Day in the Life of Mfangano Island MicroClinics

MCI’s Kenya MicroClinic pilot on Mfangano Island (known locally as the “Mfangano Health Net”) has officially reached the halfway point of our 6-month curriculum designed to empower these HIV-affected social networks with practical skills, resources, and relationships for healthier futures.  To date, 446 participants have enrolled in the program, forming over 40 microclinics  (or “kanyaklas” as they are known in Luo). Each Kanyakla is comprised of 5-15 people, both HIV-positive and HIV-negative, who agree to complete a six-month 12-session training program together.

Every two weeks, 28 local community health workers (CHWs) receive a full-day training at the Ekialo Kiona Center, a solar-powered resource facility operated by our partner, the Organic Health Response.  Each CHW then returns to his/her own village around the island to conduct MicroClinic discussion groups with his/her assigned Kanyakla about special topics related to living with HIV.  At the same time, the EK Center staff presents an ongoing series of weekly Special Seminars, open to all MC participants, featuring in-depth workshops about HIV treatments and opportunistic infections, lectures on scientific advances, couples communication seminars, tours of the organic demonstration farm, etc.    This 3-tiered curriculum has been designed by MCI Senior VP, Hal Campbell, in collaboration with UCSF students, and our local research team, to address the broad range of social, biological, ecological, and economic factors that contribute to this massive epidemic here on Lake Victoria.

Sessions 1-3 have focused on HIV biology, highly active anti-retroviral therapy, and adherence. Session 4-5 focused on communication and psycho-social support. This week, session 6, we have decided to shift gears and focus on Reforestation, a critical component of long-term food security for this island ecosystem.   Mfangano is facing unprecedented rates of deforestation due to high levels of poverty, the collapse of the fishing industry, scarcity of cooking fuels, and unsustainable maize cropping techniques.   Session 6 seeks to utilize our diverse MicroClinic network to mobilize a rapid response to this crisis.  In the process, MC’s redirect energy from personal problems towards a team goal, engendering solidarity and self-pride.

I traveled this afternoon with our new Program Manager, Peter Manwari, and our Research Manager, Dan Omollo to visit two MicroClinic classes in the remote beach villages of Makira and Sena. Here are my fly-on-the-wall observations:

Makira Beach MicroClinic Class: “Sunrise A” and “Golden”

- Makira Beach is home to about 250 people. They live in iron sheet houses and shacks directly beside the lake at a very popular location for “gogo netting”. This is a fishing technique that involves dozens of people standing on shore and pulling a large net that is position by a single boat out far out in the lake. In fact, gogo netting has been the primary metaphor that we’ve been using with our CHW’s to describe the MHN goal of everyone pulling together towards common health objectives, making sure that no one is left outside the net.  Boats from the mainland come to Makira Beach every morning to buy fish. The community is comprised of both long-term Mfangano residents, as well as many migratory fisherman and women who travel along the lake. They stay for a year or two in beaches where the Nile perch catch is good and then continue moving.  These migrant communities are one of the most challenging populations in Africa in terms of HIV/AIDS care and prevention.

- Our CHW Kanyakla Facilitator in Makira, Benta, has been very active in mobilizing for this program. She has helped her village form 2 different microclinics, each of 15 members, the maximum limit for kanyaklas. These 2 Kanyaklas have named themselves “Sunrise A” and “Golden.” They are sitting mixed-up in an informal outdoor classroom. When we arrived there were 12 women, 5 men, 1 CHW Facilitator (Benta), 1 CHW Coordinator (Pamela), and 1 MHN Trainer (Silvance).  Some of the men and women are wearing their Sunday best, suits and colorful dresses, others have clearly come directly from their farms, knees muddy from the work of weeding their maize crops up on the mountain.  Two young mothers are in the group breastfeeding. More and more participants arrived as the session continued, 27 people were in attendance by the conclusion.  We’re realized that punctuality is a losing battle here on Mfangano, so we’ve tried to be very flexible

-Each Kanyakla “Class” is formed from two to four MicroClinics living in geographic proximity. Each class gets to choose its own seminar location in their village and time at their mutual convenience.  These 2 groups have decided to hold their bi-weekly sessions in the grass in the shade of a large tin shed. They are seated on wooden benches and plastic chairs. Silvance has taped a large piece of flipchart paper to the back of the shed to use as their blackboard.  Dogs and children cruise through the classroom at regular intervals.  Hawks circle overhead, searching aggressively for any unguarded piece of fish.  Silvance has to raise his voice over the noise of roosters, and the corn mill that is on grinding maize on the other side of the village.

