at the rescue center after the parade

I will miss these kids so much. They live a life on the streets that none of us could begin to imagine and yet they manage to keep smiling, singing and just being kids. As much as I would love to see them again if I come back next year, I hope that most of them are not around and have finally been sent to school!!

Garden Update

Have I mentioned how wonderful it's been to have a garden year round? This is one of the many things that I will miss about living in Kenya.

I have successfully planted and harvested the following from seed:

swiss chard (this has been growing nonstop since September...it's monster chard and I can't get enough of it)

tomatoes (3 plants yielded about 70 tomatoes in January)

carrots

peppers (Only 1 grew but I'm still hoping for more)

scallion

onions

beets

cilantro

dill

parsley

basil

spinach

mixed greens

romaine lettuce

arugula

kentucky blue pole beans

watermelon (this didn't work but it was a fun attempt)

cucumbers (also a failure...I think my soil needs work)

Here are some pictures

tomatoes

pepper

lettuce

carrots

swiss chard

Watering the garden

Khunyango

If you remember, the TB team went out for a field visit back in March and I had mentioned that I would hopefully have the opportunity to implement the child contact register in the small Khunyango District Hospital. Well people...dreams do come true!

Last Monday, I joined one of the AMPATH vehicles on the 3 hour journey west to Khunyango. I met with the District Tuberculosis and Leprosy Coordinator (DTLC) on Tuesday morning, and we spent the first half of the morning discussing pediatric TB, the Kenyan national guidelines, and what actually happens in her clinic.

Not surprisingly, here were some of her comments:

-Kenyan national guidelines suggest screening every smear positive household child contact. That rarely happens in Khunyango...sometimes she will ask if she remembers but she was honest and admitted that she usually does not remember.
-Kenyan national guidelines suggest isoniazid preventive therapy to children < 5 and HIV+ kids who have been exposed to TB in the home and were screened to rule out TB disease. Her response: "Well we don't really screen and right now all of the isoniazid we were given for this has expired" hmm...classic.

The second half of the morning was spent introducing the child contact register and filling in some information for the active source cases so we would be ready to go the following day when patients lined up for clinic.

On Wednesday, we saw 14 pulmonary TB patients and identified 28 child contacts. There is always 1 case that ends up shocking me the most. We met a 12 year old HIV positive girl with TB who came in with her mom and 10 month old brother. Mom and the 10 month old are also HIV positive. She has two other children who have not been tested yet for HIV despite the fact that she has witnessed her eldest daughter suffer. After several counseling sessions regarding PMTCT (preventing mother to child transmission) and the importance of delivering in the hospital, mom was still convinced by her family to deliver at home.
This brings up an important lesson that I have learned this year: culture and family will often trump doctors. This should not be a surprise to us, but instead it should be expected. It's important to just continue being patient, educate as much as possible and applaud those who take the leap towards things like pmtct. Anyway, we counseled her to bring her other children in for HIV screening, and we encouraged her to bring the 10 month old in for TB screening. Fingers are crossed.

The best part of this trip was working with someone who is really passionate about TB and the health of her patients (unfortunately, this hasn't exactly been the case in the Eldoret TB clinic). This DTLC runs the entire clinic by herself, she actually fills out all of the paperwork required by the ministry of health, and she seems to actually enjoy it. Hopefully she'll adopt the child contact register and she can help some of these kids!

The DTLC and I in the TB clinic

Here is a picture from the hotel balcony. I dragged a chair out here to read and enjoy the African sunset. :)

Last Hurrah

4 weeks left in Eldoret and I still don't think I've accepted the fact that this wonderful year will be coming to an end very soon. At least the people around me are paying attention so they planned one last longtermer trip last weekend.

We headed to Hell's Gate National Park and Mt Longonot. I've been looking forward to this trip all year since it's known as one of the best weekend trips if you live in the Eldoret area.

Why is that?
Well, Hell's Gate National Park does not have any lions or leopards so people are allowed to walk and/or bike through the park. I doubt that there are too many other places in the world where you can bike next to zebras, ostriches, buffalo, warthogs, etc.
We biked about 5 miles to a gorge and then hiked for about 1.5 hours through the gorge.

Giraffe!




Trying to get up close and personal with the zebras...


The gorge




Jump!


On Sunday, we climbed Mt Longonot which is a dormant volcano that last erupted in the mid 1800s. The hike up to the crater rim took about 1 hour and then we hiked the entire crater rim loop which took about 2.5 hours.

The rim of the crater...




The peak of the crater in the background



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Tumaini Barrack Screening

Before I left for the states, we organized a TB screening event in one of the street children barracks. The term 'barracks' is misleading because everyone assumes that this is an actual structure where the street children live. Unfortunately, it just refers to an area in town - either in a field, by a river, outside a store - where a group of children sleep and hang out. There are approximately 8 'barracks' in Eldoret and each one has anywhere from 10-40 children. Each barrack also has an older barrack leader who watches over the younger kids and intervenes if there are any problems.

We were a bit worried to start screening in the barracks...what would we do if we found a positive case? How could we ensure drug adherence in this difficult population? These kids are constantly moving around, most of them are addicted to glue, and many of them do not have phones. An interesting ethical issue: is it better to screen and identify with the risk that adherence will be low or is it better to avoid screening a difficult population?

We had many discussions with the Tumaini drop-in center and the TB projects office team about this issue and concluded that it would be best to confirm that it is impossible to maintain a street child on treatment before we decided to stop screening this population. We created some possible scenarios for how we could maintain drug adherence if a TB case was identified in the screening. The solutions included working closely with the barracks leader and empowering him to help find the child daily, providing incentives for the child (food, transport costs), having the health outreach worker go to the barracks daily etc.

