My India Stint Starts with an Adventure

I was supposed to fly from NYC to Delhi via London, leaving JFK Sunday Dec 28th, arriving in Delhi on Tuesday Dec 30th at 2am. Fifteen minutes before landing, the captain announced on the loudspeaker that he could not land due to the poor visibility. The plane would be diverted to Mumbai.

Now I'm now stuck at a hotel in Mumbai until further notice. It was a bit scary to arrive in the middle of the night, 2 hours by air from my destination. One billion people in this country, and I don't know anybody! Luckily, I was able to contact the team in Delhi to let them know what happened. I will fly to Delhi as soon as British Air is ready, brief with the team in Delhi, then fly to Bihar state the following day.

Bihar India

In three days, I will leave for Bihar India to work on another MSF project. Bihar is one of the poorest States in India. It is in the Northeast part of the country, just south of Nepal and West of Bhutan. The project is on diagnosis, prevention, and treatment of visceral leishmaniasis (also known as Kala-Azar). Kala-Azar is a protozoal infection transmitted by the sandfly. More on this disease in future posts.

I first heard about the project just two weeks ago, when I was in Liverpool, finishing up my tropical medicine course. I have not had enough time prepare for this trip, but I am excited nonetheless. I feel lucky to have the opportunity to work in Asia (my fourth continent in three years!).

Leptospirosis Outbreaks in Triathletes and Adventure Sportspeople

Leptospirosis is a bacterial infection of rats and other rodents. It can be transmitted to humans when they swim in fresh water bodies contaminated by rodent urine. Although many American doctors regard this disease as an exotic tropical infection, leptospirosis infections actually occur world-wide. The organism is a spirochete-- a coiled bacteria similar in shape to the organisms that cause syphilis and lyme disease (see electron micrograph pic at left).

Most people who get leptospirosis have a non-specific flu-like illness about a week or two after exposure. About ten percent of patients get serious complications, including kidney and liver failure (Weil's disease). Textbook cases present with subconconjunctival hemorrhage (red eyes), but of course this symptom is hardly sensitive or specific.

I was surprised to learn that there have been several outbreaks of leptospirosis in triathletes and adventure sportspeople. The largest outbreak in the United States was after a triathlon near Lake Springfield in 1998, when 12% of participants reported a post-triathlon febrile illness. Of 474 participant blood samples tested, 11% were spirochete positive (Clin Infect Dis. 2002 Jun 15;34(12):1593-9. Epub 2002 May 24). ] In 2000, there was an outbreak in Athletes who competed in the 10-day Borneo "Eco Challenge 2000, multisport endurance race." The event included jungle walking, swimming, kayaking, spelunking, climbing, and mountain biking. About half the athletes got leptospirosis. There's an interesting report of the epidemiological investigation in CDC's Emerging Infectious Diseases, Sejvar J, Bancroft E, Winthrop K, Bettinger J, Bajani M, Bragg S, et al. Leptospirosis in "Eco- Challenge" athletes, Malaysian Borneo, 2000. Emerg Infect Dis [serial online] 2003 Jun. The CDC suggests that athletes who participate in these events might want to consider taking Doxycycline for pre-adventure sport prophylaxis!

Hookworm

Hookworm is a major cause of anemia-related morbidity in the developing world. The Ancyclostoma Duodenale hookworm species looks scary under the electron microscope. Actual size is only 8-11 mm. The worm sinks those teeth into the wall of the small intestine and drinks blood from the capillary rich mucosa.

Each adult worm can consume up to about 0.25ml of blood per day. Many patients--especially children--are heavily infected. An infection of 100 worms could cause 25 cc blood loss per day, which is one unit of blood every 10 days. On top of HIV, tuberculosis, malaria, sickle cell, and poor nutrition in subsaharan Africa (all causes of anemia), it is easy to see how hookworm-related anemia is a big problem.

Kristof on XDR-TB

Kristof has a column in the New York Times today on XDR-TB in Armenia. Nothing new here, but I find it reassuring that other people are getting as worried about this as I am.

Excreta Control and the VIP Latrine

I am reviewing the water and sanitation module this morning. One of our practice essay questions: "describe briefly how you would provide an excreta control programme in a refugee camp during the first few weeks of an emergency."