-As we arrive, the class is in the middle of playing the “Wheel of Hope” Review Game.  Hal Campbell, our famed curriculum designer, has developed this game to help the Kanyakla’s review the topics and lessons covered in the previous session.  Participants take turns spinning a large wooden wheel labeled with markers for “100 Points”, “300 Points”, and “500 Points.” The class then answers questions of variable difficulty in various categories. Points are recorded on the flipchart paper for correct answers—although the only prize for winners of this game is a big handshake from the instructor.  This week the review topics include questions from all 5 of our previous Kanyakla Seminars:

-HIV Biology and Transmission

-Voluntary Counseling and Testing (VCT)

-Prevention of Mother to Child Transmission

-Organizing Your Anti-retroviral Medication

-Adherence Issues

-Communication and Support

-First Question: VCT for 100 Points…

            Q: “What are two benefits to knowing your HIV Status?”

            A:  After some discussion the spokeswoman for Golden answers first… “Number one: you can plan your life once you know your status. Number two: you can take precautions to prevent spreading the infection. And Number three! you can start care and treatment if you are positive”. (CORRECT!)

-Next Question: Prevention of Mother to Child Transmission for 300 Points…

            Q: When do most HIV infections pass from an HIV-positive mother to her new baby, during Pregnancy, Delivery, Labor, or Breastfeeding.

            A: Sunrise sits together and discusses as a group… the spokeswoman stands after 1 minute of deliberation… “Most infections pass at birth because there is a lot of blood and the virus has easy access to the child”. (Correct for 300!)

- Counseling and Testing for 500

            Q: “On the ‘Determine’ Test Kit, what do two red lines mean?”

            A: The Golden Spokewoman stands to answer. Before she speaks though, a man from Sunrise stands up and loudly declares: “We are surprised this question is worth 500 because it is too easy!”. Everyone laughs including the man.  Silvance tells him to be patient, reminds him that the points are only to help us learn, and that he’ll send an easy 500 point question to his group next.  The man sits down smiling. We’re finding that Luo and Suba people are surprisingly competitive, even in informal trivia review games, and we’ve worked hard to make sure that cooperation is emphasized above competition. Golden now answers: “Two red lines means that the client is HIV positive and should go for treatment!”. (Correct!)

-       Adherence for 500 is next question for Sunrise:

            Q: “If a person is taking ARV’s and starts to feel sick from the drugs, what is wrong with stopping the drugs for a couple weeks until he/she feels better?”

            A: “The Viral load will increase if the patient stops taking her ARVs.”

            Silvance adds, “And remember, HIV is very clever. If the patient stops taking drugs and then tries to start taking them again, the virus can mutate and escape the effect of the drugs.”

-HIV Prevention General for 300 Points :

            Q: “What are two benefits of the female condom?”

            A: (Surprisingly there are no giggles or smirks as a man from Golden stands to answer): “One, if a man refuses to wear condom, the woman remains protected from HIV and so is the man. Two, unwanted pregnancies and STI’s are also prevented.”

-Adherence for 500:

            Q: Why is it important to carry your medications with you when you go to the clinic:

            A: “So the doctor can make sure that you are taking your pills refill your drugs, and so that the doctor can evaluate how you are storing and organizing your medicines.

After 20 minutes, Silvance wrapped up the “Wheel of Hope” game and moved onto the primary lesson for the day: Reforestation. Each lesson is built around a group discussion and brainstorming sesson, followed by the development of an “Action Plan”. For each lesson, each Kanyakla is expected to draft a specific “Action Plan” that outlines their chosen roles and responsibilities to address major health issues on Mfangano. These Action Plans are then recorded as part of their individual “Kanyakla Constitutions”. Our groups have already completed “Adherence Plans” and “Communication Plans.” Today they will be tasked with developing a “Reforestation Plan” for their group.  We provide furnished templates that each Kanyakla can use to document their ideas.  We’re finding that community members already poses a great deal of knowledge about health and environmental problems, and many have innovative ideas of their own. We hope to capture these ideas, and translate this resource into dozens and hundreds of local responses, large and small.

Silvance started by asking the class to help him make a few lists.  On 3 new flipchart sheets he wrote 3 questions. On the top of each page he wrote:

            “What are some ways that we have affected the forests of Mfangano?”

            “What are the Major Effects of Deforestation?”

            “What are your ideas for what we can do about it?”

I was pleased to see that participants immediately started raising their hands. Silvance made a point of calling on individuals who volunteered answers, as well as some of the quieter members of the group. (We’ve found that unless prompted, young women in particular tend to remain very quiet in these sessions, deferring to older women and men).   Here is an abbreviated list of some of the answers that were posted from the Sunrise and Golden Kanyaklas.

