The Road to Kilimanjaro

I am writing this from Moshi, Tanzania, a small town at the base of Mt. Kilimanjaro. Well – let’s be honest:  I’m lying in a twin bed, encased in mosquito netting, reeking of DEET, being meticulously watched by two rather odd looking Daddy Long Legs who are currently holding court on the ceiling.   

There’s a daily shuttle that runs from Nairobi to Moshi via Arusha.   We were (barely) on the shuttle by 8am, and on our way by 8:30.    The ride was advertised as a six-hour journey (insert Gilligan’s Island theme song HERE), but that time estimation clearly doesn’t take into account potholes or roadwork.   Let’s put it this way – we arrived in Moshi shortly after 5pm.   It was a long day.

You know that moment when you get on a bus – or a plane – and it looks for a few minutes like…just maybe…no one will sit next to you?   You get that unbelievably righteous “Thank God…I deserve this” feeling.   And as soon as you get it, someone sits down!    That’s what happened at 8:25.   A very pleasant-looking but also very large Muslim woman with a beautiful head covering sat down next to me.    It was fine…until I inhaled.

WOW.

My nostrils went on an instant strike.

The smell was terrible.  

How could this beautifully dressed woman have such a stench?

Part of me wants to spend a year going door to door in Nairobi, dropping deodorant on peoples’ doorstops. 

I turned my head to face toward the window, hoping to avoid any airflow from her direction.   It worked a bit, but I couldn’t sit like that for a six hour drive!   Talk about a neck cramp!

Dami saved me 20 minutes later.   We stopped and a hotel for an additional passenger, and she immediately asked the smelly woman to trade seats with her.  I am forever in Dami’s debt for instantly putting my nose back in business. 

The rest of the ride was thankfully relatively stink-free.

With the exception of the distressing moment when I realized there was no bathroom on the bus, the first two hours of the drive were relatively uneventful.  

Looking out the bus window, I felt remarkably like I was driving through the middle of Nevada.   Well…Nevada with the possibility of seeing giraffes and zebras.   

The ground was dry and dusty, and tufts of small brush littered the ground.  

But the birds!   I’m not much of a bird person, but every bird I saw looked like it had just flown straight out of an imaginative child’s coloring book.     

They’d perch on the flat-topped acacia trees that would appear every so often. 

As we drove, the acacia trees became more and more frequent – to the point that the view looked like God had reached down in a moment of frustration with a giant machete and cut off the tops of all the trees with one quick swing.  

Why this visual popped into my head I’m not really sure, but as I was thinking it the shuttle lurched.   We’d hit a giant pothole.  

It was about this time that the roads really started deteriorating.   Every few miles, we’re run into a giant cement pipe lying in the middle of the road next to a hand-painted sign reading “DIVERSION.”   The sign was invariably tilted, as any good sign should be, at a 45-degree angle.  

Well put.

The road would end, and we were relegated to using a side dirt road for up to many miles at a time.   If the whole thing wasn’t so entertaining and the scenery so fantastic, I’m sure I would have been ill.

After about the third hour, we started seeing Maasai.   

Intellectually, I know that the Maasai exist and that some still live in tribal conditions, but I guess I didn’t really believe it until I saw it.   As we drove, we started seeing tall, spindly-looking men with shaved heads wandering along the side of the road, following herds of goats, cows and donkeys.    

On their feet were straps attached to what looked like pieces of tire from a golf cart.  

They walked with a slight bent, and most had silver dollar-sized holes in their earlobes.   They were wrapped in brilliantly colored sarongs, and had equally colorful scarves wrapped around their shoulders.  

Each man carried a bamboo walking stick – sometimes tucked behind one arm, sometimes carried behind theirs backs as though they were hanging from it.   The sticks came in handy – if a goat stepped away from the group, the stick would wave in the air until the goat stepped back in line, looking as guilty as a goat can. 

What was amazing was how far from anything we would see them.   These men were miles from anything, and I can only wonder how many miles they cover in a day.

Not all that much closer to the village “centers,” we started seeing some Maasai women.   They walked along the side of the road, too, but usually in pairs (as all women prefer to do).   Large baskets or buckets sat perfectly balanced atop each of their heads.    Most of these women also kept their heads shaved, and nearly all the women had so many ear piercings, so much jewelry and beading hanging many inches from every bit of their ears, it made western women with two or three ear piercings seem ridiculous.  

I snapped so many pictures out my window that I think I drove the rest of the bus crazy.     

