Dudedoc writes...

The daily trek form Kilimani to Mbagathi

2011-10-18T14:36:00.000-07:00

My 14^th day in Kenya is only an hour away and I have not gotten to post much about my time in Nairobi. I have been ruminating on several potential blogs topics but have not had the time to develop them fully. I will try to catch-up over the week.

What am I doing here? The short answer is that I am working at Mbagathi district hospital in Nairobi. The district hospital happens to be less than half-block from the national referral hospital, Kenyatta. The proximity means that we have relatively good ability to send complicated patients to a higher level of care.

The long answer requires a good amount of background. First the pubic hospital (healthcare system) system in Kenya, which caters to the 80% of the population is organized in tiers. The bottom tiers are more community based, smaller clinics, which ideally should progressively refer up the chain with more complicated patients. The district hospitals are the sixth level of care before patients have laser-guide their hope onto Kenyatta Hospital. The district hospitals also have some special concentrations/specializations, which they own. In the case of Mbagathi, it is the infectious diseases (HIV, tuberculosis and the likes) referral hospital.

Also a quick summary of the medical health workers structure will be helpful. More like Europe than the US, we have medical doctor education with medical schools, with further training to become medical officers. A few people go ahead with specialization to become registrars, then consultants. There is also a parallel system for a lower-level health workers, clinical officers. Clinical officers (CO) are close to the idea of physician assistants in the US, but COs are not always directly supervised or scrutinized by medical doctors. The lower levels of health care facilities may be entirely run by an autonomous CO. COs have 3 years of -post-secondary school- university level education. Then all graduating COs complete a year of internship at a government approved facility where they spend 3 months rotating through internal medicine (adult medicine), surgery, pediatrics and obstetrics. COs are registered after completing the internship based on varying mix of subjective and/or objective criteria set by the different training locations. A minority of COs do further optional training in the different specialties. The actual real-life responsibilities of COs vary widely based on their expertise, comfort level and how under-resourced their job destinations are; for example ‘minor surgeries,’ deliveries, c-sections, treating HIV are routinely in the purview of COs. The parallel and hierarchical system is how the Kenyan healthcare system has chosen (willingly or not) to deal with delivering health services within limited resources; I do not intend to debate the ethics or discuss the pros/cons of the system.

With that background, I will answer the question. I am working on the female general medicine ward, which has 30 beds but on average about 40 patients are admitted. Mbagathi is a training hospital for COs. CO interns are directly responsible for caring for the day-to-day activities of the patients; each intern has 6-10 patients. The CO interns are supervised by a medical officer (MO) intern, who is responsible for both the male and female general medicine wards (60-80 patients). The MO intern reports to a medical officer, who calls the shots on patient care. The final say, however, is an internal medicine specialist, who is also the medical director of the hospital. Daily patient rounds ideally should be done with the MO, MO interns and CO interns. Twice a week, the specialist comes on rounds. If you are a novice to medical jargon, I am sorry but I hope you are following; I suggest a quick Google or Wikipedia search for unclear words. I am the equivalent of the medical officer (knowledge and experience-wise); I basically run rounds or assist in running rounds in the morning. The afternoons are packed with a variety or procedures: placing intravenous lines, doing spinal taps, ultrasounding peoples bellies, placing grastric tubes, removing fluids for places they should not be; and checking off a crazy-list of mundane things. As you may imagine, the patient acuity level is quite high (probably 50% would qualify for ICU care at any US hospital); and resources are palpably limited.

So, on a regular day, I wake up sometime before 7am; exact time varies depending on whether or not I plan on running. I get to the hospital sometime between 8 and 9 am. My walk to work is 30minutes of brisk walking from the Kilimani residential area. Kilimani is on the edge of Kibera (Google Kibera!). The walk takes me past cars stuck in traffic, dirt back roads, urinating men, charcoal sale stands, chicken cages, and small market grocery stands. My most memorable walking companions are the poof of smoke that inevitably bellows in my face as I walk by some truck or large bus, and the sorry mentally ill gentleman who I encounter two blocks from my apartment gate with half-a-head of dreads as he compulsively scratches the other half. I also walk back home, usually at a more leisurely pace and stopping to by avocado, tomatoes, cilantro or eggplant. That is my working day.

Of course, I have a favorite café; I will write about “the Mug” later. I will also surely dish on many other things in the coming weeks.

Avocado heaven

Avocado and beet for breakfast

Swanky Nairobi pad

Nairobi pad-2

What happened to Europe? And what happened to little pleasures on transatlantic flights?

2011-10-13T08:55:00.000-07:00

Please join me as I mount my soapbox. While searching for flights to Kenya, I stumbled on Turkish airlines, a relatively new airline. I am not sure it is a new airline, but I had never heard of it prior to 2 months ago. My mother and my experience have taught me that air flights are not something you skimp on. Imagine the regret when you end-up on a no-name flight as the nervous pilot shakes the plane like crazy at 11,000 feet and blames it on “turbulence;” or the skid landing that he* blames on people’s excess luggage; or the spilling of hot tea on your laps that the flight attendant blames on the narrow inter-seat distance. Of course, you would rather have an uneventful flight with twilight sleep, gorgeous flight attendants and clean enough restrooms rather than having to cuss someone out or scream out to Jehovah, Shiva or Sango to save you.