            “How have we affected the forests of Mfangano”:

            1)Tree slashing and burning during corn planting season

            2) Cutting trees to make charcoal

            3)Cutting trees for building purposes (houses, fences, and boats)

            4) Burning bush and vegetation on the mountain has decreased vegetation cover leading to soil erosion and landslides

           

            “What are the major effects of Deforestation”

1)   Reduced agricultural capacity of the environment

2)   Loss of rainfall

3)   Less herbal remedies and medicine from the forest

4)   Food scarcity and hunger

5)   Land Erosion

            “What are your ideas for what we can do about it?”

1)   Plant Many Trees!

2)   Legislation and law enforcement (ie demarcating the forest as government conservation land)

3)   Terracing and Contour farming the hills to prevent erosion

4)   Teach people to avoid slash and burn on steep slopes

5)   Reduce charcoal use

After a great brain storming session, the group was instructed in how to draft their own Reforestation Action Plan. It was also explained, that once the reforestation plan is complete every member in the Kanyakla will be given a tree seedling from the EK Demonstration Farm to plant at a location of his/her choosing where it can be protected and water.

Silvance then asked the class, “When is the best time to plant a tree?” The class started arguing about whether morning or evening was the best time?  Silvance eventually interrupted, “Your all wrong! The best time to plant a tree was 20 years ago!” (Everyone laughed). “The second best time to plant a tree is today!”. At this point, Silvance shifted gears for a short lesson in how to properly plant a tree.  Silvance did a great job drawing out answers from the participants, rather than simply telling them upfront.  On a final sheep of flipchart paper the participants recorded these key factors in tree planting.

            How to Plant a Tree (Factors to consider)

            -Location is important

                        -Is it raining or will you have to water it from time to time?

                        -Can goat or cows eat it?

            -Dig a hole 2’ by 2’ deep and wide

            -Remove plastic tubing from seedling before planting

            -Do NOT disturb the root structure

            -Cover with soft soil and manure mixture

            -Fence completely if needed

At this point it was time for us to depart and check in on another Kanyakla training in a nearby village. We greeted the Kanyakla’s briefly in Luo and thanked them for their participation.

Sena A Kanyakla Class: Jirani, Rinruok, Yaw Pachi, and Sunrise B

After a quick cruise down the dirt road on motorcycles, we reached Sena Beach. Sena is the primary administrative village for the whole island, the offices of the chief and provincial officers are located here, as well as the only health center, the major Sunday market center, post office, and fishing selling bandas. Sena is home to roughly 2000 people.  It is by far the most developed community on the island, but its economic growth has come at a large cost. Sprawling slum conditions, extremely poor sanitation, many bars and brothels for local fishermen. 

Our Kanyaklas here are also comprised of a mix of long-time residents and itinerant fisherfolk.  We have 9 Kanyaklas in Sena, 3 of them meet every Wednesday afternoon at a small tin house near the shore. They have named themselves “Jirani” (Neighbors), “Rinruok” ( “Togetherness”), “Yaw Pachi!” (Open Your Mind!). 

We approached the building and found 35 people inside, I counted over 30 women, but only 3 men! (Women by far have been the more active gender in this program. We are working hard to identify other ways to engage men more fully… for example, we hosted a Couples Communication Seminar at EK for all MC members this past week that was very highly attended by men and women…). Inside people sat on benches and plastic chairs around the center of the building. The building was in terrible condition; in fact, a third of the cement slab floor had collapsed and caved in. Once inside, I realized we are only about 5 feet from the water’s edge!  Due to high rains and rising lake level, waves from the lake literally crashed underneath the rusted tin sheet walls onto the rubble of the collapsed floor, splashing water on participants who sat too close to the wall!

I noticed that many members were now carrying their new “Personal Treatment Organizers”: fashionable handbags and briefcases that were handmade by local HIV-positive artisans. These bags were distributed last week. Each bag has been designed with partitions and slots to help people living with HIV organize their medications and health records.  I was happy to see all these colorful bags on members’ shoulders, and that they were already using them to store their MC documents.

Unfortunately the class was just wrapping up as we arrived. The CHW’s were serving tea and snacks to the participants. We’ve learned that a spot of food makes a huge difference in attendance and participation.   We were all served a hot cup of sweet black tea and 3 “mandazis” (a favorite local snack… like a triangular donut!).  The CHW’s have been doing a great job making sure that tea and snacks are always provided. People relaxed and chatted together in small groups as the

Finally, before dispersing, the group sat together and reviewed the Student Handouts for the Session. Each participant was asked to remember key take home points and reflect on our 3 part MicroClinic Motto as it pertained to this session:

-       “Nitie gima ang’eyo kuom kute mag ayaki!” (I know something about HIV!)

