Going back?

It's reunions this weekend (but I'm not there), my little '11 buddies are all grown up and graduating, and I have less than a month left in Kenya. A few days ago I wrote some reflections in order to help me try to decide what to do in my last month to finish up my project, but it turned into more of a personal reflection. So it seemed like a relevant thing to turn into a blog post, although now that I reread it it is largely nonsensical:

Today marks exactly one month until I fly back to the US and head almost directly to the Compton retreat in San Francisco. That means it’s been about 11 months since our retreat last year and just over 10 months since I arrived in Kisumu on July 19, 2010. The other night I was talking to Ricky and he was commenting on how looking back on the beginning of his time here (he arrived around the same time I did) everything seems sunny and happy and in recent months he has become more stressed about his work, more tired of the tiring things about living in Kenya, and more ready to go home. So I had to think about whether I have gone through a similar transition – was I happier when I started? Am I ready to go home? Is that a result of failures and challenges or just a desire to have fast internet and be able to relax and not stand out every time I leave the house?

In my first five months here I had no thoughts of wanting to leave. After I went home for Christmas, came back, and left again for my time in the UK, the idea of being back in a developed country, with my friends from college and where everything is easy, started to appeal to me more. Now, as my departure date approaches, I feel less ready to leave the great friends I have made here, abandoning my project, the beautiful weather, affordable living, access to incredible places. To make up for it I have planned to visit about 6 US states and 3 countries in the summer before starting graduate school next year. I think my experience in Kenya is roughly paralleled by the weight I have gained and lost this year – ten pounds on gradually, represents filling myself with Kenya and starting to feel like I don’t fit in my current set of clothes, need to change and shed and start over in a lot of ways. Most of that 10 pounds off again, still sticking with my new clothes, my new life, but being better able to control myself and no longer needing to gorge on Kenya-ness and feeling a better sense of fitting in here in relation to fitting in elsewhere, home in Kenya, home in Europe or the US, home nowhere, but it doesn’t matter. I am so lucky to have this experience, and I tell myself this every day. I am 23, and I live in Kenya, I travel to France for conferences, I can communicate online with people back home, and I am managing a project that involves Zebu cattle and learning about diseases and public health and pathology and technology and research and management. I think I am ready to go home, to start grad school, be taught microbiology and statistics and research practices – this year, I opened up the spaces in my brain by trying to teach myself all of these subjects and more, and next year, I will start to fill in the gaps and I will be able to do such awesome work when I come back to Kenya to do my MSc research.

Has the US changed since I’ve been away? Will Kenya change over the next year when I’m gone? KEMRI/CDC is facing major budget cuts, laying off close to 1/3 of all staff, cutting programs, cutting global health research. Will it be a different center when I come back? Or will it be the differences in my perspective and knowledge that are more important than these logistical transitions?

Garissa!

Right now I am in Nairobi. This morning I was in Garissa, the provincial capital of Northeastern province which is on the border with Somalia. Don't worry – it turns out you only need an armored convoy if you drive past Garissa, for example to Dadaab, one of the main Somali refugee camps in Kenya. This trip to Garissa was planned and cancelled and planned again but I'm glad I got to go along for the ride – Dr. Njenga, the head of the new zoonoses program at CDC Kenya, worked in Garissa a few years ago during the Rift Valley Fever outbreak, and he's been wanting to get more projects set up there ever since. Now that we have a zoonoses program, and some exciting new collaborations, the plan is to set up a demographic surveillance system for livestock potentially in combination with an extension of my mobile-phone based surveillance – this time in a place with wildlife too!

Long story short, we met with lots of people, from the District Veterinary Officer to the Kenya Wildlife Service guys to my friends Kelly and Victoria who work in Kisumu but also happened to be in Garissa on Thursday night…Garissa is a predominantly Muslim town, so the only place that served alcohol (and since it was Victoria's 30^th birthday, the place where we had to go) is the Government Guesthouse. The town also features a lot of camels, a lot of dust, and one or possibly two fancy hotels that cost no more than 3000 shillings (about $35) per night. Our fancy hotel, the Nomad, had a staircase with stairs of varying heights. This is actually fairly common in Kenya and is extremely disconcerting. In any case, I had a really good time in Garissa and brainstorming how to set up an integrated human and animal disease surveillance system –plus I got to meet a baby giraffe rescued by the Kenya Wildlife Service after being abandoned by its mother. She is only a few days old (still has umbilical cord) and is already as tall as me!! I also got to see my first baobab trees on the drive over there. It is such a different part of Kenya than where I'd been before.