Ok, ok; I am being dramatic. I did a search on Turkish airlines, and to my pleasant amazement I found that it was rated best airline in Europe in 2010. Best in Europe in my mind meant that it beat out British Airways, Lufthansa, KLM. Turkish Airlines was the $#!+ and it was the cheapest. Do such marriages ever happen? I should have suspected something was not quite adding up.

Pre-flight arrangements were quite smooth. I had a seat; I checked in online. At the airport, the folks working at the counter were good enough, exotic looking with plastered fake smiles and all. Their uniforms had the logo of some Swiss company; which I promptly inquired about. My biases gave me a sense of security; “Oh, a Swiss company is contracted to service the airline’s business; that explains the awesome rating,” I thought.

On entering the plane, it was sweltering! The Mediterranean looking hostesses were prancing up and down the aisle like they were in heaven; I reached up to adjust my personal fan/air-conditioner that usually sits next to the reading light. To my shocking amazement, the personal fan was nowhere to be found; every other unfortunate fellow like me in economy class did not have the amenity. The seats were comfortable enough. They tried to play psychological games on me by giving me a pillow and a blanket; but I was not falling for the dirty trick. The sweltering cabin was not to help me fall asleep; I am smarter than that.

My next disappointment: doesn’t every European now speak English these days? Well, my pilot spoke Turkish and some language; it had to be English but I can’t be too sure because I could probably make out 10% of what he was saying. Hope you are not too shocked at my apparent support of English hegemony, but I think a pilot or his* assistant or a flight hostess should be relatively versed in the official languages of both the originating and destination countries.

As I pile on my quibbles, I admit that I can be a prima-donna sometimes; but in this case I think having high expectations from “the best airline in Europe” was not unreasonable. Here are a couple more minor things, which are probably indicative of broader cost-cutting and corner-cutting measures. Orange juice (OJ)¹ orangeade. OJ is about the only thing I can tolerate on long flights and this is the first time (even on stingy American flights) that I was served some orangeade--less pungent version of SunnyD- in place of OJ with no explanation. Also powdered creamer! Seriously! Is real cream/milk too much to ask?

Overall, I admit that it was an uneventful flight. I would not be &!+@#ing and moaning about fake milk and OJ if the plane skidded or had some significant mechanical dysfunction. It is a technically solid airline after all. However, shallow consumers like me expect to be pampered some, even while flying economy class, from the “best airline in Europe,” perhaps, something on par with Emirates, Qantas or Singapore. I hope the rating agency was wrong and this does not mark the downfall of Europe.

I now dismount by box.

Lumpy-bumpy

2011-10-08T05:37:00.000-07:00

Why is procrastination so tempting? I will have to elaborate my thesis on that later. For 4 months I knew about by upcoming trip to Nairobi; and I looked forward to the experience—a fully funded opportunity to travel and work in a different part of the world. So why did the thought of packing for the trip only dawn on me 36 hours before leaving. I bought my ticket several weeks in advance. I had also being preparing my mind for the trip in a variety of ways. But packing my bags, placing an ad to sublet my apartment, placing my phone and Netflix accounts on hold, filling my prescriptions for malaria prophylaxis, tidying up my clinic-related message box; the long to-do list goes on of things I attempted to squeeze into 12 hours prior to my departure.

There were sundry, not-surprising, consequences of my procrastination. I always marvel at my inability to ‘travel light.’ I clearly do not need 5 pairs of shoes or 3 pairs of jeans for a 6-week trip; but in the frantic multi-tasking craze of last-minute packing, such decision are only allowed fleeting microseconds of brain time. Hence, I end-up with 2 bags to check-in, a weighty carry-on, and a ‘personal item’. Other sequela: my Zip-car was 2.5 minutes late; I missed my 11:45am train and paid an additional 120% to reschedule the train; my point-and-shoot camera was unwittingly left on my side-table; I still had a list of over 10 people I felt I should have called/emailed; and I felt incredibly worn after getting only 2.5hrs of sleep the night before.

Everything ended up all right in the end. The Acela was on-time and efficient; the train to Jamaica Plains arrived less than 15 minutes after getting to Penn station; I successfully hobbled my luggage up and down escalators and squeezed out of the super crowded Air-train to JFK; and Turkish Airlines was Terminal 1. All together door-to-luggage check in under 2 hours and 45 minutes!

I probably should not wait for a catastrophic consequence before I rein in my procrastination tendencies.

A-Roused!

2011-10-08T05:31:00.000-07:00

It has been 18 months, and I now have another life experience that is worth rambling about. It is not that the past year has been full of boring or less life-transforming events, but there is something about being away from routine life, being in an ‘exotic’ place that gives the opportunity to reflect.

I will periodically post about my experiences and impressions as my time in Kenya unfolds.

Tourism in the developing world- beneficial or exploitative OR both?

2010-03-16T14:42:00.000-07:00

Response to Josh Ruxin

It is quite an interesting article. However, I have several qualms and reservations.

Unfortunately, Ruxin makes a very common mistake we see over and over again with people who do development and international work. He is quick to generalize the Mayange experience and success story. If one looks hard enough, one can always find exceptional examples of success cases to illustrate whatever opinions one has, however deeply flawed those opinions are.