-       “Anyalo timo gimoro ewachni kendo (I can do something about it for myself)

-       “Nitie gima anyalo timo ne nga’tno ma chandruok mag kute mag ayaki kata ayaki omako!” (I can do something about it for people in my community)

Afterwards, members quickly dispersed, heading home to start evening chores before sunset. The CHW Facilitators remained behind to fill out their Session Evaluation Reports and the Managers updated the Enrollment logs with new members.  I’ve been so impressed with the CHW’s, or MIHNIS Research Staff, and our two new managers. They’ve been very active translating feedback and participatory observations into program modifications and fine-tunings. As a result, the program has become remarkably responsive to both individual Kanyakla needs and general community sentiments.   

As we rode back on our brand new motorcycle (thanks DZ!) to the EK Center, the sky opened up and the evening rains began.  New moisture for hundreds of new tree seedlings that will start their lives in Mfangano soil this week. A good sign.  Over the 100cc motor and bounding thunder, I could almost hear the words of my favorite General Surgery Professor back at SFGH in San Francisco:  “We’re doing things.” 

Thanks to everyone who’s helped us grow this program to this stage.  Stay tuned for the next monsoon report….

-CS

Strike Force EK

We assembled just before dawn on the veranda of EK.  A dozen freshly-coffeed volunteers, American and Kenyan, clad in new OHR t-shirts.  Quietly we checked our supplies and equipment: clipboards, markers, shipping labels, multitools, sisal ropes, life jackets.  We reviewed the whiteboard one last time. We had outlined our strategic positions and assignments the night before in dry-erase red and green.  At first light, we waded out from Kitawi beach and boarded two big empty Mfangano boats, “Elizabeth” and “Msafiri”.  Across perfect glass, with an equatorial sun peeking over the horizon under last night’s rain clouds, we opened up our 40-hp outboards and raced side-by-side towards Mbita.  Our mission this morning: mountain bikes.

In the morning hours between our April monsoons, our job was to complete a journey that began in December on a cold snowy day in Denver, Colorado. Thanks to the generosity of OHR’s newest partner, Bikes for Humanity (www.b4hcolorado.org), 325 mountain bikes were donated and collected from the greater Boulder area and jam-packed into a 40-ft shipping container.  Our family friend Greg Lynch also personally donated 350 brand-new helmets to ensure safe riding for the hundreds of novice bicyclists waiting in Kenya.  After 2 months on the open seas, and 2 more months clearing customs at the Mombasa port, our container hit the road last week, traveling 500km overland to the shores of Lake Victoria. Once in Mbita, our Executive Director successfully arranged for the container to be “dropped off” at the sub-district hospital.  (In order to offload this 12-ton behemoth, Richard had to skillfully bribe a local road crew to push and pull the container off the truck with backhoes and bulldozers in the middle of the night.) We arrived at 10am, to find our container resting peacefully in the hospital parking lot surrounded by several confused looking security guards and hospital officials. 

We quickly broke into teams. Marco ripped off his shirt and dove into the pile of bikes in the container, unloading Gary Fisher after Cannondale after Mongoose after Trek after Specialized after Huffy. Olambo, Rosemary and Paul numbered and labeled each bike as Jenna and I tried to record a quick inventory before piling them into the back of a pickup where Tillen and Lucas were waiting. Down at the shore, Walter, Dennis, Oratu loaded bikes onto the boats, as Osodo and Otindo, EK Security Guards, worked hard to control the growing crowd of onlookers.   We were all extremely impressed with the quality of bicycles pouring out of the container…so were numerous local politicians, hospital officials, police officers, and area businessmen who appeared one after the other hoping to score a bike on the sly from one of our team. We maintained a hard line: “EK Members only”, but encouraged countless Mbita residents to come visit us on Mfangano and join the club.

