Food for Thought

Alas, our exploits through Africa have reached their final chapter. However, it was just as grand as the rest of our trip. Thursday started off with a departure to the Nairobi Jhpiego office. There we debriefed the directors and coordinators on our incredibly fascinating and informative journey. Jhpiego has been a godsend in helping to orchestrate these adventures into areas unknown in order to advance our understanding of this country, its people, and their medical system. I’d like to take a moment and personally thank all of those involved in this process (especially Lynn Kanyuuru and Steve Oluoch) for making this trip a possibility.

After our morning debrief sessions we set off to locate the Ministry of Health. Our meeting with one of their representatives shed some light on the programs that are currently being implemented, and gave us some clues on how to execute our own. Luckily for us, the rep was incredibly knowledgeable and was more than willing to share his experiences and answer all of our questions.

2^nd to last day, and a full one at that. We started our day extra early (5:30am) in order to make our way about 3 hours north to the Kenya Community Cooker in Naivasha. ­This incredibly innovative concept kills multiple birds with one stone. Community members bring their (or randomly collected) trash to a collection site, then through combustion in excess of 800 degrees Fahrenheit using water and used motor oil, the garbage is incinerated and the excess heat is used to power stoves, ovens , and hot water heaters available for a nominal fee to the community members.  They use this to cook dinners and even wedding cakes!

After a tour and info session (and much begging), we convinced Steve to teach us all how to cook chapatti using the community cooker stovetop.  We received a bit of ridicule (from Steve) and a lot of encouragement from the locals as the How-are-you’s learned to cook.  We then left to the Masai Market to do last minute shopping. Although everyone found everything they were looking for (and probably some trinkets we didn’t), we definitely had to pay Mzungu prices. (the bargaining for 5 trinkets started at 34,000 shillings or around $400!)

I Can Feel Your Heartbeat



Nursing intern Tanui explaining the difficulties of using a pinard

For the past couple days, we have been observing clinical care at Bondo District Hospital and Thika Level 5 Hospital.  BDH is a local hospital that sees patients who get referred from health centers and TL5 is a referral hospital, mostly for people who went to a local hospital and got referred to Thika for a more complicated condition.  At BDH, I was finally able to watch someone listen to a fetal heart! The most commonly used tool is a pinard horn, typically also called a fetoscope by the nurses here.  Health care providers must palpate a pregnant mother to figure out where the head and back are, then listen closely with this device and count the beats.  Pankti and Michael were both taught how to find the fetal heart by an experienced nurse, and they both agreed that it is quite difficult to hear. 

Yesterday, Pankti and I were able to conduct a workshop as a part of Continuing Medical Education.  Michael and Aaron graciously volunteered to be our pregnant patients for demo purposes, and also took lots of photos of our demonstration! We got to show our fetal heart rate prototypes to 30 different midwives, nurses, medical and nursing students, and a couple doctors.  We think the feedback we got was very helpful and they seem to think we are on the right track for solution that will actually be easier to use and save them time. It took us a total of 6 hours to finish the workshop and we were all very tired at the end of it. We are really grateful to Jhpiego for organizing the opportunity for us!

Pankti demonstrating how to use our fetal heart
 monitor to listen to the beats on patient Michael

A nurse practicing using the prototype

In addition to the study, we also spent some time observing labor and delivery and MCH (maternal child health clinic).  Aaron and I got to see two births with healthy babies and healthy mothers! I am very impressed by the women who give birth and immediately get up and walk around and give their bed to the next patient.  In MCH, Pankti and Michael got to listen to a health talk given to all the patients waiting for their clinic visits.  Lots of topics were covered from preparing an individual health plan to nutrition and health warning signs.  Aaron and Michael also got an opportunity to meet with a person from the office of District Disease Surveillance team.  They got to learn how certain diseases are monitored closely so that the district can try to intervene based on trends from previous years and potential disease outbreaks. 

Today we return to the Jhpiego Nairobi office for a debrief on our trip and later we are meeting with people from the Ministry of Health to get their perspectives on implementing new health technologies.