It is true that the Mayange people may have experienced a dramatic improvement in their lives as a direct result of opening up their village to tourism; this outcome is perfect and very welcome. But, can we 'learn' from the Mayange example and open up all villages to tourism? Are there some villages that would have very similar improvements as the Mayange? Certainly! But will all villages have such an outcome? What about the myriad of other things that are intrinsic to the Mayange that may have contributed to their success?

Ruxin rightly (wittingly or not) mentioned several elements that led to the Mayange success-- formation of cooperative, grass-root involvement of the villagers, good organizational structure, and reputable and transparent partners (Millennium Villages Project) to name a few. From my travels on the African continent, I think the Mayange example is a rarity and an exception. Many-a-villages in Africa are open to tourism, but with little to none of the crucial elements I listed above. The lodges and tours are routinely run by African elites and foreigners, not by the villagers. The villagers rarely have much of a say in any of the process, and very little of the money trickles down to the actual villagers, whose lives are being paraded. The story I hear numerous times is that the local chieftain gets a cut of the revenue, while the rest of the village remains in squalor. A documentary from a couple of years ago, Milking the Rhino, shows a contrast of different extremes of approaches to tourism.

I think tourism in villages is permissible under the right circumstances. Unfortunately, the ‘right circumstances’ are rare. Many visitors do not take the time or effort to seek out places like Mayange. Too many western visitors simply want to check off the “visited an African village” and “experienced the naked bush men” boxes on their ‘bucket-list’. On average, I think much of the tourism revenue makes a fraction of the impact in other villages as it has in Mayange.

Another fallacy Ruxin’s article propagates is that the presence of benefits obviates the possibility of exploitation. I will cite a few examples. A child laborer may be paid some money for their work (monetary and economic benefits to the child and family), but child labor is deemed exploitative. Trafficked sex workers may be given money or promised citizenship by their handlers, but we consider them as being exploited. In the same way, the improved economic standing of Mayange does not equate to the absence of exploitation. The more relevant questions are- “What is the cost to the Mayange people?” “Are they fully aware of the costs and benefits?” “Are they willing (without coercion) to trade these costs for the benefits?” Limiting the discussion merely to economic benefits misses the point.

The Cove

2009-08-11T21:01:00.000-07:00

Cove. n.

i) a small sheltered bay

ii) a sheltered recess, esp. one in a mountain

iii) a place to trap, maim and kill

I guess it takes a documentary as compelling as this one to resurrect my blog. The film is centered around the rather barbaric practice of mass dolphin slaughter in Taiji, Japan. From my random facts memory, I already knew that Japan was always smack at the center of any international dispute that involves fishing, whaling or preservation of ocean. However, I had no idea of the untold story of the dolphins.

Dolphins as entertainment in aquariums all around the world is a multi-billion, yes BILLION, dollar industry. An unfortunately perverse effect of the industry is the employment of reckless and unsustainable ways of obtaining the animals. Even more bizarre is the slow and prolonged killing process of the left-over animals, after the desired ones are sold. Imaging killing a 10 foot, 500 pound animal with repeated stabs using a kitchen-knife size blade; now imagine killing hundreds of them. Sorry for the graphic imagery, but I'm not making this stuff up. And worst of all, dolphin meat is not that desirable, even in Japan; it has toxic levels of heavy metals, especially mercury.

So why are these animals killed? First, nobody, well almost nobody, is aware of the practice. Also, the dolphin meat may be deceptively sold in place of less toxic and more desired whale meat. And, dolphin fishing is the life-blood of the Taiji economy.

The Cove is trailblazing; the movie is nicely done and is sure to stir emotions.

Please share your thoughts.

Unbelievably long hiatus!

2009-01-04T23:57:00.000-08:00

Happy New Years!

I will join in saying the cliche statement, "I can't believe it is 2009." It is a new year, but everything feels the same. I guess things should feel the same. The passing of time is all the same, it does not really change. We know the creation of different time measures is an artificial human construct. Enough rambling!

I have probably disappointed a few readers of this blog since I never finished chronicling my time in Uganda. My sincere apologies. I do understand some of the feelings you may have; I also disappointed myself. However, don't lose heart. Though I will refrain from making any promise, there may be some hope. I will try to round 0ff writing about Uganda soon.

I am not sure what for the blog may take this year but I will make you aware of my plans.

Thanks for reading

Even more pictures!

2008-11-30T22:37:00.000-08:00

At an orphanage in Kampala

Another Sipi falls picture

Ndere Dance Troupe weekly performance

Additional Pictures from Uganda

2008-11-24T12:15:00.000-08:00

Sipi falls in Eastern Uganda
Japanese tourists! Well, Yale residents behaving like Japanese tourists
Moi, doing some serious drumming

Northern Uganda Conflict 101

2008-11-24T12:01:00.000-08:00

Parts of Uganda have suffered tremendously over the past 20 years. Some areas in the North have been caught in the midst of conflicts between rebel groups and the government. Specifically the Acholi people have borne the brunt of much suffering. Rebels of the Lords Resistance Army (LRA) led by Joseph Kony have targeted the Acholi for a variety of reasons rather too complicated to delve into. Unfortunately, children have been major targets of kidnappings and recruitment into the rebel resistance.

