Monday, April 21, 2014

Camille Writes About the Hospital

 I (Camille) thought I'd finally bow to demand and write about the hospital.  Or, you can scroll to the bottom for some Easter pictures of Eric.  

The male ward
Naivasha District Hospital, a level IV government hospital, has about 200 beds.  There are 10 or so medical officers (doctors that have completed a general internship and are working as general practitioners, “paying back” the government for their medical education), 30 clinical officers (the equivalent of physician assistants in the US, who, along with the nurses, handle nearly all of the outpatient care), 20 clinical officer interns, and 14 medical officer interns.  We have four “consultant” doctors who oversee all of the medical officers and interns (one surgeon, one obstetrician, one pediatrician and one internist).  We have nutritionists, physical therapists, and a psychiatry nurse.  We have two sets of operating rooms, a pharmacy, outpatient clinics, a lab, a public health office, a physical rehabilitation center, and 4 wards:  male, female, pediatrics and maternity, which includes a unit for newborns who need special care.

We have one oxygen concentrator and one nebulizer per ward, an x-ray machine, and two ultrasounds.  We have most of the medications on the WHO essential medicines list.   We have ventilators for surgery only.  We have two ambulances, which are primarily for transferring patients to and from other facilities. 
Patient meals

Each ward has about 30 beds, and is staffed by 2-4 nurses.  When the census is high, as it frequently is, patients are two or three to a bed.  Medications are theoretically handed out three times a day, but with so many patients to care for, it often ends up happening twice, or maybe even once.  Interns do their own blood draws that must be brought to the lab by noon.  Results are generally not reported until the next morning.  We can get a CBC, some electrolytes, blood cultures, basic urine tests, HIV tests, tests for Cryptococcus, and blood cultures.  Last month we got a GeneXpert machine from the government, which lets us test for TB more accurately.
We treat many of the same diseases here that are common in the US, and some that are not:  Heart failure, hypertension, diabetes, pneumonia, cancer, major trauma, strokes, sepsis, GI bleeds, psychosis, gallstones, gastroenteritis, appendicitis, pancreatitis, alcoholism, TB of every variety, typhoid, malaria, rickets, malnutrition, hippo attacks.

Tuberculosis
Things break and run out a lot.  The oxygen concentrators frequently don’t work.  We run out of jelly for the ultrasound machine, reagent for labs, gas for the ambulance, money for the power bill. 
The residents who come here from the US are usually prepared for a lack of resources.  They expect limited laboratory capacity, a basic formulary, and no high-tech imaging.  They are prepared to use limited means to diagnose and treat very sick patients.  But they are frequently unprepared for overworked, underpaid, and deeply demoralized hospital staff; nurses, interns, doctors who seem like they don’t care.  Why did a septic patient not get fluids for three days?  Why hasn’t a blood pressure been checked in a week?  Why were no meds given over the weekend? 
During ward rounds one day, the consultant (or in-charge) physician turned to the team of medical and clinical officer interns he rounds with once a week.  “What is the most deadly disease in the world?” he asked.  Everyone was silent.  “HIV?” someone answered.  “Cancer?”  “Poverty!” he said, and turned to the next patient. 

Patient chart
He was verbalizing the feelings of many of the doctors and nurses:  that we don’t really have a chance, that we’re defeated before we start.  And in many situations, he’s right.  But this implicit acceptance of the inevitability of poor outcomes for our patients is troubling.  You are poor, therefore you are in a poor hospital, and nothing we can do will change your ultimate fate of ill health, suffering, and early death. 

Although the diseases and patients are different, Kenya does not differ all that much from the US in this defeatism.  Health care in the US is also rationed on ability to pay.  In the private hospitals in Nairobi, just as in private hospitals in the US, no one goes without oxygen. There are enough nurses for every patient, there are MRI scans, chemotherapy, dialysis, stat labs, and even, occasionally, organ transplants.   

EKG machine
Global health work is, at its best, a quest for equality.  What frustrates the residents is not just the glaring inequality they confront, but the demoralization and perceived complacency of those who deal with it everyday.  And yet the same complacency is endemic in our own country.  Here in Kenya, perhaps, it is a little more blatantly, painfully in our faces.  But in both countries, the poor get worse care.  They suffer more and die younger. 