By noon we were back on the boats, squeezed into the stern behind huge piles of bikes- 173 in total. We rocked in heavy waves back to Mfangano, as veteran boat drivers laughed at the nervous faces of their muzungu passengers, and kept our bows into the wind. When we reached Kitawi, we were greeted by a crowed of excited kids.  Bikes began flying out off the boats as soon as we hit the beach, and we had to work hard once again to keep everything organized and accounted. We enlisted the help of up dozens of little kids, each thrilled to roll a bike up the hill to our storerooms. We were all thrilled B4H also threw in dozens of kids bikes.  We were able to cram 150 into the storeroom at Kitawi, and hung 25 beautiful full-suspension bikes from the rafters at EK. Many of the nicest bikes had tags from the University of Colorado Police Department warning students that if their bike was not unchained and removed from its rack it would confiscated and donated to a local charity.  Pretty cool that all these forgotten bikes have found their way here where they will be truly cherished. Mountain Bikes of this quality are impossible to find in Kenya, where even shoddy Chinese-knockoffs sell for around 10-15,000 shillings ($150-200USD).  We plan to sell these bikes to all EK members at around 3000-5000 shillings as a sustainable business for a team of EK mechanics. We hope these bikes, with fatty tires and serious shocks, can encourage more people to learn their HIV status through our club, and provide alternative means of transportation here on our muddy ring-road where motorcycles and motorboats remain the primary options.  We also plan to set aside several dozen for local community health workers and researchers to assist their important work for this population.

We all went home so excited that Marco and I both forgot completely about the six-pack he hid in the container back in December that never arrived in Mbita: a PBR tip for the customs agents who did their part in the great Mfangano mountain bike relay. Thanks so much to everyone back home who put energy into helping these bikes travel across the world.

CS

Chwera Chwera beach

April 24, 2012

Apologies for long radio silence. We’ve gone deep into island time the last few months, neglecting our inboxes and blog updates. I figured I’d try to bring you speed with a simple “day-in-the-life” post. We’re starting to feel the rhythm here. This was my Tuesday, March 20th…

6:45- Woke up when the sky turned red, filling our tent with pink dots through the mosquito net. Half asleep I put a kettle of drinking water on the Coleman stove (we’re boiling all our water now after both Jenna and I picked up a few amoebae over the past couple months→metronidazole treatment is not that much fun)

7- Ana’s mom, an artist from Maine, is visiting us for a couple weeks, helping conduct a painting workshop at EK for the Sisterhood Exchange Program artisans. Over a cup of coffee we discussed a few different ideas for murals for some of the large concrete spaces at the EK center. We’re all very excited for color to arrive on our walls and domed ceilings.

7:30- Put on my ragged work gloves (still trying to protect these soft muzungu hands…) and headed over to the building site on the northeast corner of our farm. After much dreaming and minimal formal planning we’ve fully launched ourselves into house construction. In a nut shell, we’ve decided to build a semi-circular house, under tall thatch roof with ferro-cement walls, a homegrown design Jenna and I cooked up over many late night cups of tea. The decision to build using timber was challenging for both us, since this is such an endangered resource here in Kenya. However, I was able to talk some of the local power company guys into selling us 3 large electricity poles that were rotting here on the side of the road (in fact there are hundreds of poles lying around this island rotting, and I think a small guerrilla reclamation movement is in order to protect our dwindling trees. Deforestation is surging at a horrific rate here on the island right now…more on that later). Using a large axe and pry-bars Adam, Gabby and I were able to split and quarter two 30ft poles into dozens of outstanding 10-ft wall posts. The third pole we planted and cemented 4 feet deep at the center of the house as our primary roof pole. This morning before the heat kicked in, I climbed our creaking ladder up the center pole to drive a few final screws into a small crowsnest that Adam and I have been building at around 24ft. This afternoon we’re planning to use this little perch to begin attaching our first roof poles…

10- After a quick swim to wash off the sawdust, I headed 1-km down the road to Kitawi. I dropped by the farm where Jenna and the team were weeding the new drip irrigation lines, long rows of green kales, onions, and tomato plants stretching up to meet the careful fingers of our farm team. Had breakfast under the mango tree, some hard-boiled eggs and mango-oatmeal that Jenna put in a hotpot for me this morning.

10- Crossed the road for a weekly planning meeting with my Microclinic Program Managers, Peter Manwari and Dan Omollo. We strategized for half an hour about our “targeted mobilization” strategy to recruit more people living with HIV/AIDS into the microclinic program. Already Dan’s team has completed the baseline phase of our research, and we’ve gone forward to enroll nearly 350 participants, train 32 Community Health Workers, and organize everyone into 43 different microclinics across Mfangano East Location. Everyone started their first of 12 training seminars this past week and I’m so proud of my team. It’s been very exhilarating to step back and let this talented local staff take the wheel.