Let's see... well, I would definitely pull out my Sphere Project Humanitarian Response and Minimum Standards in Disaster Response handbook. The sphere project was started in 1997 by a group of humanitarian NGOs. They collaborated on a comprehensive disaster response handbook, which is free and downloadable from www.sphereproject.org. WHO also publishes a "Guide to the development of on-site sanitation." Of course there is always MSF's "Refugee Health: An Approach to Emergency Situations,"also free and downloadable.

These resources say that at the start of an emergency, you might only have time to build shallow trench latrines, which are essentially shallow pits that are covered by a thin layer of soil after defecation.

After a day or two, you will need to build something mroe permanent, such as a simple pit latrine, or better yet a Ventilated Improved Pit Latrine (VIP). A simple pit latrine is just a slab with a hole over a pit that is at least 2m deep. The bottom of the pit needs to be at least 1.5 meters above the water line under the soil, so that the excreta doesn't leak into the surface water supply. There should ideally be at least one latrine for each 20 people.

The ventilated improved pit latrine (VIP) has several clever features that make it a better option than the simple pit latrine. There is a superstructure over the latrine part that keeps the it darker inside than outside. There is also a ventilation pipe that exits the latrine roof. Odors from the latrine exit from the pipe. Flies and mosquitoes are also attracted to the light of the pipe, rather than the dark of the pit. You can put a trap at the top of the pipe to kill the insects as they fly towards the light. Image from Water Aid, an International Charity that helps poor people gain access to safe water, sanitation, and hygiene.

The Dispensary

I've been studying a lot for our upcoming exams, but I've still had enough time to get some medicine from The Dispensary.

NYC Public Health and Human Rights Event Dec 5th

I wish I could be in New York on December 5th for this Public Health and Human Rights event sponsored by the Johns Hopkins Bloomberg School of Public Health and Physicians for Human Rights. The speakers will discuss progress since the UN adopted the Universal Declaration of Human Rights in 1948, and the many challenges that remain. The list of speakers and the panel discussion topics look promising. It should be an interesting afternoon. The full program and list of speakers is here.

Giardia Trophozoites

Giardia protoza can cause chronic diarrhea in hikers and travellers who drink contaminated water. The trophozoite attaches to the mucosa of the small bowel, preventing nutrients from being absorbed into the bloodstreem. To my eye, the trophozoites look like cartoon characters. At right, a Kohn stain, below left, a giemsa stain (pics from CDC DPDx).

Practice quiz

Try your hand at three questions that were on our Vector Biology Revision Quiz.
Hit the "comment" button at the end of the post to see the answers.

Q #1: What is this?


Q #2: Pic at left. Which mosquitoes may commonly be associated with this environment? What mosquito-born infections may be transmitted by these vectors?



Q#3: Which two insect vectors breed in this environment (pic below)? What diseases do they transmit?

World Trip Practical

In our lab practical yesterday we were assigned the stool sample of a patient who took a trip around the world. He came back to Liverpool with 22 gastrointestinal parasites. I was only able to identify 10 out of 22 species in 45 minutes. My paper was graded "average marks," which is english for C+, I believe.

Afterwards, they told us the stool contained:

Bastocystis hominis
Entamoeba coli
Entamoeba histolytica/dispar
Endolimax nana (below left)
Chilomastix mesnili
Giardia duodenalis (below right)
Iodamoeba butschilii
Taenia species
Diphyllobothrim latum
Hymenolepis nana
Schistosoma mansoni
Schistosoma japonicum
Opisthorchid group
Paragonimus westermani (above left)
Fasciola
Ascaris lumbricoides
Trichuris trichiura (above right)
Capillaria philippinensis
Hookworm
Enterobius vermicularis
Strongyloides stercoralis larve

International Night

One of the biggest nights of the year for the liverpool DTM&H course is International Night, a multiculti food and entertainment extravaganza. Students dress up in traditional dress from their country of origin, bring typical foods to a potluck dinner, and entertain fellow students with music and dance from their country of origin. The American contingent was weak; I wore jeans and brought a bottle of bourbon. The other three were just as half-hearted. The Germans outdid themselves with a marzipan and traditional cookie desert table. The Indians coreographed an elaborate Bollywood number. Below, three Scot Internists. At left above, Nigerian, Indian, and Italian pediatrician trio.