Drug cabinet
Everyone has a right to be healthy.  When we get sick or hurt, we should receive medicines or procedures that will restore (or at least improve) our health.  Health care works best when we are all on the same team, when we’re all part of a system that’s population-driven and evidence-based.  This is not to say that customized or personalized care is wrong or inappropriate—the best health care is both custom and personal.  But market-driven care is not good care, nor is it cheap care.  As demonstrated every day in both Seattle and Naivasha, tiered health care is expensive financially and, more importantly, morally.  Here in Naivasha, the human cost is unavoidable.  What kills our patients isn’t scarcity, but inequality.







That was heavy.  Your Eric fix for the week:  Easter!


We went to play with our neighbor's baby bunnies.
Bunny is soft.
Easter egg hunting with Geoffrey and Matilda


Should I put them in my mouth one at a time or simultaneously?  

Monday, April 14, 2014

Nairobi


Camille is kind of a big deal.  She had an appointment with the FBI on Friday.  I am not authorized to go into the details, but she now walks around wearing this t-shirt.

The FBI headquarters are in the U.S. Embassy in Nairobi.  We decided to pack up the baby and have a Nairobi weekend.  First stop, the Embassy!  Whoa, did they have some security at the U.S. Embassy.  They literally had to make a few phone calls to allow Eric in the building, since he wasn’t on their approved list.  He received his own I.D. badge.  He wore it proudly.  After Camille finished her conference call with Obam…um, I mean finished her mundane work, we jetted into the city.  

Afterwards, a soldier with a large gun nicely told us we were not allowed to take this picture. 
Highlights of the trip:

The Baby Elephant Orphanage.  The David Sheldrick Wildlife Trust created a haven for baby elephants just outside Nairobi.  90% of the orphans are due to poaching.  Elephants rely on their mother’s milk for two years or they will die.  Visit this link to see a moving video on the plight of elephants.  I wrote previously about the desecration of rhinos in Africa and the lavish rhino tusk trade in Vietnam.  The bottom line is that the ivory trade should be outlawed.  As this New York Times editorial states, America is the second largest market for ivory in the world.  President Obama proposed legislation in February banning all elephant ivory trade in the U.S., and legislators in New York support banning all ivory sales in New York State.  Elephants feel grief, they cry, and they bury their dead.  Please find a substitute to ivory. 
    
We watched and petted baby elephants!  They played soccer, nuzzled with each other, and seemed to have specific friendships within the group.   

Eric was really jealous of those bottles
According to Camille, elephants feel "warm and squishy."

Soccer!
See the tiny hidden baby?

Eric, of course, seemed more interested with playing with the rope by the area surrounding zero elephants.  Also, if he had a choice between the real elephants and the elephant statue outside of the grocery store, Nakumat, he would choose the statue.  He loves the statue.

Eric, the elephants are the other way!
Sigh
Dad, you should try playing with this rope.
LOVED this statue.
The Giraffe Center. BUT, Eric would first choose the giraffe center.  The highpoint of our weekend was Eric feeding the giraffe and shrieking in delight.  Just awesome.    

This was fun.

Giraffes have hard horns and rough, drooly tongues
Wait, come back!



At first Camille was really scared of the giraffes.  She was like:


But then she was like:



She warms up fast.  

Nairobi National Park.  Baboons are fond of Eric. 


They made each other yawn.

Rhino!

Hi, Mommy
One of my favorites.

Some shelter pics from last week.


He somehow tied this huge beetle to a string.  With help, he eventually let it go.

Some of my 4th graders

Some 2nd graders.

I'm just trying to get some work done.  Typical.


  Some randomness:


Eric, catching up on his reading on the ride home from Nairobi.
This enormous bug jumped on a resident's head during dinner.  She wasn't thrilled. 

Flop.


A tired little guy after a day of playing with elephants and giraffes.
Our journey continues.  Thank you for reading!

Monday, March 24, 2014

Kenya! Mailbag




Welcome to the first Kenya! The Blog mailbag!  All of the questions are from actual fake readers. 

Hallo Dan!  Enough with the “everything is rainbows and butterflies” stuff.  Have you faced any challenges?  Danke!  - Finn, Berlin, Germany (I have a strong German following).

Camille and I have had wonderful experiences in Kenya, but many challenges too, and lots of reality.  For example, I am lucky to have many Kenyan friends.  I have learned from them, had fun with them, and I respect them greatly.  However, being American, I have access to more resources and opportunities than many of them.  This frequently creates a gap in our friendship, no matter how close we become.  Sometimes, it becomes clear that a friend (understandably) hopes that I can give him something (money, a new job, a scholarship, etc), which frequently I can't.  When I can, it's hard to know when to say no and when to say yes.  How can you say no to one and yes to another?  Where do you draw the line?  What are the limits?