11- Theresa, one of our VCT counselors, interrupted the meeting to ask us if we would mind seeing a patient at the reception. Even though we don’t have any clinical services available at EK yet, Peter (a trained nurse) and myself (an untrained 3rd year med student) have been offering free advice and referral recommendations to community members who show up at our reception every day with various simple and complex health problems. We were introduced to a relative of one of our security guards, a young women with a two week old baby at her breast. We headed back to one of our confidential VCT rooms. There Peter explained to me that he knew this woman from 4 years ago, when he worked here on the island at the FACES HIV clinic in Sena. Apparently, she had been enrolled in Anti-retroviral treatment at that time but had been lost to follow-up when she was forced to return to her home village near Kisumu after a domestic dispute. She had returned to Mfangano this past month and was still taking ARV’s. However, she had forgotten her official transfer letter from her clinic in Kisumu and the clinic here on the island was refusing to re-enroll her in care and treatment until she brought the letter. She was desperate: with only 3 days left of her medication and a breast-feeding baby, we all knew the clock was ticking. We also knew that she did not have the resources for the long trip to Kisumu and back for that letter. Peter quickly got on his cell phone, called several connections, and was able to get a clinician at her clinic in Kisumu to give us all her relevant information. We relayed this to the clinic on the island, and after a bit of smooth talking by Peter, she was re-enrolled in treatment. I’m realizing that this type of problem is one of the key gaps that Ekialo Kiona Center can fill her on the island; advocating for patients and connecting the dots between numerous organizations and facilities that are often overstretched and under-resourced to deal with the social, economic, and political issues interfere with treatment. I was very proud of my team for going out of their way to find a solution that saved this women considerable time and money, and prevented a new infection in her newborn.

12:30- After a quick plate of beans and chapatti at Grace’s new EK Restaurant, Adam and I headed back to the farm to continue working on the house. Today we got serious on our roof. With Oliver, Seth, Mike and I measuring and sawing on the ground, and Adam up on the crowsnest with our site line and a bucket of 5” nails, we secured a dozen 23-ft roof poles in a half-cone around the perimeter of our ring-beam. Each pole was hand-selected by Walter last week in Kisii; he traveled in person to the Eucalyptus tree farms there to pick out 40 straight, tall beautiful “blue gum” poles. (For each tree harvested, two were planted on the spot…a simple and smart policy). Very exciting to see the roof take shape.

4pm- Adam and I climbed down from the crowsnest, took a quick swim in the lake, and headed back to EK. Today we had scheduled the first “EK Mfangano Health Net Seminar”. As part of the micro-clinic program we are offering weekly seminars on special topics to the community at large. Today it was my turn to give a brief presentation on the origins of Ekialo Kiona Center and our research here in Kenya supporting social networking strategies for HIV/AIDS. I was happy to see ~50 people sipping tea in the social hall, waiting for the seminar to start. Powerpoint is still a very new and special technology here, and although we in the west are a bit jaded with slides and bullets, it was really fun to give this presentation about our own history to the “home crowd.” I’ve given this presentation to many audiences in San Francisco, Colorado, Oxford, etc, it was very fulfilling this time to see the same friendly faces in my slide photos recognizing themselves from their seats in the audience.

6pm: Started my “commute” back to Chwera Chwera with Jenna, 15 minute stroll at the best time of day.

6:15: Jumped on the pump and watered all the trees (no rain for over 4 months, everything is very thirsty.)

7pm: Chopped tomatoes, onions, and pineapple (“Island Fried Rice” and for Dinner tonight…yeah!)

8:30pm: Reclined for some lemongrass tea with Jenna in our “Mfangano lazy boy” (I sit on the wooden folding chair made by Elija Okeyo, Jenna sits on my lap).

9:30pm: Day is done. The mosquito net beckons back…

-CS

Ekialo Kiona Center, Kitawi Beach
March, 26th, 2012

I’m attempting to speak duluo as much as possible – Just one of the many things we’ve been doing instead of blogging! Yes, we have been lost. On mfangano, when someone tells you ‘you are so lost’, it means that they haven’t seen you in a good amount of time – in other words – ‘where have you been’?

Well, I’ve been doing a number of things….