By 1pm we reached the Tanzania border.   Getting out of Kenya was no big deal, but once we drove through, quite literally, the big steel gate that marked the entrance to Tanzania, things got weird.

At the immigration office, we got in line at the Visa Application counter.    An angry looking man sat behind the glass who would bark every so often at his colleagues.  

Dami presented her Nigerian passport, and was told that the fee for an entry visa was $50.    $50?  

All the guidebooks said that the visa would cost between $20 and $40.

Emily and I felt badly for Dami – sometimes presenting a Nigerian passport can be problematic and cost extra.

Then Emily and I went to the desk.   The angry man told us the fee would be $100 per person.   WHAT???

Oh – and it had to be in cash, using only US Dollars, and the Dollars had to have been issued no earlier than 2004. 

WHAT?????

“No,” we said, “we only want a single entry visa.”

“No – you get a multiple entry visa.   $100.   US Cash only.” 

The immigration office wouldn’t even take the local currency!

I could feel my blood beginning to boil.

The cost was probably really about $20, and the additional $80 was likely just the requisite tax on being American.   This is a tax that I’ve come to expect, and the tax rate varies by day and depending on the person overseeing the transaction.

I hate feeling powerless, and yet I really had none.

Thank God I had a stash of US currency with me.   I’m not sure what would have happened if I’d shown up with only local currency. 

We handed over $200.   What we got in return were our passports back, and a regular stamp on our passports.   The $100 bought us some chicken scratch next to the passport stamp that said something about it being good for one year.

By the time I left the immigration office I was so angry I could hardly see straight.   But there was nothing to be done, and I had to force myself to let it go.   In the scheme of a large trip like this, $100 is nothing.

Hey – at least they let us into the country. 

We still trudged back to the bus looking and feeling rather defeated.

The terrain changed significantly once we crossed the border.   The scenery became much more lush, much more mountainous.   We continued seeing Maasai all the way to Arusha, and on occasion were able to glimpse their living quarters – small stone or mud huts. 

I was expecting somewhat expecting Arusha to be a booming metropolis.   I feel like I hear enough about it that it would at least have a couple large buildings.

I was very wrong.

When we first pulled into Arusha, I thought we were driving through a slightly larger village than usual.   The main road was paved, but everything else in sight was dirt, and there were dilapidated shops built from old pieces of aluminum siding along the road.   Ads for Kilimanjaro and Seregeti Lager were hand painted on everyone building, and palm trees were everywhere.   I almost felt like I was driving through Central America. 

It was Dami who first saw a sign indicating that we had arrived in Arusha.  

I was shocked by how underdeveloped things were in the city.   People were everywhere, though, and they were a mix of women with baskets on their heads, men in Maasai sarongs, muslims, and people wearing T-Shirts and jeans. 

We stopped briefly in Arusha to drop some passengers, and then continued on to Moshi, a smaller town located at the base of Mt. Kilimanjaro. 

It was cloudy, but 15 minutes outside of Arusha I realized that the large dark cloud in front of us – that seemed to take up the full horizon – wasn’t a cloud at all.   It was Mt. Kilimanjaro looming over us.

It was a weird feeling – it’s something I’ve wanted to see for years  - and to suddenly know that it was right in front of me, to FEEL it in front of me and yet not be able to see it – shook me a bit.

Kilimanjaro rises nearly 20,000 feet in the air, and it has a more authoritative and commanding presence than any mountain I’ve visited.   

I kept hoping that the clouds would clear so I could get a good view, but I was short on luck.   I could only see the bottom, but even the bottom revealed its enormity. 

We arrived in Moshi shortly after 5.   It’s a small, run-down town, the center of which is marked by a 20-foot Clocktower that prominently displays the words “Coca-Cola” on each of four clock faces.

We checked into the Kilimanjaro Crane Hotel – it was $55 for a room with three twin beds, mosquito nets, and a continental breakfast.    We were exhausted, but not so exhausted that we couldn’t go for dinner at one of the local recommended restaurants.    We dined at “El Rancho,” which, naturally, serves exclusively Indian food.

Riiight.

And now we’re off to sleep.    The goal is to get up at 5:45 to see the sunrise over the mountain.   Hopefully we’ll be able to see it!  

$32.00

It’s good to know that morning rush hour traffic is universal.  

8am marked the start of a University of Nairobi Medical School class called “Complications of Type II Diabetes,” but the professor didn’t show up.   She was stuck in traffic.  An announcement was made that class would instead be held at 11am, and no one seemed terribly fazed by the schedule change. 