Can you picture me?

On Sunday, we spent some time exploring other areas of Bondo! We took a local boat over to an island in Lake Victoria, home to a small fishing village.

Island town off the shore of Usenge

And let me tell you… we were swarmed by kids who saw Melissa’s camera and LOVED getting their pictures taken and being able to see the screen.

Michael and a bunch of excited African kids being captured my Melissa's expert photography

We also got to visit Mama Sarah Obama, one of our President’s grandmothers! We pretty much have the best conversation starter if we ever happen to sit down for a chat.  In the evening, we all headed down to the local market to look at all the food and clothes that were being sold. Melissa and I bought wraps and samosas, as we wandered and people yelled to us, "Mzungu, why you don't buy my tomatoes??"

The team meets Mama Sarah Obama!!

We're now in Thika, which is a suburb out of Nairobi, to experience care at this Level 5 facility (i.e. high volume, referral facility!) It's very different than some of the rural clinics we've been at for the last few days.

Mzungu!

The last few days we've spent roaming around diffrerent villages near Lake Victoria  in Bondo District with Community Health Workers (CHWs). These volunteers are respected community members selected by their neighbors; they represent the lowest tier of the health care system in Kenya, but they are an integral part of the Health Ministry's education initiative for issues like disease control and maternal and child health. The first day in the community was spent with Samuel, pictured above. His enthusiasm for the education of new and expecting mothers was inspiring - he was insistent about the use of treated mosquito nets and proper diets. The CHWs generally walk quite a bit each day through some pretty rough terrain - we estimate around 5-6 miles. For us, these walks were full of shouts from the fields - children yelling, "Mzungu, mzungu!" which is Swahili for "white person." If we got close enough, the kids were all pretty shy, until we pulled out the cameras, after which they implored us, "Pictcha, pictcha!"

Our next day, Aaron and I spent on the Polio campaign trail with Mary, a CHW, and Paris, a CHEW (Community Health Extension Worker). The CHEW is a link between the CHW and the local health facility. The past few days saw a Polio outbreak in Somalia; some of these cases spilled over to the Somalian refugee camps in Kenya. According to protocol, vaccines must be distributed to children under 5 years of age after such an outbreak. The CHWs in Bondo district had the formidable task of reaching 120 children each day durinrg this campaing. That goal requires quite a bit of walking. Mary and Paris were rather excited to treat Aaron and me to some free exercise. Along our journey, we met a village elder (picture above) who was intent on keeping Aaron. Mary told him, "Aaron, you have a bride now."

While the engagement was short-lived, Aaron did manage to find a few children along the way. One child, having fallen down on the way back to her parents' home, was swept up into Aaron's arms and carried home. She clung tight to the "mzungu" in the white coat as we walked into the family's compound. Once we arrived at a home, we located the children under 5 and the CHWs administered the vaccine orally. Aaron managed to make quite a few friends on the trip - a group of children found him extremely entertaining as they followed us through the village, giggling uncontrollably every time he turned back suddenly to confront them. One mother let Aaron hold her newborn child, and posed for a picture. She allowed the picture only on the condition that we send her a copy once we get back Stateside.

Even though it is technically winter in Kenya, it is still quite hot. Having forgotten sunscreen on my first trip into the field, I was quite burnt for our second and third visits. After taking refuge in her home during a sudden downpour, I emerged with a pink umbrella she supplied me to protect my matching neck. Aaron was intent on getting a picture of the spectacle, and, with some hesitation, I've included it here. A special thanks to Mary for her thoughtfulness and patience for all of our questions.

While Aaron and I were on the Polio campaign, Melissa and Pankti had joined Joyce, another CHW in the Bondo District. Each of the CHWs is responsible for around 100 households, and Joyce was kind enough to guide the girls through a day in the life. Their trip was full of laughing, posing children, pictures of chickens (typical mzungus), and insightful conversations with an inspiring CHW. Joyce was motivated to become a CHW in order to educate her neighbors about important health issues. She is the biological mother of one and the adopted mother of two more.