Congo

The BBC world service has a lot of information about what's happening in Congo. Warning: It's upsetting.

Mosquito classification

I have been working hard on my vector biology. To be honest, the vectors are of less interest to me than the diseases that they transmit, but I'm trying nonetheless.

A few tidbits on the classification of mosquitoes:

1. To determine the sex of a mosquito, look at the antenna. If the antenna are "plumose" (hairy), the mosquito is male. If the antenna are "pilose" (not very hairy), the mosquito is female (see diagram above)

2. To determine the genera of medically important mosquitoes, look at the palps (sensory organs just lateral to the proboscis, the stick-like organ that punctures the skin for blood meal). If it is a female mosquito with long palps, the mosquito is Anopheles. If the mosquito is female with short palps, the mosquito is Culicine.

3. To assist with genera identification: Anopheles mosquitoes rest and bite with their bottoms up (approximately 45 degree angle to the skin). If you see a mosquito biting you with it's bottom parallel to the skin, it is not likely a anopheles, and you can rest assured that you won't get malaria from that bite (although you could get Yellow Fever, Dengue, Fillariasis, West Nile virus, or another mosquito-borne arthropod virus. The diagrams of Anopheles and Culex below were downloaded from CDC's National Center for Zoonotic, Vector-Borne, and Enteric Diseases
I won't go into the details on how to identify and classify mosquito eggs, larvae and pupae, but I do know how, believe it or not.

Health and Human Rights

The Journal Health and Human Rights, published by the François-Xavier Bagnoud Center for Health and Human Rights at the Harvard School of Public Health, has recently gone online, with full text of all articles accessible for free.

In the current issue, Gavin Yamey has an essay on the importance of free and open access of the biomedical literature:

Arthur Ammann, president of the nonprofit organization, Global Strategies for HIV Prevention (http://www.globalstrategies.org), tells the following story:

I recently met a physician from southern Africa, engaged in perinatal HIV prevention, whose primary access to information was abstracts posted on the Internet. Based on a single abstract, they had altered their perinatal HIV prevention program from an effective therapy to one with lesser efficacy. Had they read the full text article they would have undoubtedly realized that the study results were based on short-term follow-up, a small pivotal group, incomplete data, and unlikely to be applicable to their country situation. Their decision to alter treatment based solely on the abstract’s conclusions may have resulted in increased perinatal HIV transmission.1

The physician in southern Africa could not afford to view the full text article due to its exorbitant cost. The full text version of a research article in a medical journal typically costs US$30 to download, while an annual subscription to a journal usually costs several hundred dollars. Hence the physician was forced to rely on abstracts alone (abstracts of some research articles are made freely available in the online database, PubMed, at www.pubmed.gov). The full text versions of most biomedical studies — an essential treasury of life-saving knowledge — are locked away behind access barriers. These access tolls bring enormous profits to the traditional corporate publishing industry, but at the same time make it impossible for many people worldwide to access the biomedical literature. The imposition of such tolls arguably violates the spirit of the Universal Declaration of Human Rights, which states that everyone has the right “to share in scientific advancement and its benefits” (Article 27, section 1).2

Sleeping Sickness

Trypanosoma brucei, the agent that causes sleeping sickness, is my new favorite protozoan. The African tsetse fly is the vector for both species of typanosoma: T. brucei gambiense, which causes sleeping sickness (Human African Trypanosomiasis, or HAT) in West and Central Africa, and T. brucei rhodesiense, which causes a different form of HAT in East and Southern Africa.

As I learned today, the best way to identify the tsetse fly is by the "hatchet cell" shape framed by wing veins 4 and 5 (seen upsidedown in upper wing in this pic), and by the characteristic way that resting fly holds its wings, folded over the abdomen in a "pair of closed scissors" formation. [Medical entomologists are a mad bunch, no?]

Both male and female tsetse flies inject the metacyclic trypanomastigote form of the parasite into the human host when taking a blood meal. In the peripheral blood, the trypanomastigotes multiply by binary fission, to form three different forms: the "short-stumpy" form, the "long-narrow" form, and the intermediate form. All of these forms look a bit like worms smimming in the blood stream, but of course they are single-celled organisms, not worms. What looks like the eye of a worm is actually a bit of mitochondrial DNA material called the kinetoplast. The tail of the worm is the flagellum, that ungelates for motility.