With our sudden free hour, we went up to Ward 8B – the Adult Internal Medicine ward – where Mercy is currently doing a rotation.   Dr. Clara, the Intern on duty, quickly took us around the ward and debriefed us on each admitted patient.   There was some pretty gross stuff, I have to say, but we all managed.

We stayed for full rounds, and one thing in particular sticks out in my mind.   One of the many patients we saw was in end-stage renal failure.   
The resident leading the rounds explained that the woman couldn’t afford the dialysis she needs to stay alive.   I asked how much dialysis cost, and the answer was approximately 3000 Kenyan Shillings (KSh) three days a month.   

That’s about $32.00.
I had about twice that amount in my pocket at that very moment.

IN MY POCKET.

The realization made me cringe.
Of course, even if I paid for the dialysis on the spot the same problem would arise next month.  What’s more – that wouldn’t be fair to the other patients, who no doubt have equally important needs.   So handing over what was in my pocket felt wrong and almost demeaning to all of them.  

The woman is dying.   

The doctors are just managing her pain for now, but clearly not very well because silent tears streamed down her face the entire time I was there.
To make things worse, her family has stopped coming to see her.   They apparently know that she’s dying and that there’s no hope, so they’ve abandoned her for all intents and purposes.
Good God.
I found the whole thing very difficult.   Of course – who cares if its hard for me – imagine how hard it is for the patients, and the people who deal with this and suffer from it every day.

Meanwhile, today we had to register our phone and internet SIM cards.   Kenya has this crazy new policy in place where, when you buy a SIM card (one is necessary to use each cell phone and each Internet modem), you have to register it within 7 days or it is automatically shut off.  “Registration” involves going to an authorized dealer – like a Verizon or AT&T store – presenting a photocopy of a drivers license or a passport, and filling out some paperwork.   Of course – this process isn’t posted anywhere.   You’re supposed to “just know.” 

Its one of those things where you show up to Register and they say “oh by the way – we need your passport.”   And when you present your passport, they say “oh – but actually we will only take a photocopy of your passport.”   “Do you have a copy machine?”  “No.”   Riiiiight.
All of us had to register both of our SIM cards by COB today, or they’d be shut off.

The other thing I wanted to do today is get a TB vaccination.   TB Vaccinations are standard issue in Africa for babies born in hospitals, and most Africans have little round scars on their forearms to prove it.   As over-vaccinated as we are in America, for some reason the TB vaccination is left off the list in the offices of American pediatricians. 

Given that we’re spending our days interacting with numerous patients hacking and coughing TB germs, I really want that vaccine.

I had asked for the vaccine at the hospital, but was told that anyone over 5 years old could only get the vaccine at City Hall.

City Hall?

Emily and I took a cab downtown, and found the “Innoculation Office” at City Hall where supposedly you could get vaccinations.   
I asked about the TB vaccine, and the guy behind bulletproof glass looked at me and said, “you’re supposed to get that when you’re a baby.”
“I know,” I replied, “but they don’t do that in America.  That’s why I’m here.  I want it.”
“We don’t have that.”
“But the people at the hospital told me you did!”
“No.   Have you tried the other hospital?”
“No.”

D’OH!
There is no such thing as a simple process in Africa.   NONE.
So I still don’t have my vaccine.

From there we registered our phones, which was a whole other NOT-simple process, and then we had a beer at a downtown trattoria.   The local beer here is called “Tusker,” and the logo involves a large elephant.   It’s not bad!

I picked up a newspaper – everyone here is buzzing about the upcoming election on Wednesday.  Today’s headline reads “Green vs Red is Obama’s New Headache.”

Kenyans are convinced that the Obama Administration is funding one side of the major election debate.   Who knows.

Tomorrow we take an 8am shuttle to Arusha, Tanzania!   The ride will take about 6-7 hours, but I can’t wait.    It should be a gorgeous drive.   Our hope is to see both Mt. Kilimanjaro and Oldevai Gorge over the weekend, as neither is terribly far from Arusha.  

Wow.

I GOT TO HELP DELIVER A BABY TODAY!!!!!!
AHHHHHHHHHHHHHHHHHHHHHHHHH!!!

It was so amazing.   
I almost started crying.

What a feeling.
It was a C-Section, which amazingly I didn’t find gross in the slightest.   We lifted the baby girl out – she was only at 32 weeks - and I think I had my jaw on the floor.
I’ve never been so in awe in my life.
She started crying within 30 seconds, and for some reason they let me determine the APGAR score (as the doctor put it – “we don’t have litigation here, so you may as well go for it.” ) They handed me a stethoscope and taught me how check the little thing’s heart and lungs.