Giraffe calf being bottle fed at the KWS office

Baobab tree along the Garissa-Nairobi road

The extreme poverty in and around Garissa is in stark contrast to the ridiculousness of where some of the people that I work with live in Nairobi – there's kind of an ex-pat wonderland up near Muthaiga, which is a neighborhood full of extremely large fancy houses, and high stone walls with electrified or barbed wire on top. When we stopped inside Njenga's double-gated – think airlock except made of bars - compound to use the bathroom before hitting Nairobi traffic to get to our hostel, we wandered in to the community center which contains a store stocked full of American goods, as well as a large number of extremely well-dressed American stay at home moms and a group of teenage boys each on their own laptop with headphones on sitting around a table next to a pool and tennis courts. This is the neighborhood that I read about in It's Our Turn to Eat by Michela Wrong – where corrupt Kenyan politicians spend their millions. Speaking of millions, the top news story in one of the Kenyan papers was about $10,000,000 (yes, ten million US dollars) that one of the Ocampo 6 (the Kenyan leaders accused of war crimes for their role in the post-election violence in 2007) was clever enough to lose at the airport when coming back from hearing his accusations at the Hague. First of all, WHAT? And second of all, WHAT??? If you are carrying $10,000,000 in $100 bills in a duffel bag, shouldn't you handcuff it to your wrist? There is just so much fishiness in this story, including the question of how it is possible to carry 100,000 $100 bills in a carry-on, I don't even know where to start. Hopefully Robin Hood stole it…

The pictures you have all been waiting for

So I'm currently sitting at the Duke of Breeze Rooftop Bar (DuKe stands for Dutch Kenyans since it is run by some Dutch people, apparently they showed the World Cup final here and all the Dutch in town (which is many) turned up).

The reason I'm not at the office, besides the fact that the internet there is awful, is that this morning I had to renew my visa! That means I've been here three months. Which is ridiculous since, if you count the month or two I'll be in Scotland and other places, it means that I am a third of the way through my time in Kenya. Ahhh I'm scaring myself. But renewing the visa was thankfully painless, although I had to strike a delicate balance and make sure to emphasize that I am not working but just came here on holiday because I love Kenya. Which is pretty much true. I also had to give real ink fingerprints, and my hands are a bit stained now but presumably that won't last forever. And apparently in a month I can go back and pick up my Alien Registration acknowledgment, whatever that means.

So I decided to take this opportunity to use the fast internet and download all the programs I need to start setting up a data collection program on Android. And post a ton of pictures.

First, the house I live in:

The living room. Note the parquet floors and tasteful interior stone wall.

My backyard (there is a very noisy construction site on the other side of the wall).

The view of the sunset from my porch.

The view from the top of Mount Kisian (aka the hill near the CDC/KEMRI HQ)

A newborn calf reported and responded to.

Participants in our Participatory Epidemiology interviews participating by deciding how to divide buttons to indicate the causes of certain types of diarrhea.

My job as recorder mostly involved counting buttons and reminding the translator to tell me what was going on.

On Ndere Island, there are a ton of swallows.

Jo, Steph and Per walking ahead of me on the island.

This calf was the last one recruited to the IDEAL study that I talked about a few weeks ago. They get sampled every 5 weeks from birth to a year, so this calf, at the last visit, clearly knew what was in store for it.

What was in store for it involved being measured with a giant ruler. By the way, this calf, according to genetic markers, is 100% native African cattle with no European blood. They used it as a really prime example of why you can't tell the breed just by looking at color.

This is the view of the Kisumu skyline from the lake. The one relatively tall building that stands out is a 30 floor (ish) monstrosity that was built as the provincial headquarters. That's where I went to get my visa renewed this morning. Unfortunately, the building was ahead of its time, and they may have run out of money while building it, so it sat empty for a long time. Now the bottom 6 floors are in use, but none above that because there is no elevator.