The clinical maifestations of HAT are as bizarre as the parasite morphology. The T. brucei gambiense form of the disease is much more insidioius and chronic than the T. brucei rhodesiense form, which progresses rapidly towards death. In both forms, the patient may present with a chancre or ulcer at the site of the tsetse bite. Multiple non-specific symptoms follow the bite, including: fever, fatigue, wasting, lymphadenopathy, rash, and itching. Once the parasite enters the central nervous system, the patient may get confused, then fall into the reverse sleep pattern of daytime somulence and nighttime agitation that gives the disease its nickname. If left untreated, the disease is uniformly fatal.

Like most diseases that occur only in poor countries, HAT has no decent treatment options. The only drugs available are toxic compounds that cause debilitating side effects (and 5% chance of mortality from the drug alone). All of the drugs were developed decades ago. There are few or no other options in the pipeline.

I was always taught that HAT is a rare disease, but our professor told us that it is actually prevalent and wide-spread. The 50,000 cases that are reported to WHO every year are probably at least a 12-fold underestimate. He believes that HAT and "nagana," which is the animal-version of the disease common in horses and livestock, are the reason that European colonists "gave up" on their conquest of Africa. The livestock ranches in the colonial era failed miserably due to illness of colonists and their herds, he says.

David Livingstone was onto the same idea way back in 1857, when he published a description of nagana in Missionary Travels, the narrative of his famous mid-century African expedition. Soon after, the colonists started calling the sleeping sickness syndrome "negro lethargy." They called HAT by this name until the white colonialists started getting sick too, at which time the Royal Society sent an expedition to investigate. In 1903, they identified the trypanosoma parasite in the blood and CSF of sick patients. They even managed to infect monkies with the agent, proving that typanosomes cause sleeping sickness disease.

Famine in Somalia

Another depressing story about the famine in Somalia.

Refugee Camp in the Heart of the City

MSF's "Refugee Camp in the Heart of the City" exhibit, will be in California over the next couple of weeks. People who saw the exhibit last year in Manhattan and Brooklyn recommeded it for both adults and for families. It takes about an hour to tour the whole thing. Admission is free. The schedule is:

San Francisco, Little Marina Green Park
Oct 15-19

Los Angeles: Griffith Park
Oct 22-Oct 27

Santa Monica: Santa Monica Pier
Oct 31-Nov 2

San Diego: Balboa Park
Nov 6-9

Much more information at www.doctorswithoutborders.org, or by clicking on the above link.

World Mapper

The World Mapper Collaboration has more than 350 of these "density-equalising maps," on its website, www.worldmapper.org. Each cartogram re-sizes countries according to the variable being mapped. For example, the cartogram above left shows the relative prevalence of HIV worldwide. The map categories include: goods, services, resources, work, income, housing, education, poverty, health, disease, disaster, death, polution, violence, and many others.

Small quiz: of the maps below, which shows relative malaria deaths? Which shows military spending in 2002? Which shows electronics exports?

You can download pdf posters of all maps for teaching material. For more information on the map-making technique, see worldmapper website, or Michael T. Gastner and M. E. J. Newman (2004) Diffusion-based method for producing density equalizing maps Proc. Natl. Acad. Sci. USA 101, 7499-7504. Maps copyright 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan).

Myiasis

is not a topic that was taught in my medical education prior to this course. I'm sure about this, as it is the kind of thing that I would certainly remember. Here in Liverpool, we spent a whole precious day on myiasis. Medical Entomology for Students is on my bedside table.

Myiasis refers to the invasion of mammalian tissue by fly larvae (more commonly known as maggots). There are many species of fly larvae that cause myiasis, some of which burrow deep into healthy tissue and some of which infect already necrotic tissue.

I will not post any gross pathology pics of maggots in human tissues, as I know that it's not the kind of thing that everybody likes to study as much as I do. At left is a light microscopy image of an ear infected by Dermatobia hominis (human bot fly) larvae, which is endemic to Central and South America. [The larvae are the three yellowish cone-shaped structures buried in the pink ear tissue.] The botflies have evolved an ingenious way to infect their hosts. They lay sticky eggs which glue onto the bodies of biting insects (e.g mosquitoes). The eggs drop off onto the tissue of human hosts when the carrier takes a blood meal.