Two weeks ago, there was a peace festival in Kampala. The festival was over two days; it showed documentaries about two major areas with persistent conflict, Juba and Acholi-land, and held spirited panel discussions on the issues. Only after the documentary, Uganda Rising, did I begin grasping the magnitude of the devastating impact the LRA has wrought. Estimates of almost 50, 000 children have been kidnapped, forced to fight in the army, subjected to sexual slavery and compelled to do horrible things like killing their family members to prove loyalty to the rebels. The bulk of the rebel force is now made of such kids whose innocence has been stolen away. They do not know any other way of life. It is hard to fully understand the poisoned framework of these children’s reality. The have grown up in constant migratory rebel camps in very harsh weather conditions in Northern Uganda and Southern Sudan. The primary mode of survival has been by the gun; they use it to raid villages for a means of survival, for protection and now for self-preservation.

In the mid 1990’s the government of Uganda in a proclaimed attempt to protect the Acholi, who have been subject to constant attack by the LRA rebels, forcibly removed the Acholi form their villages and ancestral land to Internal Displaced People (IDP) camps. In all, about 1.5 million people were moved. Unfortunately, though the proclaimed goal appeared noble, the reality was starkly different. The IDP camps comprised of huts in very close quarters; there was no provision of farmland or a means for income generation. Worst of all, security at the camps was non-existent, or at best very lax. These same people who were moved for security concerns were abandoned in concentrated camps where the rebels still easily attacked, maiming people and kidnapping even more children. An entire generation of Acholi is passing without knowing any peace, many are displaced from the ancestral lands, many have no skills and can not even farm, many have never worked, many have been completely reliant of foreign aid all their lives. Grown men lounge all day in IDP camps, they cannot provide for their families; they cannot protect them. Women suffer from abuses from their frustrated husbands, rebels and even government soldiers. Children are helpless; they are again being forced into local militias to protect their IDP camps.

Stories abound of the brutality these people have endured, lost limbs, machete scars, stub remnants of what used to be lips, noses and ears, and the unseen emotional scars. There are also stories bravery and the drive for survival in the face of daunting odds. There are kids who walk tens of kilometers daily to attend school. There are those who keep living with the scars even after losing most of all of their family members. There are the night commuters who, before sundown walk several kilometers from IDP camps to the nearest big city to sleep in shelters, verandas and street corners to escape the violence at the camps. There are women who are caring for their young children though they are products of a rape encounters. The stories of survival are loud but have not yet drowned out those of human brutality.

Today, the situation appears better. IDP camps still exist, though they were recently disbanded by the government. The LRA rebels are currently involved in peace talks with the Ugandan government. There is reported better security in Northern Uganda with the rebels currently in Southern Sudan, just north of the Ugandan border. Amnesty agreements have resulted in many rebels abandoning the LRA for reintegration into society.

One story of reconciliation resounds. The Acholi people have as part of their cultural traditions a reconciliation ceremony. Rivals from different clans or families, or outcasts traditionally underwent this public ceremony to make peace. This ceremony is used today to reintegrate former rebel militants into the community.

Quote of the day.

When a rebel is rescued, the government says an Acholi child has come home; when one is killed, they say we have killed a terrorist.

For more info visit:

www.invisiblechildren.com

www.ugandarising.com

…And the beat continued.

2008-11-19T11:51:00.000-08:00

Yesterday, 11:47 am, 6 year-old boy, TJ, died of respiratory depression. He was just admitted to the Cancer institute earlier that day. He had stage 4 Burkitt’s lymphoma. The tumor began in his jaw, 6 months earlier. It slowly spread from one side of his jaw to the other, then to other parts of his face. Unlike other cases of this type of cancer, his face was not grossly disfigured by a prominent mass; rather, he seemed to have generalized facial swelling. He had lost several teeth and his eyes were slightly more protruded. He had sought medical care, but for a variety of reasons, ranging from frank incompetence to the uniqueness of his presentation, his diagnosis was delayed. The oncology team examined him at around 11am that morning. He was found to have decreased level of consciousness, likely a result of metastasis to his brain. He also had involvement of his liver and spleen. We made a treatment plan and started him on IV fluids. At 11:42 am as the team continued seeing other patients on that ward, the boy’s mother called one the resident doctors to his bedside because his breathing seemed more distressed. All the resident could do was turn the patient on his side and watch alongside his mother as he struggled some more to breathe, until he stopped altogether; it was the end.

All the resident doctor and TJ’s mother could do was watch. This child was on a regular ward with about 15 other adults and children, many just as sick as he was. We did not have an oxygen tank close by, and with the limited resources, intubating or resuscitating him would have been futile. As everything unfolded with TJ, the rest of the team was about 20 feet away discussing another patient. TJ died, and other than the two resident doctors who were directly attending to him, no body else on the team seemed to acknowledge it; we kept rounding. The nurse isolated the area around his bed with a curtain. Most patients on the ward and their families understand the symbolism of the curtain; it is sometimes used multiple times a day.