Much News

Hello! This past week helping out with the Zoonotic Enteric Disease participatory epidemiology study was GREAT! Except that the tiny hotel room I was staying in developed a puddle problem. My Luo language skills improved significantly, although unfortunately for real life mostly I now know lots of words for diseases, especially types of diarrhea. Oh well… I got to meet all sorts of cool people that do awesome public health work, and spend lots of time in rural villages where I obviously get to see cows and goats and dogs of all different colors (sheep too, but they aren't so exciting, the sheep here are really ugly). And people! Nice, welcoming people that really (for the most part) seemed to enjoy talking to us and telling us about their lives and all the types of diarrhea that their children under 5 have. One woman in particular was so enthusiastic (here they would say "keen") and always wanted to tell us what she thought or help arrange the button counters (used to indicated visually how frequently certain symptoms are seen with different diseases, for example), and then at the end of the interview she thanked us profusely for coming and made extra sure that we're really coming back to talk to them again in November (which we are). It made me really happy to see how much she (and other less expressive participants) appreciated us being there and learning from them. The only sad part is that I'm sure this particular woman would have loved to go to college, and done well, but probably didn't even get the opportunity to go to high school.

On Saturday when I got back I finally realized that I am never going to find this 8,000 shilling ($100) Android phone that I heard rumors about because they decided to sell it for 16,499 instead. So then I went and bought one, because $200 is still way not expensive for a smartphone! And now I have to figure out how to make it work perfectly for disease data collection!

Then today I went to Ndere Island National Park with Steph, Per, and Jo. It's about an hour's drive outside of Kisumu through the most beautiful/interesting area…there are a ton of rock formations and oddly balanced boulders. Anyone know how this happens? Would it have anything to do with the fact that a few geological time days ago the whole area was under The Lake? This drive and the PE study both made me want to spend more time out in the rural communities, so hopefully I'll get to actually stay out at the field site once things are up and running! At Ndere, I managed to pay the resident's rate and we took a boat out to the island and had a nice hike around for a few hours. The island is awesome, and we were literally the only people on the whole thing (it's about 4 or 5 km squared) until when we were leaving a school group arrived. We saw impala, baboons, monitor lizards, a huge crocodile in the water, a ton of birds, a bushbuck and also unfortunately a lot of invading water hyacinth. No giant snakes though.

I know I keep saying I will post pictures and I'm really gonna try now. And then I will try to post one picture each time because it has to work with just one, right?

At Ndere Island...the bright green in the bay behind me is water hyacinth.

An example of the boulders and the general landscape.

Happy Half Birthday to Me!

I'm writing this from my teensy weensy hotel room in Bondo, a small town about 50 km outside of Kisumu. I arrived here earlier this evening with a group of 12 people that will be conducting a participatory epidemiology study to determine how much local knowledge there is about zoonotic causes of childhood diarrhea. In the process, I will learn all about participatory epidemiology techniques and hopefully organize to do some semi-structured interviews of my own next week or the week after. In any case, the proof of the teensy-weensy-ness of my hotel room is in the fact that the shower head will undoubtedly dispense most of the water directly into the toilet bowl, and the tiny sink that is less than 3 feet off the ground didn't even fit in the bathroom. The part of the room that is not the bathroom is also small, though. I almost got a bigger room but it turns out the hotel manager was reading the wrong line on the spreadsheet.

To fill you in on what I've been doing for the past forever since I posted, it has mostly been 1) stressing about applications for next year, 2) ordering pretzel m&ms from Amazon.com because now that I'm not being vegan it clearly makes sense to ship chocolate halfway around the world, 3) going to the movie theater to see movies that were out in the US when I was home 3 months ago but that I didn't get to see, 4) making lists, and 5) tallying all the Compton money that I've spent so far. Turns out the perk of my new(ish) house which means I no longer have to pay for public transportation very often is far outweighed by the extra money I spend on food because I live alone but still cook as if I had several extra mouths to feed.

The other night I went to a potluck type party hosted by the director of the Walter Reed Army Institute of Research in Kenya. This party (held on the first Friday of every month) apparently inspires all the wazungu that normally hide inside their embassy security level compounds to venture outside, so I met a lot of people I had never met before. Mostly everyone else that works for Walter Reed has a southern accent, and mostly everyone that works for CDC has some kind of east coast accent, with the best one being this guy John who has a ridiculous Boston accent and sounds like JFK from Clone High, almost. I was told by two people that I "don't have an accent" which I think just means I am good at melding everyone else's accents. I have also now met two Peace Corps volunteers here, and as inconvenient as it is that Doug wasn't placed in Kenya, it seems like PC Kenya is extra screwed up and inefficient, and West Africa is probably a way better region to be in from that perspective.