The comical things I’ve been up to:

• Conversing in my terrible Duluo to almost anyone who will respond (I’m getting better though – you gotta practice somehow)
• ·Investigating where our stolen grass went (we are building a permanent house, oriti tent!, and doing a thatch roof) which led us on a trail hunt to the nearest thatch house with a surprising newly thatched roof!
• Wearing these excellent and quite fashionable ‘floaters’ (foam sandals)
• ·Borrowing my ladies jeans to my fellow male farm worker, Olambo – he looks great in them
• · Loving/eating ugali/kuon like I’m Kenyan
• · Speaking in Kenyan English … ‘do you take sugar?’ , ‘I want to bathe’ ,
• · Admiring how the ladies get to change their hairstyle every week
• · Cheering on (and probably embarrassing) our young friends at soccer matches

The beautiful things we’ve been doing:

• Sunrise and sunset bathing
• Dinner with Adam and Ana – fusing past culinary experience with local foods
• Night-time strolls under rising moons
• Gathering with friends we’ve met who are also living in Kenya and those who are just stopping through
• Growing as many trees as we can possibly keep watered
• Relentlessly growing vegetables regardless of our chickens, the birds, the drought, the soil, the grass, the heat (praise the lord for trees, fencing, and drip irrigation)
• Eating delicious fruit: mango, papaya, pineapple, mkuyu, passion fruit, tangerines, lemons, banana
• Raising two local puppies: Sulue and Omwenzi
• Star gazing at the brightest stars I’ve seen
• Bird watching in bird heaven
• Tree identifying and desert kicking
• Making true friendships and becoming family with our friends here on Mfangano
• Understanding the nuances of Mfangano culture

The things I am learning from being here:

• How to cook over fire even when it rains         
• Own dogs
• How to make a plastic bag last til the bitter end
• Tupperware is remarkably useful
• How to repair a shoe
• Don’t eat day-old food
• How to begin parenting (so much more to learn)
• Keep important items in a safe place (they will disappear)
• How to carry water comfortably on my head
• Be patient, especially during discussion (here, the loudest person doesn’t get all attention, everyone patiently gets a chance to speak without being interrupted, it is so amazingly great)
• Boil your drinking water - ALWAYS
• It is okay to tell people to leave your home when you want to bathe or need space/privacy
• Understanding people’s differences, strengths, and weaknesses with a kind heart
• Generosity.  don’t keep tabs – just give … ask and receive
• My limits
• True malnutrition and hunger
• True peace
• Strength
• A million other things

We will try not to get so lost next time!

much love,

Jenna

We were just putting a pot of lemongrass tea on the fire for our daily post-dinner cup when my mobile started ringing. It was Elija, a friend from Kitenyi beach.

 

“Charles, do you have that medicine for the snake bite?”. (I felt the ugali in my stomach turn over).

 

“Elija. why do you need snake bite medicine?” (I already knew the answer but was praying that this was merely a casual inquiry.) 

 

“A child has been bitten here at Kitenyi by a snake”. (Elija was breathing hard and I could tell that he was running).

 

“When did it happen?”

 

“Just now, 5 minutes ago.”

 

“What color was the snake?”

 

“It was the small black one.” (The real deal, exactly the answer I didn’t want to hear.)

 

“Elija, that medicine is in the solar-cooler at EK Center. I’m going there now. You bring that child as fast as you can and I’ll meet you there. Is the snake dead?

 

“Yes they killed it.”

 

“Tell someone to put it in a bag and bring it to EK.”

 

“But they already threw it in the latrine…” (So much for a positive ID…)

 

Even though we’ve talk about snakes for years on Mfangano, this was the first real snake bite I’ve experienced out here. Considering how much all of us have dreaded exactly this scenario, I felt pretty calm.  I found my headlamp and put on my running shoes. I began loading my backpack with a few key ingredients from the first aid kit: ace bandage, dressings, IV-starter pack, epinephrine, stethoscope, blood-pressure cuff.  Marco and I had outlined and discussed the snake-bite emergency protocol at least a dozen times; I knew that Marco’s single vile of polyvalent anti-venin was safely chilling in our insulin cooler at EK. The new EK emergency boat was fueled and waiting down at the farm.  Kissed Jenna and headed for the road just as I saw Elija’s flashlight bobbing towards the gate. I could see him running with a small kid on his shoulders under a bright Mfangano moon.

 

As we jogged the 1-km to the EK center, I dialed the only 911 line we have out here: “Hey Dad, its me. I need your help… again.” It was Thursday morning in Glenwood and Dr. Paul had just arrived at the office. I tried to bring him up to speed: 5-year girl bitten by an unidentified black snake on her right foot 15 minutes ago, two fang marks 1 cm apart, between the 1st and 2nd toes, minimal bleeding, very painful to touch, no swelling, patient alert, crying a little, breathing ok, no signs of systemic envenomation…yet.