Today, 9:25 am, 5 year-old, SE, died in his sleep. He had been on this same cancer ward for one week. He was diagnosed with ALL (acute lymphoblastic leukemia) with involvement of his spleen. He had very thing arms and legs but a distended belly. He looked quite stable 3 days previously and had been started on chemotherapeutic treatment. Yesterday, he had abdominal pain that worsened with motion and change in position, signaling a likely infection in the fluid accumulation in his belly. He looked jaundiced, very ill and had grunting sound with his breathing. He also had low blood cell counts and a fever of 40 Celsius. The oncology team re-evaluated him and decided on improving his pain management, giving him a blood transfusion and covering with antibiotics. SE’s father had been by his bedside all through his hospital stay; he was clearly becoming more frustrated as his son’s condition had progressively deteriorated while on admission. SE looked very sick and was unlikely in his current state to make it for much longer. Today around 8:45 am, four residents and I arrived at the ward to examine some patients. SE’s bed was right at the entrance of the ward, I was relieved to find him sleeping apparently peacefully; his blanket was being raised and lowered in a rhythmic fashion. He was still breathing. At 9:25, we were walking out of the ward as I took a five second glance at SE. There was no motion; “he must be fine; he was fine this morning,” I thought. I had greeted SE’s father earlier that morning as he stood over his son’s bed, he was again in the same position as we left.

A few seconds after walking out SE’ s father grabs me to come examine his son. I glance at him for a couple of seconds and again seeing no motion. I beacon to the residents, jointly we determine he is pulseless, with no breath or heart sounds and fixed dilated pupils. He is peaceful and motionless. We tell his father it was all over. He cries, sobs and thanks us for caring for his son. We get the curtain and isolate his bed.

These two stories have been my most direct encounters with dying patients. Sadly, both patients were very young, both had cancers and both had potentially curable cancers. Here in Mulago, death lurks everywhere. It is commonplace to find patients’ beds empty on returning to the wards in the morning. These deaths in absentia are much easier to accept; you come in the morning and go along with the tasks of that day. But how should one deal with deaths that one personally experiences during your day. Should one call off the day to mourn the loss of one precious life or spend only but a moment consoling the family and getting on with one’s day? Are we expressing contempt for life or nonchalance by not stopping to reflect with the passing of a life? Can one actually afford to be introspective or distraught with each death in a setting where deaths occur and are experienced multiple times a day? Ultimately, how does one maintain ones humanity while also keeping the necessary focus to get mundane daily tasks accomplished?

Many questions, many questions and no clear answers!

The End

Please take a moment to think about these two kids and many others who have died in Mulago without much notice. You can say a quick prayer for their families.

Quote of the day:

It has cost me 300 000 shillings on transport and medications. I have had to sell all the livestock I have. I am far from home and cannot work or farm to raise more money. Father of nine with a child getting cancer treatment at Mulago, about 500 kilometers from their home. (Many Ugandans don’t make 300 000 shillings in 1 year)

Some pics from Uganda

2008-11-17T10:15:00.000-08:00

Some lovely kids on my trip to Sipi falls in Eastern Uganda
Edge House. I stayed here for the first 3 weeks
Mulago Hospital. National referral center. I work here
King Fisher resort at Jinja, close to the source of the Nile

So you call yourself a man…

2008-11-17T10:02:00.000-08:00

I would not say I have given much thought to what makes the distinction between boys and men. I am sure some really knowledgeable people have spent their whole or some significant part of their lives studying and writing about the transition from youth to being a man.

You may ask, “Why write on such a random topic?” I will respond saying that the topic is really not that random. Just under 50% of the worlds population has to make this transition at some point, though much less spend more that a few seconds contemplating what the transition means. But, the real reason is to tell a story of what this transition means for people of the Sabin culture in Northeastern Uganda. These people live in a relatively rural district less than one hour from Mbale, a major Ugandan city. I heard this story about 36 hours ago from a 21 year-old Sabin man I will call Mr P. I will try to narrate as accurately as my memory permits and will take as little liberties as possible embellishing the story.

Here it goes.

There are three times in life when you have a big celebration: first, when you are born; then, your circumcision; and of course, when you die. We do not celebrate big weddings because they are expensive; not many people have the money to have a big wedding. Circumcision ceremony is a very important part of our culture and they mark the successful transition to being a man. You cannot be a man until you have undergone the circumcision ceremony.

The ceremony is performed on boys of ages 12-14. It is a community ceremony; I mean a big celebration that everyone attends. The celebration takes place once every two years and this year is a circumcision year. It usually happens in the month of December, starting from the first of the month till about the second week depending on the number boys participating from the town. Participants come from all over, even from the US so far as they identify with our culture. I hope you make it to see this year’s celebration.

The ceremony itself is just a culminating event; the process starts as much as one month in advance. Participants start traveling to personally invite all their relatives all over the country to the ceremony. The relatives in turn make gift promises of bulls, land, money and other valuables to be delivered at the ceremony. The next step is intense preparations by elders in the community. The participants are coached, and their readiness for the ceremony is accessed. Then, the boys begin a pre-celebratory period of 2 weeks. They have a very unique outfit and anyone would be able to recognize them when you see them around. Initially they wear the outfits only at night, but as the day draws near, they wear the attire even during the day, and during the ceremony itself. Their outfit comprise a T-shirt and shorts, two sashes made from bed-sheet material over each shoulder to the opposite waist, one sash used in a belt-like fashion across the waist, and beads along the neck and each ankle. They also hold on each hand a dancing ornament made from a special monkey’s tail; the monkeys are hunted specifically for this occasion.

The day approaches with surprisingly little fear and trembling. The night before the ceremony is probably the most grueling; the participants have to dance and prepare all night till the sun rises. The events begin shortly after sunrise. The participants clad in their outfits line up in an open area of town. They are cheered on by a multitude that includes their family members as well as other random community members; every one is welcome. The people who have honor to performing the rites are specially chosen and trained elders.