In other news, my toe is healing nicely, but yesterday I narrowly avoided getting mown down by a bicycle (boda boda) and then a couple hours later tripped over the curb when the matatu I was about to get on started pulling away and I fell and ripped my jeans and skinned my knee. I think I will claim that my new(?) clumsiness is a side effect of Lariam.

I was thinking of going to Nairobi this weekend to try to track down the inexpensive Android smartphones (that supposedly exist and that I want to use for data collection), but I didn't go, for various reasons, and instead asked everyone in Kisumu that claims to work somewhere that sells phones about them and nobody knew anything about anything. Not helpful, but one of the people I talked to was nice enough to claim she'll look into it and call me back, so I may be on my way to becoming an Android developer. Once the smartphones are up and running I can hopefully stop trying to receive SMS reports in the tiny mobile network dead zone that surrounds the desktop computer in the field office, and get the project moo-ving.

I've also been learning to speak Dholuo, and yesterday had a lesson in which I learned lots of names of animals, which may be helpful in my interpretation of what we will talk about this week, but probably I still won't understand anything. I was hoping to be fluent by now, but shockingly, after two whole hour long lessons, I am not even proficient. People from the Luo tribe do not like to speak Swahili and do like to speak English, to make a broad generalization, so overall I have mostly been learning to speak Kenyan English… Me I think Kenyan English is great.

IDEAL (More about cows)

So there is this study going on in Busia, right on the border with Uganda, and it is called IDEAL…Infectious Diseases of East African Livestock. Basically they recruited a cohort of about 550 calves at birth, paid the owners for the right to tell them how to raise the calves, told them not to dip them or treat them or anything, and visited them every 5 weeks or whenever they get sick. This study will form the basis of the data that I will use to create a diagnostic support tool because they gathered extensive information on clinical signs and attempted to diagnose every clinical episode in the life of every calf. The disease burden here is high, 16% of the calves died, with almost 90% of those deaths from infectious causes, and 60% of the infectious causes were East Coast Fever, the disease that I did my thesis on.

So today I traveled to Busia for the workshop and party celebrating the end of the field work, and to meet the people that I'll be working/living with in Edinburgh in January. After watching a bunch of cool presentations about what they've found so far in the study, we drove at breakneck speed to the farm where the last calf lives, to collect the last set of data! Actually, we didn't drive at breakneck speed because CDC cars have "governors" that use GPS to track the car, and notice and beep anytime the car goes over 80 km/hour, so we had some trouble keeping up with the ILRI vehicles that don't have speed restrictions. It was really cool to see them collecting the samples and examining the calf, since I adapted our collection protocols from theirs. Also, it was great to be in the field again! I am desperate to finish doing office-y things and get back out in the field actually playing with cows (and other animals).

I also met a really cool guy named Mark who is the District Veterinary Officer for one of the districts near Kakamega (north of Kisumu). He is super enthusiastic and is really interested in mobile technology and setting up animal health surveillance that can be done in real time instead of what they have now which is a system of reportable diseases and paper forms that are often faked and take months to travel to the central offices. So I hope hope that this spring I can try to expand my ADSARS (everything has to have an acronym…Animal Disease Surveillance and Response System) to his district, where it will be in the hands of local government, headed by an awesome DVO!

I want to post some pictures, but I think that will have to wait until tomorrow. Sorry.

I Like Cows

When I was at Maasai Mara, one of the women I was with was telling a story about her 5 year old cousin who lives in Uganda. She had control over a camera on some vacation that her family took, to places where you can see giraffes, lions, elephants, zebras and other exciting animals. When they got back and she showed her pictures to everyone, they were mostly of cows, because they are her favorite animal. It's hard to believe that someone would find cows more exciting and photo-worthy than the wildlife in this part of Africa, but I can definitely understand why she likes cows. Last year at Mpala I was so frustrated by the fact that I couldn't get close to any of the enormous amount of wildlife that we saw, so when I had the opportunity to play with a dog or pet a cow I was super excited. Yes, that happened less frequently than seeing exotic wildlife.