“Gulotts,” in the grand scheme of things, what impact can foreigners hope to have in Naivasha?  Also, does it bother you that your son is already a better writer than you?  - Stuart, Boston, Massachusetts

Ouch.  The snow must be making Stu cranky, but thank you for the perfect follow-up question.   You're right, it can be naive (or worse, arrogant) of outsiders to think they can "fix" things.  Both Camille and I have seen firsthand examples, at the shelter and hospital, of outsiders basically shouting, “You're doing everything wrong!  Our way is better!  This is how we do it in our [western country].  We won't trouble you Kenyans by including you in the decision making process.  It's quicker and easier if you just listen to us."   Usually these people really do want to help, but their cultural arrogance defeats them.  Collaboration is key.  While we can offer our resources, time, training, and expertise, we must work with those we seek to help, and respect their experience and expertise.  For example, the teachers are talented, smart people who care deeply about the boys, and their jobs.  If they are not given a voice, are not included in the decision making process, the opportunity to take advantage of their expertise and experience will be lost, as will their trust and faith in your leadership.  

Leadership is not unilateral implementation of one's own ideas, but empowering others, developing ideas together, and inspiring change from within.  People must believe in the ideas to ignite change. 

 Hi Dan, love the blog Let me know if you need a job someday.  What is something you have learned teaching in Kenya as compared to teaching in America?  Also, I may have a cousin in Naivasha.  – Barack, Washington, DC.  

That kids are kids!  Kids are kids, no matter the location, environment, race, economic status, etc.  My 7th graders, all former street boys between 13-16 years old, are a bunch of goofballs who just want to be engaged in class.  I’m having a blast. 

A couple of my 4th graders.  I told them to smile for the picture.
My 7th graders.  My instructions were, "Let's group together for a nice class picture."
"Now get back to work!  No more smiling for the rest of class."
A few pictures of the shelter




You can see Lake Naivasha in the background


What are kids in Naivasha listening to these days?  - Justin, Ontario, Canada

Summer Time by Vybz Kartel.  Sorry, “Justin,” from Canada.

Eric is so cute!  You should have a blog of nothing but Eric pictures.  How’s Eric doing at school?  -Nana, Sheffield, Massachusetts

Eric is such a stud.

I bring Eric to an outdoor preschool three days a week.  It took some adjusting, but now he loves his school.  We have a very set routine which we must follow.  As we pull into school, Eric starts shouting, “Woof woof!  Woof woof!” until I open his door.  Three huge St. Bernard dogs live next to school, whom he adores.  The other kids are scared of them, but not Eric.  I pick him up and we walk over to the fence.  The dogs all stand on their hind legs to see and sniff and lick Eric.  Eric smiles, laughs, touches their noses, and says bye, and we turn to enter school.  Eric arrives a little later than the other kids, who are waiting for him when we arrive.  As soon as we reach the entrance, Eric runs towards the electric keyboard.  Usually, this is when I say a quick goodbye and run off.  If I linger, Eric realizes I’m still there, and then it's “Daddy must hold me and never put me down” time.  Eric clings to me with all limbs like the baby aliens in the movie, well,  Aliens.

The other day, I decided to hide and peek at Eric for a while.  What I saw was adorable.  As soon as Eric ran to the keyboard, Eric’s two four-year-old girlfriends, Zara and Medja, ran up to Eric.  Eric extended his little arms to Zara and gave her a big hug.  Zara looked at me and smiled.  Eric then did the same to Medja. 

I need to install a hidden camera at school to catch these moments.  It made me reflect on how teachers share so many wonderful moments with kids that parents never get to see.  Having a kid is some of the best professional development I will ever have.

Eric's woof-woofs
Running into school


Giving a hug.  He, uh, changed clothes real fast after that last shot. 
We had Eric's teacher (left) and nanny and  her son (right, middle) over for dinner.


Eric didn't have any fun.  We're very lucky.


Eric discovered bubbles
BUBBLES!


Eric is also learning Kiswahili.


Camille, what was your reaction to finding a cockroach 30 seconds ago?   
- Dan, Naivasha Kenya




(Editor's comment:  I didn't actually freak out and wedge myself on the ceiling.  I think I just told you to kill it.  But not the grasshopper.  Don't kill the 6-inch grasshopper.  Just put it outside.)




  
 Responding to all these questions is tiring!  Please send me questions in the comment section below.  Thanks for reading!