Apparently there has been a recent upsurge in interest in "maggot therapy" in developed countries. This therapy uses sterile (lab-grown) larvae of Callifora and Lucilia species (bluebottle and greenbottle blowflies) as a means to debride chronic wounds. Again, I will spare you pics. For additional reading: Parnes, A et al "Larval therapy in wound management: a review." Int J Clin Pract, 61, 488-93.

Identification of Parasites in the Lab

The teaching lab at LSTM is massive. On the first day, they issued each of us a lab bench, microscope, and lab coat. Every day we prepare blood smears and/or stool smears from unknown samples on our lab bench. At the end of the session, the faculty tell us the pathogens in the unknown samples. Below, a pic of the students at my bench.


The CDC has a fantastic reference website for parasitic disease diagnostics. They have lifecycle diagrams of every important organism, as well as an image library to help with diagnositic microscopy.

Genius Doctors

Two doctors I admire won MacArthur Foundation grants today. Wafaa El-Sadr (right) is an Epidemiologist and Infectious Disease doctor at Columbia University and Harlem Hospital in NYC. She has probably done as much or more for expanding HIV and TB treatment worldwide than any other single person. She is the PI for some of the largest HIV treatment studies. She also advocates for access to treatment in the poorest and most vulnerable people worldwide. She is the first person who taught me that HIV and TB are "evil stepsisters," who often travel hand-in-hand.

Diane Meier (left) is a geriatrician who works at Mount Sinai hospital in New York. She specializes in palliative care, which means care directed at comfort, rather than cure, at the end of life. The MacAuthur website says:

She recognized that modern medicine’s focus on curing disease and prolonging life failed to treat the physical and psychological distress of patients in both early and advanced stages of serious illness. Her studies found that a high percentage of seriously ill patients in hospitals were experiencing limited communication between patients and clinicians, poor management of pain, and insufficient support and social services for family caregivers. To fill these voids, Meier established the Hertzberg Palliative Care Institute at Mount Sinai, a model program that assists patients and families in navigating the complexities of illness and devises strategies for managing pain and other symptoms, such as anxiety, depression, sleeplessness, and loss of appetite.

While many doctors recognize these challenges, Dr. Meier does more to resolve them than most. I have heard many talks about palliative care, but I have never heard anybody speak with such wisdom and empathy as Dr. Meier. Her work will both save money for the American health care system, which spends an inordinate amount on the last two weeks of life, and spare patients and families pain that comes with useless tests and treatments at the end of the end.

University of Liverpool

I am a student at the University of Liverpool School of Tropical Medicine for the next three months. My course has exceeded my expectations so far. There are about 90 doctors from more than 25 different countries enrolled in the course. Half of the students are from UK and half from other parts of Europe, Asia, Middle East, Africa, or North America. I've found the other students like-minded. Almost everybody plans to work in the developing world or works there already. The curriculum is focused on what we need to know in order to practice in low-resource countries in the tropics. Many of the sessions emphasize exchange of information among the students who have practiced in different countries, so we can learn more about the nuts and bolts of practice in various settings.

I love the old school crest (at left above). They replaced this logo with a hideous new one, but the old school building (at right above) still has stained glass windows with the historic crest.

MSF nurse dies in Nigeria

This is terrible. The MSF website reports that a nurse died last week in Nigeria on the first day of his first mission. He was electrocuted while in the shower.

My Last Weekend in Kenya

This was over a month ago, but I've re-discovered these pics and want to post them here. In mid-August I spent my last weekend in Kenya at the family homestead of our housekeeper Margaret, near Nanyuki in the Great Rift Valley. Margaret and I took a mini-bus 3 hours from Nairobi to get there. Margaret's mother Ruth lives in this house, along with several of her 14 children, and a few great-grandchildren. Margaret is shown in the fabulous red and pink dress below.

I was priviledged to stay as Mama Ruth's guest for the weekend. The family welcomed me. In fact, Mama Ruth insisted that I sleep in her room. Although I offered to go to a nearby hotel, my hostess would not hear of it. She slept in the house's main room along with eight other people. Nevertheless, she seemed delighted with my visit. She and the rest of the family would burst into Kikuyu prayer every hour or so. Of course I couldn't understand what they were saying, but "Nelly" was mentioned several times per session, so I assumed they were happy I was there. Pic of Mama Ruth in Blue at right.