On The Road Again

Wake up call, 6:00 am. Michael, Mark, and I all rose before the shine to catch the sunrise over the Indian Ocean on our last day in Mombasa. Michael decided to go for a morning jog along the shoreline, while Mark and I jumped into the water one last time and swam out to sea as far as we could before the sun peaked over the horizon. The water was magnificently calm from the protection of a distant choral reef allowing Mark and I to float just above the water, even with the imperceptible point where the ocean and sky meet.

Following an excellent continental breakfast of African cuisine, we set off back to Coast General Hospital (CGH) for the first half of the day before our flights. Prior to entry, we all took the time to write personalized thank you notes to the nurses, doctors, and staff who were gracious enough to host us and answer all (and I mean all!) of our questions. I spent the first half of the morning in Labor and Delivery on rounds with the other interns and students. Michael and I left to pursue answers in the Maternal and Child Health Center and Records departments, while Melissa and Pankti stayed behind to watch 9 deliveries! 

With our questions answered, a lust for adventure, and a smidgen of free time before our departure from CGH, Micheal and I ventured off in search of cold drinks and the ocean that lies just behind the hospital. After walking through the alleys and over the craggy dirt road, past metal workers and fiscal automobile repairmen, we not only found the ocean, but also a shipwreck graveyard. The men on the shore worked diligently to dismantle the hulls for use in construction, while the children practiced back flips and played stick-ball in the sand. 

Unfortunately we couldn't enjoy their company for long because we had to get back to the group and depart for a quick stop at the local bazaar. We were lucky enough to have a guide and professional negotiator (our driver’s wife) to aid us in our quest for souvenirs. Lindsay shopped in the fabric boutiques, I ran around to 8 different shops looking for anything that would even fit the members of my family (Only 1 store I found with a size that fit me), and Michael performed his now infamous disappearing act and made some friends with the locals.

With our shopping done, it was off to the airport for our trip to Kisumu through Nairobi. The flight between Nairobi and Kisumu was a total of 20 minutes and making the longest leg of our journey the odious 3 hour layover in Nairobi. Although short, the flight from Nairobi to Kisumu earned Melissa and I special treatment from the flight attendants (extra baggies of mixed nuts and drinks), and for the first time in my life (and likely the last) my luggage was the first around the carousel (followed promptly by Melissa’s)!

After a small drive to our hotel, we set off to find some grub and wanted to sample the local cuisine. We courageously crammed ourselves into a van of the public transport system, and ventured into the night in search of something to satiate our hunger. Satisfied, but still looking for full immersion into the Kenyan culture, we took tuk-tuks home to prepare for what awaits us in Bondo.

PS – Foods I have tried in Kenya to date that I hadn’t prior to this trip:

·        Ostrich

·        Ox Balls (not the meatball kind)

·        Crocodile

·        Chicken Gizzards

·        Lamb Liver

·        Ugali and Chapatti

·        Kale, Arrow Root, and other local veggies (also some unnamed fruits)

Lala Salama

Yesterday, the team arrived in Mombasa, Kenya, which is a coastal town on the Eastern side. We had to go through a hanger, which had been outfitted to be the domestic flight terminal because of the Nairobi airport fire. Mombasa weather is much warmer than Nairobi, and we were finally able to meet with Dr. Lynn Kanyuuru at Jhpiego Mombasa headquarters. She walked us through an orientation that welcomed us to Kenya and discussed briefly the Kenya healthcare system.

Melissa all set to head to Mombasa!

This morning, we headed over to the Coast General Hospital – largest government hospital in Mombasa,  bright and early for a very busy day at the hospital! To start, Lindsay and I headed over to the labor and delivery ward, and were able to witness the miracle of life (twice!). We also saw one child born asphyxiated, and were able to see neonatal resuscitation in action. Fortunately, the baby quickly began to cough and cry after suction and is doing perfectly fine! It’s also extremely cute. J

Michael, Nurse Shiela, and Melissa coming from Kenyan theater (i.e. OR)

Aaron was able to observe care in an antenatal clinic, and Michael and Melissa were able to watch a C-section. In the afternoon, Michael and I headed over to the antenatal ward, which is where women stay during the latent phase of labor. A clinical officer taught me how to take the fetal heart rate! Melissa and Aaron headed over to L&D and talked about healthcare with some of the nurses there.