I’m on such a high.
The craziest thing – we didn’t have any lights in the operating room or the adjacent rooms.   And yet it was the first time that I could actually see why people DO this – come down here to the Third World and work in situations with virtually nothing. You can still make it work as long as you’re resourceful, and doing so successfully feels AMAZING.  

Untitled

First day at Kenyatta National Hospital. The smell is sour and distinct. The building is a dull gray and the lights are dim. The patients are desperate. The day was spent in the pediatrics department that consists of four separate wards. Mercy has suggested we spend most of our time here because it is the most organized of all the departments. That is, as organized as could be while maintaining nearly double the capacity of beds and operating completely on a system of paper records and steno pads.

And then there's Isaac. Isaac is one of about 25 children housed in the pediatric oncology ward where we spent some time entertaining. He is about 4 years old and hops around on his remaining leg. I spoon fed him some saucy mystery meat and rice and then he fell asleep in my lap. He stood out in the room because of an unusually kind smile but the reality is that each child shares a similar story. Heartbreaking.

Day two brought a little more comfort but no fewer challenges. I spent the morning in ward rounds in another pediatric unit including the acute cases. The overcrowding was no less than Mercy had described. The mothers are living in the hospital right along side the children. In one case, there were two adjacent beds that housed mothers-to-be, in addition to their already severely ill children. And I literally mean “housed”. These families are living here. The cart comes along in the morning with some sort of slop and a piece of bread. And it is carefully rationed. It's too bad the little girl in the hallway barfed all of hers up because she won't be getting more. And then there was the puke trail that made it's way into each of the units because nobody even noticed that the little girl lost her breakfast. I should have been disgusted but I laughed really hard. I hope that's not insensitive. Coping, I guess.

Dami and I were together for the day and in hindsight, thank goodness. We were standing in the back of a group of students while a festering IV port had to be removed. The child was screaming and writhing, making the process much worse as the needle tore through his skin. I looked at Dami and she was clearly upset but said she'd be fine. I was doing pretty well, just shivering a bit because they keep all of the windows open. I suppose the alternative is to have TB floating around in confined areas. At least now it floats around, then floats out the window. I hope I don't get caught in the crossfire. Anyway, I was cold and I looked to Dami and sweat was beading down her face. She left the room and I later found her in the staff room. A short pep talk was all she needed and we were back at it.

The afternoon was spent in the lecture hall with the medical students for “grand rounds”. That includes a presentation about work related stress (ha. Really? You're telling them now?) and a lecture on a case of tumor lysis sydrome. Thanks to a biology class and a minimal histology/pathology background, it made a surprising amount of sense.

And now I'm exhausted. Since I arrived in Nairobi and as of today, I hadn't spoken to my mother. We connected for only a few seconds before my cell phone time ran out. Shoot. Most know by now that she was diagnosed with breast cancer just weeks ago. She goes in for surgery the day after tomorrow and I think about her constantly. I would brave all the TB, malaria, and meningitis in Kenyatta to make sure she's ok. Miss you mom.

Hospital Smell + BO = Wow

First day at the hospital today and I think my brain might explode.  

The morning began at 8am.   Decked out in white lab coats (and admittedly feeling rather pleased with ourselves), we made our way up the stairs to the fourth floor to the pediatric ward (the elevators are apparently a little sketchy).   There, we met Mary and Margaret, the two nurses who serve as Pediatric Department Heads.    Mary sat behind a large wooden desk in a room that was clearly once an exam room.   A rotary phone sat in front of her where I would have expected a computer to sit.    Margaret sat across from her flipping through steno notebook.  Handwritten in the notebook was a list of patients currently on the ward, and what was scheduled for the day.
Mary and Margaret welcomed us to Kenyatta, and told us a bit about the pediatric unit.   
The unit was built to accommodate 60 patients.   Yet, at the moment, they have 93 admitted children.   Many of the admitted childrens’ mothers are also living on the ward, as they can’t afford a local hotel.   So there are approximately 180 people living in a ward built for 60.    How do they deal with this?   They have, in many cases, two children to a bed.
What’s more, there is a policy in place at Kenyatta Hospital that doesn’t allow patients to be discharged until all hospital bills have been paid.   Naturally, being a public hospital in Nairobi, many patients have no money to pay the bills.   Amazingly, the hospital’s solution is to keep the owing patients at the hospital.   Apparently there are women living at Kenyatta, admitted during childbirth and unable to pay the bill, whose children are now 2 and 3 years old.   Imagine that – having a baby at a hospital, not paying the bill, and being forced to stay for years.  
Some of these mothers, so desperate to leave, will try to escape by literally jumping off the second and third story window ledges with their babies.  
Other mothers – even mothers who are able to pay their bills – strategically choose not to, aware that their children will be forced to stay at the hospital.   Their strategy is to keep the children at the hospital until they fall ill again.   It’s quite a cycle – one that keeps the children fed and house, and keeps the mother unburdened by the child.
The tragedies, inefficiencies and costs associated with this boggle my mind.