The moment of truth arrives. There is a stage where the elder stands; he backs the crowd about ten meters away. In turn, each participants walks to the stage with his own knife, looks at sun in the horizon, places both his hands on a stand at a level just beneath his breast line and experiences the ultimate act. The process takes about 3 minutes. During this time each person does not flinch, sob, cry or show any expression associated with pain, and keeps his eye on the sun in the horizon. After each participant the performer washes with soap and warm water and moves on to the next. During my time, we all had a successful transition. Then the big party began. Anyone who fails is called a coward, ridiculed and becomes an outcast for disgracing the culture. Usually, everyone is successful since there are various stages of screening to ensure that only people who are ready get to the stage.

There is no anesthesia or pain medication used in the process. There are only very few complications; some may bleed too much while others may collapse dues to exhaustion from staying up all night. Occasionally, health workers are available for people who may bleed too much, but we also have local herbs that help. Rich people may also buy some pain medication and pay for stitching. Otherwise, there is no role for health workers; they do not perform the ceremony. However, it is also well known that some elders may be bribed to allow a select few to receive local anesthesia before, but this is all behind the scene.

Circumcision is a vital part of our culture. You cannot become a man without undergoing the ceremony. You have to feel the pain that your father and uncles felt. Anyone who successfully goes through with the ceremony can defend his family and the community in the face of any obstacle. Even doctors have said that circumcision is healthy and it prevents the spread of HIV. I don’t look down on people from other cultures who do not get circumcised or are circumcised as babies, but for people from our culture, you cannot not do the ceremony. You will forever be a coward and cannot own much, hold an important position or have a voice.

The End.

Quote of the day:

I got the knowledge freely and I pass it on freely, or the knowledge dies and decays with you as you end up in heaven or hell, whichever is closer. Prof. B B. Infectious disease consultant at Mulago

Racial Profiling- Uganda Style

2008-11-13T12:15:00.000-08:00

Here is one of the highlights of this past week.

There is much positive talk in travel guidebooks and amongst other Muzungus (foreigners) here about safety in Kampala. You can walk around at anytime, even till mid-night and beyond, without feeling threatened. I can attest to the above sentiments; I routinely stay at the internet café till about midnight and occasionally even later before embarking on a 13 minute walk back to my apartment.

On Thursday, I left the café at 1 am. As I walked back home I saw a black owl, about a feet tall, on a street signpost. The post was about eye level; even though I walked on the far end of the road I was still less than 15-feet from the animal. The owl starred and twisted its neck about 180 degrees as it watched me walk by. Black owl, hmmm… probably a not-so-good sign.

Earlier that day, as a result of some changes in my living arrangements, I had moved to a new apartment about a block from my old place. On my way back from the café I decided to move a few last things; I had some clothes that I could not move since they had been wet from recently being washed. I put the clothes neatly in a small box that fit right under one arm and I had my computer bag around the other shoulder.

After taking a few steps outside the gate of the old place, a security/police officer walks up to me. I started chatting with the guy and told him I was moving; little did I know I was a suspect being questioned. The policeman had a huge gun, probably an AK-47 and a 6-foot long metallic rod; these accessories are routinely seen on security officers all over the city. The barrage of questions begun: “Who are you? Where are you from? Where are you going? What are you doing at Makerere University? How long have you been here? Why are you walking around at night? What are you carrying? Do you have any identification? What program are you with? ...” So I answer all these questions and explain that I just moved to the new place a few steps from where we were. Fortunately, I had both my Yale and Makerere IDs with me. I also had a flashlight, which I used to show him the clothes. He proceeded to checkout my computer; “How sure am I that you did not steal this?” I opened the computer to show him my name on the settings. All the while, I was going with the flow; I had everything he asked to see and expected to be ‘released.’

After showing him all the evidence that I was a foreign visiting student, –anyone would garner that fact from the different accent the moment I begun speaking to him –he decided I had broken the law. My offence was walking around Kampala past midnight. He went on to say, “I am sure you got a proper orientation when you arrived in Kampala, but you decided to do what you want. This is Uganda and that is the rule. I will have to take you to the station.” All the confidence I had till that point suddenly dissipated. What in the world do you do in the face of an unreasonable officer with a gun? I was utterly on the losing end of the exchange, and I could not run. I attempted appealing to his reason again, but it seemed to go now where.

So my options were going to the station as well as either paying a fine of 20K shillings or spending the night in detention. Either way, I still had to go to the station; there was no bargaining. I told him to get the police vehicle and take me there immediately so I could get the ordeal over. The cop says,” There is no car. You will have to carry your things and walk with me to the station. Also, there is no guarantee we would release you after you pay the fine. We may have to keep you for the night for your own safety.” I cannot remember my exact response, but as I simultaneously said a prayer, I responded in an irritated and firmer tone. Reasoning with this cop certainly could not get me out of the mess and I had had enough of the pushing around. I made it clear that my options were paying the fine or staying in detention at the station. I was not going anywhere until he was explicit that doing both was not an option. I was not in a position to make demands, but what the h#$%. Then I said, “Do you want me to call the US embassy?”

About 40 minutes had passed with the back-and-forth. I was done talking, the cop continued blabbing and 5 or so minutes later decided that he would let me go.

If I were white, like other Muzungus, would this cop have stopped me? Almost certainly not. Would he have let me go if I did not feign being American? Probably not.