Sunrise from our hotel looking over the beach!

 

As soon as we got back from the hospital, everyone jumped into their bathing suits and went for a swim in the surprisingly warm and lovely Indian Ocean. Then, we went to a typical Kenyan restaurant and feasted! Steve took us for some drinks afterwards at this cool, happening lounge.

Tomorrow we spend the morning at the hospital, and then head to Kisumu in the afternoon. Going coast to coast… west coast best coast!

PS Lala Salama means good night! We've been getting some language lessons from Steve and Lynn. :) Lynn says our final debrief might be in Swahili...

Dirt Road Anthem

Today we got to enjoy a day off and be tourists in Nairobi.  We started the day with a game drive/tour of Nairobi National Park.  Although it is just on the edge of the city, it encompasses 110 square kilometers and has plenty of wild animals.  Lindsay told our tour guide that even though she's been on several safaris, she has yet to see a lion, so he raced all around the park (including off the dirt "road"), communicating with the other drivers to find one of the three prides of lions, which are reportedly very difficult to spot.  We were all very excited to find a lioness and a cub who appeared to be hunting in the distance! Then later in the day we were even more delighted that we got to see another pride hanging out right by the path! In addition to lions, we saw giraffes, warthogs, impalas, gazelles, rhinos, zebras, baboons, ostriches and many other types of birds.  They do not have any elephants at the Nairobi National Park because apparently the 110 square kilometers is not enough space for them - crazy to think how little space they get at zoos. 



A greedy baby elephant

Luckily we were still able to see elephants today, though, because our next stop was the elephant orphanage.  The orphanage adopts elephants whose mothers have died, mainly from being killed by poachers.  The smallest one they had was only a couple days old.  We learned lots of facts about how they take care of the elephants - they reportedly have a 98% success rate when releasing them back into the wild through a rehabilitation program where they can get adopted by an elephant herd. The elephants were quite playful and tried to steal each other's food (branches of leaves).



Pankti is thrilled to feed a giraffe

After the elephant orphanage, we headed to the giraffe park to see and feed some giraffes.  The proceeds from our tickets go to helping endangered animals in Kenya.  Feeding the giraffes was quite entertaining.  Pankti couldn't stop laughing; Their tongues are slimy and purple.



Aaron on his 2nds 3rds 4ths of ox balls

After visiting the giraffes, we were all starving - perfect for eating lunch at a popular restaurant called Carnivore.  According to their advertisements, the restaurant is "Africa's Greatest Eating Experience".  I'd say they lived up to their reputation pretty well.  We started with some appetizers and soup.  Then they brought out a tray of sauces with a flag on the top.  The waiter explained that we keep getting more meat until we surrender and take our flag down.  The meat options were plentiful as you can see from the menu.  Aaron particularly enjoyed the ox balls, and the waiter was very enthusiastic about their digestive powers.  Luckily for Pankti, there was a vegetarian menu, too!  I tried ostrich and crocodile for the first time.  I think they brought about 10 different meats.  After the first couple servings, I started giving half my portions to Michael because I couldn't finish them but I wanted to keep trying all the different kinds.  Lindsay was giving some of hers to Aaron too.  Once we were all stuffed, we had dessert.  I tried tomato ice cream!

Michael's plate after our surrender

Carnivore menu

Tomorrow morning we head out to Mombassa to start our observations at hospitals.  We've been having fun being tourists, but I think we are all excited to start working on field research for our projects.  Pankti and I will be focusing on fetal monitoring during labor and the currently-used practices to measure fetal heart rate.  Michael and Aaron are focusing on antenatal health screening tools with a focus on potential utilization of cell phone technologies, telemedicine.