The Culture Shock Begins

Thanks to a computer error, I somehow got upgraded to Business class for my flight back to New York. I am now hanging out in the British Air Executive Lounge at Heathrow. The African immigrants are serving me watercress sandwiches and sparkling water with lime. My memories of roast goat and ugali are fading into the background. I'm going to go check out the shower-spa.

Superbugs

Jerome Groopman has an essay in the New Yorker about antibiotic resistant bacteria (sometimes called “superbugs”). These bugs will infect my life in 2009-2010, when I will be an infectious disease fellow in the Bronx. NYC tertiary medical centers must certainly be the epicenters of multiresistant bacteria. According to a doctor-friend who works at a hospital in NYC, if you leave your coffee unattended in the morning, there will be a layer of MRSA on the surface by lunch....

Goodbye Kenya

It's my last week in Kenya. I am saying my goodbyes (pic by Rebecca).

Crocs in Haiti

On the Partners in Health Website, a story about a donation of colored plastic clogs to prevent tungiasis. [Partners in Health is the Boston-based NGO founded by Paul Farmer and Jim Kim.] Tungiasis is a foot infection caused by a burrowing flea. I can't recall even a second devoted to this disease in medical school. Hopefully, I will learn about it at Liverpool.

More Aid Workers Killed in Somalia

The New York Times ran a story on the murder of aid workers in Somalia. This is truly depressing, as the famine in Somalia continues to worsen, and nutrition projects like MSF's feeding centers can barely function due to the security situation. I saw a story on Al-Jazeera that had shocking pictures of starving people. It looked a lot like the pictures of the Ethiopian famine in the 1980s.

Celebrity

I'm featured in a story in the esteemed periodical Internal Medicine News.

Buy This Book

Sexy cover, sexy author, sexy book! Nothing to do with Africa! It won the Lambda Literary Award for Lesbian Debut Fiction, but you don't have to be a lesbian to love it. The Washington Post called it “post-gay” and The New York Times called it “engaging” and “delightfully lyric.”

Buy it from your nearest independent bookstore, or simply by clicking on this link.

Doctors Dysphoric

There's a decent article in the New York Times about discontent with clinical practice in the USA. Nothing new there-- but it is gratifying to hear somebody else describe the same discontent that you've struggled with. The article quotes a doctor on Long Island:

I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.”

When he decided to work in a hospital, he figured that there would be more freedom to practice his specialty.

“But managed care is like a magnet attached to you,” he said.

He continues to be frustrated by payment denials. “Thirty percent of my hospital admissions are being denied. There’s a 45-day limit on the appeal. You don’t bill in time, you lose everything. You’re discussing this with a managed-care rep on the phone and you think: ‘You’re sitting there, I’m sitting here. How do you know anything about this patient?’ ”

Recently, he confessed, he has been thinking about quitting medicine altogether and opening a convenience store. “Ninety percent of doctors I know are fed up with medicine,” he said.

I am not working in a convenience store, but negotiating with Kenyan bureaucrats is not exactly clinical medicine either. If American doctors choose to work in convenience stores or the developing world rather than primary care practice, isn't it time to reform the American health care system?

Liverpool School of Tropical Medicine

We are facing some major challenges to our research study. However, rather than dwell on the pain, I will try to look to the future. Specifically, I am getting excited about the 3-month Diploma in Tropical Medicine and Hygiene course that I am going to take September-December 2008.

Liverpool is a major center of tropical medicine. According to the website:

the school was founded in 1898, becoming the World's first institution devoted primarily to tropical health. It has extensive links with UN organizations, health ministries, universities, non-governmental organizations and research institutions worldwide and is involved in numerous programmes to control diseases of poverty and to develop more effective systems for health care. The School prides itself on its links with developing countries and is committed to increasing such partnerships.

Sounds right up my alley. Back in medical school, believe it or not, I was one of the most gifted students at looking for ova & parasites in stool samples under the microscope! Ro can vouch.