 

With my dad on the line we made a quick decision to pick up the anti-venom and transport the patient to the clinic 5km away in Sena. There we could start an IV for anti-venom if she was showing systemic signs, and monitor for anaphalaxis (a common reaction to anti-venom administration).   We put a lympho-occlusive “Coban” wrap on the bitten leg up to the knee, and raced off into the night on two motorcycles. When we reached the clinic, we found the place empty and dark. We sent someone running to get to the nurse and clinical officer at their homes.  As we waited anxiously, one of the security guards suggested that we take the child to a nearby orphanage a half-kilometer down the road, where there was a “Snake Bite Machine” that had been donated by some “American doctors” years go.  (Why not?)

 

We reached Gethsemane Orphanage and after explaining the situation to the security guards, they emerged from their office with a strange contraption that looked straight out of the backroom at “Factory and Army Surplus.”   It was a grey ammunition can with crank-arm coming out of the side; the words “Snake Bite” were actually written in duct tape on the side.  The security guards proceeded to clip a metal plate to my patient’s foot and attach wires to a small metal ring that they placed over the fang mark.  As I whipped through the pages of my Auerbach’s Wilderness Medicine book, I could hear the guards telling the girl to remain still.  I found the page I was looking for: “Precautions for Emergency Treatment for Poisonous Snake Bite”

 

•              Do NOT use electric shocks. The shocks are not effective and could cause burns or electrical problems to the heart.

•              Do NOT use tourniquets or constriction bands. These have not been proven effective, may cause increased tissue damage, and could cost the victim a limb.

•              Do NOT cut and suck. Cutting into the bite site can damage underlying organs, increase the risk of infection, and sucking on the bite site does not result in venom removal.

 

When I looked up I could see that a crowd of students and teachers had started to gather. To my horror, as one of the security guards began to crank the machine, the other began to tie a tourniquet over my Coban wrap with a piece of nylon fish-net.  I found myself in a very awkward cultural situation. My limited med school training (not to mention my main man Auerbach), told me that an electric shocks and tourniquets were bad ideas. However, it was clear that everyone in the crowd expected immediate treatment for this little girl; watchful waiting was going to be a hard sell. I was able to convince the guards to remove the tourniquet, but everyone demanded that this fancy apparatus be utilized. If I stopped them now, I was made to realize that I would be held responsible if the child’s condition worsened.  I watched somewhat helplessly as they applied the first shock. The girl started screaming. One shock was all I could take though, and I asked Elijah to scoop her up before they next charge was ready. We put her on the bike and headed back to the clinic.

 

Thankfully a nurse had finally arrived, looking very sleepy and a bit annoyed. I explained the situation to her again, showed her the anti-venom in my bag, and suggested that we watch the child closely throughout the night. I told her I was a medical student, and was very happy to hand over responsibility, I was just here to help out.  She smiled, and immediately took the child into a one of the delivery rooms in the maternity center and began laying some equipment on the table.

 

“What’s your plan?” I asked.

 

“We need to incise the wound and bleed out some of the poison”. (Oh s#&%!)

 

I got back on the phone with my dad, and after a small infusion of confidence from GMA, I was able to convince the nurse to put away the scalpel for the time being. We agreed to wash the foot, and give the child some Ibuprofen and some prophylactic antibiotics.  It had been about 2 hours since the bite at this point, and the child was doing very well, smiling and drinking a bottle of coke that someone thoughtfully brought to the clinic. We checked her vitals and all her cranial nerves: A-ok. At this point the mother had arrived, and we explained that we needed to keep her overnight to monitor for signs of envenomation that can develop even 6-10 hours after a snake bite. By the time the clinical officer arrived, I felt cool about handing over monitoring duty and heading home. He reassured me by saying that he’d seen treated many snake bites, but never a single death. We agreed to keep the anti-venom and emergency boat on standby just in case.

 

As Elijah and I rode back to Chwera Chwera beach, we discussed the many different local treatments people use here for snake bites. Gabby, our construction foreman, is only other person we know who has ever been bitten by a snake, a cobra 2 years ago. He survived, according to island lore, by drinking 1 gallon of cow-dung mixed with lake water. I was grateful that this particular intervention had not been proposed for our patient, but reminded myself to keep an open mind.  People have been living with snakes out here for centuries.  (And I also had to admit it, my patient’s pain at the bite site entirely disappeared after the ammo-can shock was applied….) At the same time, I reminded myself of the promise I made my dad before I left: I need to finish my clinical training back at UCSF. Dealing with medical emergencies as an unlicensed student is truly terrifying.

 

It was just after mid-night when I got through the gate. The dogs greeted me—our elite night snake patrol was on duty. Jenna had filled a thermos. My lemongrass tea was still hot.

 

-CS

 

Chwera Chwera Beach, 1-15-2012