It has not being much of surprise to me that white folks in Kampala are treated differently, as it probably is the case in many African countries as well as other developing ones. But, what continually shocks me is the lack of regard we show when we Africans treat one another. From these few weeks in Uganda, it seems if someone is not a family member, employing you, richer than you or a Muzungu, you have the license to treat him/her shitty. People care so much for their family members, but the idea of dignity for humanity does not extend to people one passes on the street, patients one treats in the hospital or other regular folks. I would dare say that our lack of respect for ourselves and others is a major obstacle that must be overcome for true progress. Respect for oneself would translate to having the same expectations from others and from the government. Having the mindset of self respect and dignity does not have any monetary costs but yet is invaluable; all the loans and aid from the IMF and World Bank cannot buy it. Our obligations must extend beyond immediate family to the nation and humanity at large.

It is unfortunate that Africans are treated as second class citizens in the West and even in their own countries.

The End

I still have other posts in the works; I’ll shoot for early next week. Other highlights of the past week: going on a Safari for the first time ever and seeing wild animals in the wild; my laptop dying, finding an Apple store and partially resurrecting the machine, and spending time on the cancer ward.

Quote of the day

“We have so many floor patients today.” 3^rd year Senior House officer at Mulago after a night of 70 admissions in the emergency department with about half of the patients with mattresses on the floor

The road to Kampala

2008-11-05T13:36:00.000-08:00

I am finally in Kampala, about 40 hours after leaving my apartment in New Haven.

My last day in New Haven passed by faster than other days; the day was on fast-forward mode. Hmm, may be it was because I was functioning on less than 5 hours of sleep, or because I scheduled 2 meetings at 8:30 and 10 that morning, or because I had left much of my packing till that day, whatever the case, I was doing something, or another non-stop till I left for JFK. At 11:15pm, I boarded Emirates’ Boeing 777-R.

I got to JFK at 6:20pm for an 11 o’clock flight; that was certainly the earliest I had ever been for any flight. I was so early that the check-in counter was not yet open. Well, I had decided to leave New Haven on 4 pm shuttle, because it was my first time taking this airport shuttle and I feared for bad rush-hour traffic. Thankfully, or not, there was absolutely no hint of any traffic delay. Even after what seemed like 50 stops at multiple shuttle pick-up locations, I got to the airport with almost 5 hours to spare.

So, I tried to occupy myself. I stood, resting on a beam, at the rear of the Departures hall- 6:40pm; ‘stole’ an abandoned luggage roller; stood and waited in-line as I watched the counter being set-up -7:00pm; # 3 on the check-in line; paid a $50 fee for being over the luggage allowance; and finally, checked-in my luggage- 7:20pm. I also had a chance to slip in a few phone calls here and there. After all that, I still had plenty of time to kill, and so decided to check and respond to emails. It took almost 10 minutes to find an electricity socket for my laptop. I found one and set-up shop on the floor along the glass wall of some fancy duty-free shop, about 6 ft from the entrance. I certainly wandered for a minute who supremely designed the airport and decided on the most appropriate, and convenient place to place electrical outlets. All that, and I still had 3.5 hrs to go. I paid for internet service, all of $7.95 for 24 hrs. Not too bad, I thought; but all I needed was 3 hrs, still not terrible. I checked emails, news, bank statement and update my podcast library. I made even more phone calls, grabbed a bite from Au Bon Pain and … continued killing time.

I finally arrived at the departure gate 15 minutes before boarding, I made even more phone calls, including one to disable my phone. During my last call, as I paced in an empty area adjacent to my departure gate, I noticed a gentleman fast asleep; I recalled seeing him earlier at the check-in counter. After a few shakes, he woke up; he was traveling on my flight. He was so grateful and he explained he had been traveling since 8am that day from somewhere in Canada (can’t recall where) on his was to Karachi and it was almost 11pm. You could certainly not blame the poor guy for dosing off.

I had not been on a trans-Atlantic flight in over 5 years. My first impression on entering the plane was: “Wow, this plane is huge.” 10 aisles of seats and God knows how many rows. We departed a few minutes later than scheduled, off to Dubai. My grand plan was to get as much sleep as possible and do one or two hours of reading. The flight was estimated to take 14 hours to get to Dubai, plenty or time to sleep. For the first few minutes, I could not help but continue pondering about being in the flying behemoth. Then, there was an onslaught of flight attendants; there seemed to be twice the attendant- to-passenger ratio compared to other flights I have taken. Also, everyone knows flight attendants are generally more beautiful than average; but both the male and female attendants on this flight were gorgeous, a good two standard deviations above average. Enough said on that.

Of course, my grand plans hardly ever work as expected. As I surfed through the media system to get some relaxing music to put me to sleep, I discovered the extensive selections of music, movies and TV shows. Before long I was watching Boston Legal episodes, then, Maid of Honor, Hancock and Vantage Point, and intermittently listening to UK top pop hits, Egyptian and Arabic pop music. Seven hours into the flight I finally was ready to sleep. I got a few hours; but it is never quite relaxing sleeping on any mode of transportation- plane, train or car. Then for the rest of the flight it was catnaps interspersed with random music.