The first screening took place at the California barracks. We chose California because the barracks leader is one of the best, and he agreed to help if we identified a positive case. He mobilized his barrack members the morning of the screening and kept them quiet during the sensitization talk. He also helped to keep them organized while the screening was taking place.

Fortunately, no positive cases were identified. It's hard to believe that we have not found a positive case yet, but perhaps this population is not affected or testing sputum is not the best test for this population.

I could not take pictures during the screening because the kids (and I!) find it disrespectful. We don't need to create any additional slumdog tourism.

I did manage to get one shot from afar as we were leaving of the entire barrack to share with you. It's one thing to hear about the street kids and it's another to actually see the conditions they live in every day.

California!

Sorry for the lack of posts last week. Two of my dearest friends were getting married so I went back to the states for the wedding.

The ceremony was on the beach in California.

Don't they look beautiful?

An Imani Thank You

Many of you will remember my post about the Imani Workshops sale that took place during the winter holidays. The sale was a success so thanks again to everyone who came and supported. I hope that you are all enjoying your purchases!

As promised, I did not simply donate the money raised to the workshops because I really wanted to make sure that it went to something that would be useful and sustainable.
After much discussion, the Imani Workshops leaders and I finally decided on....

a paper shredder!!

Let me explain...

Popular paper products like journals, cards and bookmarks are made from handmade paper. Imani receives recycled paper from the hospital and then this paper is cut, mixed with papyrus, pressed and dried into Imani paper.

The rate limiting step to this entire process was the paper cutting. Previously, several people were assigned to cutting the hospital paper into small pieces with scissors. As you can imagine, this task was incredibly tedious and these workers were only able to collect 1-2 bags of small paper pieces per day. Unfortunately, the workshop was unable to keep up with some of the paper product orders because it was impossible to speed up production.

The paper shredder purchased is an industrial 15 page paper shredder which will hopefully triple or quadruple daily shredded paper production and increase the number of employees available to help further down the assembly line. This should increase paper product production which will lead to increased profits, increased salaries, and the ability to higher additional employees!

I delivered the paper shredder last week and to my surprise, the event will probably be one of my top 5 memories from the entire year. As I walked in with the huge box, all of the women started to get up and they all started clapping. Before I knew it, they had bursted into a Kenyan song, joined hands and were dancing around me. It was absolutely beautiful, and I wish that all of you who purchased Imani items or made donations could have experienced the moment with me.

It also made me realize that we should all do a bit more celebrating about things that we probably take for granted. I'm going back to the states for a wedding this week, and I think I'm going to make a conscious effort to do this. Perhaps I'll break into song when I drive on a paved and painted highway. Or maybe I'll celebrate the dryer in my mom's house and the fact that I don't need to wait 3 hours for clothing to dry.

Here's an attempt to share the Imani moment with you...

Dancing and singing


The paper department and the shredder


Demonstrating how the shredder works...


The paper department went right back to work to finish a bookmark order


If you are interested in making any additional purchases to support Imani, please contact me at Szkwarkd at gmail.com.

Here is an album of some of the products available.

Imani

Ukrainian Ugali?

Continuing with the Ukrainian blog post theme, I thought I would share with you some pierogy making that happened in Kenya today. (I think that I can bet money on the fact that we were the only people in all of Kenya making pierogies!)

The same Easter egg making family from last week had also asked me to make Ukrainian food with them before they leave Kenya on Sunday. Since I've never actually made pierogies on my own from scratch, I figured this would be a perfect time to start!

My mom sent me the family recipe and luckily we had all of the ingredients. They were a great success!

Here are some pictures...




potatoes, onions and cheese...yuuum


one of my wonderful little helpers


this was my favorite part as a kid


folding


Almost done


Voila!



The Kenyan cooks asked what we were making, and when I told them 'pierogies' they looked totally confused. So I explained that pierogies are the Ukrainian equivalent of Kenyan ugali (ugali is a staple food in East Africa made from maize or cassava flour). They seemed to like this explanation because there isn't a Kenyan out there who doesn't love ugali. I guess every country has it's own beloved staple starch!

Aberdare National Park

A group of us headed out to Aberdare National Park for the 4 day Easter holiday last weekend. The weekend was perfect and I would go back in a heartbeat if the park wasn't so far away!

It took about 6 hours to drive from Eldoret to the park entrance.

We arrived at our first campsite on Friday just in time to set up and make dinner. We brought along some homemade chili so it made for an easy and delicious meal.


The next day, we hiked 17 km to see Karuru and Gura falls. Both of these have been claimed to be the tallest waterfalls in Kenya. Karuru had 3 drops: 383 feet, 84 feet and 427 feet. We were only able to see the first drop from our lookout point since the other two drop deep into the valley.

Karuru Falls


hiking


After the hike, we packed up to go to another campsite. Our guide told us that this site would be completely 'in the bush' and he was not lying!

A video that my friend made of the campsite...


Our campsite and our campfire




On Sunday, we hiked Satima peak which is the third highest peak in Kenya (after Mt. Elgon). It took us about 7 hours to hike the 20 km. We definitely slowed down closer to the peak because of the 13, 144 feet altitude!

On our way


Beautiful Scenery


Satima Peak...If you look closely you can see one of my friends already at the top. She is one of the most fit individuals I have ever met (she has two ironman triathlons under her belt!). She ran up to the top because apparently altitude doesn't affect her. :)


Almost there!


At the peak...


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