Forkless

I was in Busia town earlier today, about 3 km away from home, when my bike fell over and hit the ground. The rusty old fork split right in half. I started walking home, carrying my bike, when a fundi (skilled worker) appeared out of nowhere. He pulled a new fork out of his tool box, and proceeded to replace my fork, adjust my spokes, and tune my breaks. I felt like a bicycle racer with my own team of professional mechanics. After a half-hour overhaul of my bicycle, he gave me the bill: 250 shillings (4 USD) for the new fork, and 40 shillings (65 cents) for the labor. This seemed absurdly underpriced, given that he provided the exact service I needed at my desperate moment of need (5pm on a Sunday afternoon, no less!). When did I become so lucky? Has an albino crossed my path?

Albino Body Parts

I just read a grisly article in the New York Times online about a wave of Albino murders in Tanzania. Apparently, witch doctors have been spreading the word that Albinos are good luck. A market for Albino body parts has grown in the area around Dar Es Salaam. The article reports 19 albinos have been killed in recent weeks. Why are Albinos suddenly good luck? The article also mentions that albino-killing is spreading to Kenya. I will be especially careful, as mzungu could easily be mistaken for albino, I would think.

Tourists Without Borders

I visited the Maasai Mara game park in Southwestern Kenya with Rebecca last weekend. Maasai Mara is famous for the diversity of wildlife in the park, as well as the yearly wildebeest migration, where 1.6 million beasts trudge back and forth from Serengeti to Maasai Mara and back again. The wildebeests come to the Mara in July and August, so we missed the spectacle. However, we saw some unforgettable sights. This bunch of zebra crossed the Mara river right in front of a hungry croc. There was also a lioness waiting on the far shore! Also, two cheetahs jumped onto our safari-mobile. This pic isn't even zoom! She was that close....

Traditional Birth Attendant (TBA) Training

Traditional Birth Attendants are essentially local midwives in rural villages. Many of them have no formal medical training, but have worked their whole lives delivering babies and assisting women through difficult pregnancies and deliveries. Because the majority of our patients deliver their babies at home, the Rural Health team designed a training for the TBAs on Prevention of Mother to Child Transmission of HIV (PMTCT). The training was packed. More TBAs showed up each successive day.
The curriculum included the importance of universal precautions, types of perinatal ARVs, and how to monitor for signs of opportunistic infections and drug side effects.

I love these photos. Nelson, one of our clinical officers, took them on the last day of the TBA training in Madende. The women were delighted with the T-shirts and certificates that MSF gave them. (Note cheering TBAs in the background in the picture above.)

Rebecca

Rebecca works for MSF as a “flying” sexual violence reference person. She has been to MSF projects all over Africa, helping to set up or to improve the response to sexual violence in the communities where MSF works. Our project is lucky to have Rebecca's help for several weeks. She’s a gifted public speaker. One of her talks was so good that even one of our drivers asked for copies of her slides so he could remember everything she said.

Lucy and I are particularly fortunate that Rebecca is staying in the house where we live. She tells us stories about her work in Liberia, Chad, Uganda,and Eastern Europe. She's also side-splittingly funny and cooks a lovely macaroni and cheese. (Those buff arms are thanks to yoga, by the way).

Long Rains

The rainy season in Western Kenya is called the "long rains." It lasts from April through August. Our neighbors have planted their crops and are busy weeding and hoeing the land. In this region the women are responsible for tending the fields (and the shopping, and the childcare, and the cooking, and the cleaning). I took this pic from our front door.

Frustrations

There are plenty of challenges at the moment for our research study here in Busia. Delays by the Scientific and Ethical Committee have prevented us from starting our data collection. Meanwhile, we are busy with preparations. It takes ages to get even the smallest things done in the middle of nowhere. After three weeks of daily reminders to logistics, we finally got the file cabinet we ordered four months ago. When it finally arrived from Nairobi, the top was dented and the screws were lost. It won't close or lock. Now I've dented my head by banging it against the wall too much...

Found on Living Room Floor, the saga continues

I am back in rural Western Kenya. What better way to celebrate than another exciting episode of Found on Living Room Floor? Last night I got up in the dark for a glass of water. I walked to the fridge barefoot, and haplessly cruched hundreds of dudus (Swahili for bugs) that mysteriously appeared between bedtime and midnight. Lucy says the dudus are flying termites. The Kenyas here like to eat them. They sell for 20 Kenyan Shillings per small cup at the market. At right, friend and lab wizard Juma eats a spoonful of dudus.