My crazy flight itinerary had a 12 hour layover in Dubai; I did not have much control over this detail due to the last minute change I made to my ticket. I did not think much of the length of the wait until my arrival at Dubai since there was a note on my ticket stating that the airline routinely booked a hotel at the airport for people like me with long layovers. We landed at 8:30 pm at the new international terminal that opened that week. At Dubai, I tried to check into the ‘hotel’ only to find that the note I had read was a phantom. My options were to stay at the airport for 12 hours or apply for a visa onsite to enter Dubai and find a hotel. Since my sister, Fisayo, was in Dubai, I went along and applied for the visa so I could get a chance to visit with her. It was indeed the easiest visa I have ever gotten; the visa was processed in a few minutes, but the price was a couple hundred dollars of unanticipated expense. The immigration officer did not seem to care much; he was chatting on speakerphone with a friend while he processed the visa. I wondered how and why my prior application was rejected when I applied from home. About an hour after arriving in Dubai, I was in Fisayo’s hotel room on the outskirts of downtown Dubai. My taxi was a brand new Toyota Camry, so were the hundreds of other taxis I saw.

Dubai! I had always wanted to visit to experience the crazy developments from the past few years. Now all I had was about 11 hours. I would have loved stay longer, but was unwilling to make more changes to my itinerary and incur further charges. After some late night Indian food, Fisayo and I took to the road. I tried to take in the nightglow of lighted skyscrapers, cranes, store signs. Fisayo, had not been impressed with the city thus far. She had been there less than a week and had much to complain about –the difficult navigation of the highways, excessive use of the word ‘luxury,’ the crappiness of her $400/night hotel, the vast gulf separating the rich and the poor, the overdependence of the country on expatriates… to name a few. I did not sleep that night; I stayed up to watch the third Obama vs McCain, which started at 5:30am. Unfortunately, I had to leave again for the airport before the most interesting parts of the debates.

Off I went enroute to Kampala. The plane was much smaller; it was an Airbus but I forget the exact specs. Another notably difference from my prior plane was with the media options and interface; it was much more primitive. I had little choice but to get my well needed and deserved sleep. I again had a short stop in Addis Ababa. My neighbor on the fight was a Kampala shoe-trader returning from a business trip from Dubai. He seemed to be just as tired as I was and slept most of the way.

The most exciting thing on this leg trip was during out stop in Ethiopia. The stop was for a little over an hour; we offloaded over half of the passengers and had a handful of new ones. While waiting on the plane there was another Pakistani gentleman, sitting two aisles away from me, who suddenly burst into loud singing in some unknown language as he listened to music on his earphones. He then removed his earphone and tried to explain to his neighbor that he was singing a beautiful song and wanted to share it with everyone since he had one of the best voices in the area he grew up. I am not quite sure who deceived this poor guy, but I certainly can sing better than him and God knows saying I have a bad voice is a gross understatement. Anyways, almost everyone within hearing distance of this man flashed him horrible looks, but he kept singing away. I had to explain to this guy, who was now quite annoying, in as kind a front as I could muster that not everyone understood or really wanted to listen to what he was singing. He was actually quite grateful and apologetic. He was intrestingly oblivious to the idea that he may have been disturbing.

In a few hours after leaving Addis Ababa, we were descending towards Entebbe International Airport. I did not have any explicit expectations, but was quite surprised at how small the airport was. The plane taxied to a stop and stairs were rolled up to the door. We descended to the asphalt, walked to the terminal gate and were greeted with a nice air-conditioned room with countless signs of Barclays in blue lettering. The interior of the terminal was also small but had a about a 20 year more modern feel compared to the exterior airport façade. Going through immigration was very smooth and quite straight forward considering one of my luggage was an ugly light-blue glorified garbage container box with a red lid and signs saying Remedy plastered on all the sides; it contained medical supplies. I had a middle-aged man carrying a sign with my misspelled name on it; and off to Kampala I went.

Congratulations all on President elect Barack Obama.

Quote of the day:

Democracy and capitalism are the two great pillars of the American idea.

To have rocked one of those pillars may be regarded as a misfortune.

To have damaged the reputation of both, at home and abroad, is a pretty stunning achievement for an American president. – Boris Johnson Mayor of London on President Bush.

If you actually read all my ramblings above you deserve a price. I have not been able to post as frequently as I want secondary to my laziness, long days at work and inconvenient internet options. More posts are in the making: A day in Kampala, Mulago (the hospital I work) introduction, and Muzungu (Lugandan word for a foreigner or White person) or Not…

My first post...

2008-10-24T00:51:00.000-07:00

I have finally overcome the hurdle of actually starting a blog.

It has been 7 days since I arrived in Kampala, Uganda; a lot has happened and I have a lot to say... but I don't have much to post today. I typed out some potential posts on my laptop, but for some reason I cannot connect with it to the Internet today... and I am too lazy to re-type out on another computer.

Here is what I have been up to in a few lines-

I arrived last Thursday and slept for most of the day. On Friday, I got some orientation to Mulago hospital- where I work. For the weekend, I travelled with other fellows in my program to Jinja (2nd or 3rd biggest city in Uganda- depending on where you look). We visited in source of the White Nile and, yes, went white-water rafting on the Nile. This week I started work on the gastrointestinal service at the hospital.

More detailed posts and pictures to follow...

Quote of the day:

"You are not here to keep patients alive.
Yous should try your best to keep them comfortable.
It is not you who is killing them, it is their disease." -Nephrologist @ Mulago Hospital