Today I had a great time out in the field for the training session. We arranged for a man named Julius who works for a study that we are collaborating with to come up and teach our animal health assistants about how to take certain samples including how to make, stain, and read blood smear slides. I loved getting to interact with the cows, and learning some clinical skills. One of the cows was super friendly with Darryn, unfortunately I missed the photo op of her licking his face, but here she is being curious about what we're doing with all these slides with her blood on them.

On the other hand, I am unfortunately having some trouble getting FrontlineSMS to work on the computer in the field lab, and having trouble with FrontlineForms on the phones for the animal health reporters. All around troublesome. Based on this, and the fact that the lab isn't yet ready to process samples from the project, and so we can gauge how many reports we will get, and for a few other reasons we're going to start out by implementing the system on an even smaller scale than our original limited implementation plan. That means doing it in two villages, with limited sample collection and limited clinical signs collection until the systems are up and running. I think the training we did/are doing this week is still really useful, but having done some training doesn't mean the project is ready to be launched. In a few weeks when the software is ready and the lab is ready we can really get started, and we'll do another more realistic training then, because we'll have everything ready (hopefully). Darryn's leaving at the end of next week, and I think that will be a great kick in the pants for me to take charge and not rely on him so much, or rather, I guess, start relying on a wider range of people. It makes sense, too, that he wanted to do the training before he left, and to push me to get things going, but it's fairly obvious now that there just wasn't enough time, even though I was making powerpoints late at night for several days in a row.

The time has gone by pretty fast, as in I can't believe this week is almost over, and it's also strange that I have now been here exactly one month. I think this is a good opportunity to spend some megabytes and post a few more pictures.

This is me preparing my veggie concoction the night that the others ate freshly killed goat at Maasai Mara, the goat is on sticks on the leaves on the left side of the picture, the woman behind me is Marisa.

Birds are often crazy, but this one was especially crazy and was always always playing with the mirror of the car.

The dogs that live with me, Kiki and Nene, briefly sitting still.


These next two pictures are for Sarah. Delicio ketchup ("Tasty just got tastier") and an elephant in the now super green glade at Mpala.

Cows, bikes, malnutrition

This past week has been busy, I think, but it went by too quickly to really be sure. We're still planning to train our Animal Health Assistants (the primary response teams) and our Animal Health Reporters (community members who will pass on reports of sick animals from the farmer using an SMS form) Wednesday through Friday next week. There is a ton of work I have to do before then, like prepare to give presentations on a whole lot of stuff that I have very little or no experience with, like how to take a fine needle aspirate sample from a cow's lymph node. Luckily, actually-qualified-Alice will be doing most of the practical training, and I just have to pass on all the knowledge on procedures etc that I have been learning from books, and explain how the whole system works and what people's roles are. For the practical part, we have apparently been able to acquire a fetus and a dead animal's head (from the slaughterhouse), and we have a live cow or two to assess for symptoms and take blood smears from. Um, in other words, I expect to learn A LOT by "giving" this training.

MEANWHILE, I had to buy and register 40 sim cards for our Animal Health Reporters, the request for which led to some really surprised salespeople. Also meanwhile, I borrowed a bicycle that no one is using (owned by Marisa's project) and got it tuned up and new innertubes put in for about $9. I found a street stall selling helmets yesterday, which supposedly go for $8 pre-bargaining, but I'm not sure about their quality. Today I got a chance to take the bike out on its inaugural ride and I went to meet Beth and a few people she works with at Milimani Resort to swim in the pool and have lunch. It is actually a super amazing pool with underwater stools next to a bar place where you can get sodas and chips and real meals, but we got out of the pool to eat. You can also swim right along a little corridor to get to the changing rooms. It costs $2 to swim, and on a Saturday afternoon the place was pretty packed. Lots of kids splashing and yelling. I had a nice chat with a young woman (Millicent) and her 18 month old baby (Vanessa), Millicent is studing nutrition at a university in town and has just finished her first year. She asked about what it's like in the US in terms of malnutrition/overnutrition etc., which got me started explaining about food deserts and environmental justice and obesity related to poverty in the US, all problems which are obviously different to the slums and malnourished children with TB that you find here. Linda has been volunteering at a malnutrition clinic a bit, and they have to give every malnourished child antibiotics and dewormers in addition to food. Millicent asked if I thought she might be able to get a job in the US after she finishes her degree, but I said I think most US NGOs do work on nutrition out here…

Speaking of jobs, it has come to my attention that I might have to start thinking about what to do next year ALREADY even though I've only been here a month. Ugh.