The daily trek form Kilimani to Mbagathi

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?

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

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!

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?

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

Cove. n.

i) a small sheltered bay 

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

OR 

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!

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