Ramblin' Men/Women



Our Accomodations at Pepe's Hotel

After being pampered for a week in Norway by our gracious hosts, the Kenya team set off for Africa early Friday morning. A few flights and a short delay later, we landed at the small Kilimanjaro airport in Tanzania late Friday evening. We eventually located our ride to the hotel and piled into a vehicle which looked fit for a safari. Tanzania’s Speedbump Highway (actually, A23 ) connects Kilimanjaro to a small city called Arusha, where we spent the night. The hotel we stayed in was a small bed and breakfast, “basically paradise,” according to the website. Based on the employees’ hospitality, paradise is an accurate comparison.



Roadblock

From there, it was a straight shot on the international highway, A104, across the Kenyan boarder and to Nairobi. We’d like to thank Lindsay Litwin, a Jhpiego employee from the Baltimore headquarters who has joined us on the first leg of our trip in Africa, for all of her help in straightening out transportation and accommodation plans so far. Lindsay has spent time in Africa before with the Peace Corps, and we are grateful for her experience and guidance.

Kenyan/Tanzanian Border

Though it was quite overcast Saturday morning, we still caught some incredible views of the Tanzanian landscape. Jutting mountains, expansive deserts, and large goat and cow herds made for a scenic ride. Some of the locals had put up a road block at one point, but luckily it was on the other side of the road. The border between Tanzania and Kenya made for a particularly interesting little adventure. We were introduced to a few of the more daring local entrepreneurs, some proffering their photographic expertise for a sizable fee and others attempting to exchange currency at twenty times the actual rate.

Cafe in Nairobi

Another shuttle transfer and a short delay in Nairobi traffic brought us to our hotel in the city – the Desmond Tutu Conference Center. Once again, we were shown a very friendly welcome with pineapple juice served as we checked in. After retiring to our respective rooms (each of us given our own - a greatly appreciated luxury), we ventured out into the city to withdraw some Kenyan shillings and find a meal. At first it appeared we were out of luck, but Melissa’s navigation proved crucial in eventually finding an upscale shopping mall down the road. After pulling out about thirty thousand shillings between the four of us (the exchange rate is 80 shillings to one USD), we strolled over to an affordable-looking café, the Nairobi Java House. We were pleasantly surprised with the quality of the meal for the price. Having just gotten accustomed to the high cost living of Norway, where we might pay $13 for a beer, $12 seemed like an extraordinarily low price to pay for an entrée and dessert or coffee.

Tonight the four of us are resting in our peaceful hotel after a few long days of travel. We have an early morning ahead of us - a safari through one of Kenya’s famous national parks awaits us on the other side of the sunrise. 

Colors of the Wind

View from the Stavanger City Bridge

 The delay in the flights to Kenya set us back a little more than a day, but we are not complaining. Who would want to leave Norway early? This place is full of fascinating trails, beautiful scenery magnificent culture, and untold adventures. Following the scenic route of old Stavanger and our tour-guide/past Hopkins BME graduate, Sunny, we wound our way past the oil museum and the massive grain silos that can hold around 195,000 tons of grain, to a little café by the water. We feasted on fresh deli sandwiches, gourmet pizzas, and decadent desserts.

Immediately following dinner we set out on a trek through the town toward the not so distant shore to a nearby park. We hiked along a small forest trail and found a small boathouse with a small, 10 foot long, beach. The group decided here would be as good as any spot to sit, relax, and digest our food. However, the relaxation didn’t last long. It only took one person attempting to skip some stones on the calm waters for a full blown challenge to arise. With some valiant efforts, botched attempts, downright failures, and explosive rock on rock impacts, Kevin Colbert attained the title of stone skipping champion with a throw that could have sunk a boat at sea. 

After a night of debauchery on the harbor, most groups prepared for early departures to the airport. The Kenya team, on the other hand, set out for the Laerdal Global Health research center to complete some user feedback studies on new and very secret technologies. It was now off to find a dining place for a feast fir only for kings, or at least on that cost as much. Satiated by gyros and falafel, we ventured off into the city on an expedition to find hidden graffiti art on the 2012 Nuart exhibition.

Halfway through our hunt, we detoured across the Stavanger City Bridge for the view. At the midway point, there was no reason to turn back so we redoubled our pace and found our way to the other side, hoping to find a majestic island with a cliff face view. Instead, we found a small beach and diving area where Michael attempted to scale a sky scraping 3 meter wall, and I sampled the wild Oceanside raspberries. Our return home led to previously overlooked art and a pit stop through the Norwegian fashion mall. The final leg of our Norwegian adventure has yet to conclude, but we’ll save those details for the next post from Africa. 

Stayin' Alive




Tiffany practicing her
baby delivery techniques

It's been a busy and fun past few days! Yesterday, we got to interact with Laerdal's Mama Natalie and Neo Natalie up-close. It was interesting to work with the training products in a simulation setting to really understand the value of the education paired with physical simulators. After that, we did a session on design thinking to understand how empathy and user feedback can really help you design better objects (even wallets)!


Group on Pulpit Rock

Pratik, Tiffany, and Pankti atop
Pulpit Rock (Tiff ensuring Pratik
does not go off the edge..)









After that, we headed over to Pulpit Rock for a hike via bus and ferry boat. Because the weather was cloudy, we literally walked through clouds on our way to the top of the rock! I think it made a lot of the hike seem very mystical and mysterious. It also made it more difficult, most of us took a tumble a few times and Melissa even lost the sole of her shoe (they now live in a dumpster). And about 12 of us got lost somewhere up in the mountains and it took a group of shouting friends and Tor Laerdal to get us back to the rock itself. But we made it! :) Some soup and coffee helped warm us up for the long ride home. It also started clearing up on our way down from the hike, meaning we got to enjoy spectacular views of hidden lakes nestled in the mountains and the sunset from a distance.

Today, we discussed some of the up-and-coming projects in the global health field, and were able to have a focused session with people working on the fetal heart rate project at Laerdal. We also all completed hands-only CPR training!

Also, the Nairobi airport had a fire so we're no longer flying there this evening, but will be leaving Norway on Friday morning and going through Tanzania! Not sure about the exact logistics of that, but hopefully we catch a glimpse of Mt. Kilimanjaro.

Waterfalls

We have had quite a packed day of adventures in our first 24 hours or so in Stavanger! After we arrived and got settled at the hotel, Tore Laerdal showed us around the old town and the port of Stavanger.  The old town is full of wooden houses built in the 18th and 19th centuries, maintained in the original style and decorated with beautiful flowers covering the patios and front steps.

Collecting water from a waterfall

Pankti enjoying the fresh water

After walking around the old town, we had a boat tour of the Lysefjorden fjord along with people from Jhpiego and Laerdal.  Although it was pretty cold and windy on the top deck, we all had a blast seeing what is reportedly one of the top places to see before you die.  During the boat trip, we pulled up to a waterfall and the captain collected some water directly from the waterfall for us all to drink.  It was delicious - better than most of the bottle water I've tasted!

For dinner we stopped at a restaurant on the water in Lysefjorden which had a delicious buffet with lots of seafood and salads, prepared just for us.  We ate outside and the view from the restaurant was beautiful! We also enjoyed sitting with Ingrid Laerdal who taught a couple phrases in Norwegian including takk which means thank you. I don't think any of us were able to remember how to pronounce the words correctly, so we'll have to keep practicing.  After dinner, we were so exhausted that a bunch of us passed out on the boat ride back to town.

Jenny, Aaron, Kevin and Barrett braving the cold on the front deck

After a fun day of being tourists yesterday, this morning we were back to work on preparation for our developing country trips.  We had several talks and workshops on the CBID-Jhpiego-Laerdal Day of Birth Alliance and on how to get the most out of our upcoming observations in the field.  We also got to tour the Stavanger factory which was quite interesting - we learned about the manufacturing process from early stage product development through assembly and testing of products. It seems like quite a challenge to manufacture training tools for both the most resource-poor settings and the most sophisticated developed country needs.  Tomorrow we are looking forward to hands on practice in delivery and neonatal resuscitation with some of Laerdal's simulation tools!

-- Melissa