Mary and Margaret took us to spend the day in Pediatric Oncology, but we managed to get a tour of the full pediatric ward on the way.    At pediatric emergency, the line was out the door with people waiting to have a minute at a window marked “Pay Here.”    The pharmacy next door was the size of my closet in Alexandria, and yet when I looked in it only one wall contained shelves of medication.   It struck me that the amount of medication was roughly what you might find in the medicine cupboard of the average Washington DC hypochondriac.   

We then toured the pediatric outpatient unit, where, at one point, the power went out.   The outage seemed to phase no one but us.

Finally we landed at Pediatric Oncology.  The room was about the size of a New York City loft, and steel frame beds straight out of the 1940’s lined the walls – each about three feet apart.   The mattresses were no more than three inches thick, and were covered with plastic and a thin sheet.  A few children were in their beds, and a few doctors huddled in the back of the room.   The rest of the children were gathered in a small room off to the side – in what appeared to be the playroom.   The playroom contained no toys, 22 children, about 15 child-sized chairs, two lunch tables, and a pile of the small mattresses stacked to the ceiling.   
Since no one appeared to be running the unit, and our arrival was unacknowledged, we took it upon ourselves to go play with the children.   They greeted us with excitement, though most of them spoke only Swahili.   Two were not only blind – they appeared to not have eyes at all.   Another clearly suffered from gigantism, and another only had one leg.   All, we assumed, also had a form of cancer.   
The children were entirely unmonitored for the first thirty minutes we were there.    We were shocked by the lack of structure and supervision.   Shortly before noon, a woman in an apron, who spoke only Swahili, appeared with a large tray and a stack of metal plates.   On the tray was a large pan filled with rice, and another large pan that was filled with what looked like beef stew.   Next to the pans was a plastic bag filled with foul smelling cream.  
Each child was given a ladle full of rice, a ladle full of stew, and some cream.   Nothing was provided to drink.
The woman motioned for us to help feed the children.   We did.

We stayed another thirty minutes and left for lunch.  
It was at this point that we realized that not once all morning had we seen anyone wash their hands.   Having just left the children, we all desperately wanted to give our hands a good deep clean.   We found the nearest bathroom, but there was no soap.  
Distressed, we used some hand sanitizer Dami had in her purse.   We were grateful she had thought to bring it along to the hospital.   Tomorrow we will all carry some in our pockets.

The afternoon was spent sitting in on a pathology class with the crew of third year medical students from the University of Nairobi.   The lecture was 2 hours long, and taught by a Kenyan version of Ben Stein.  

I could go on and on – about how different, how shocking, how sad the conditions at East Africa’s largest and most well-known hospital are – but I’m still trying to process it all in my own mind.  
Tomorrow we go back to Pediatrics, and will map out with Mary and Margaret how we can make the best use of our time at Kenyatta.  
I’m actually very much looking forward to it.  

Pillows Are Lifesavers

I have a pillow!
Thank God for the grocery store that sells pillows.   I've never been so excited to purchase a pillow in my life.   I slept, and life now looks much better.

I have coffee, corn flakes (with milk from a bag), and we're off to our first day at Kenyatta Hospital.

Little Critters

I'm sitting up at 3:27am because I'm worried that the large quantities of blood and vomit that they warned us about at the hospital will seep into the shoes that I brought. That and there is a big crack under the door of my bedroom leading to the balcony where I fear the cockroaches are getting in and are going to crawl all over me. We put the piece of foam from under the hot dog mattress on the floor and it's SO much more comfortable but now I'm worried about the roaches. Then my mind started to wander about the skeeters that have been buzzing around my ears for the last hour. The girls have talked about the countless malaria cases they see at Kenyatta although this is not an endemic area. So who's to say I won't get malaria? The doctor said not to take my pills yet.

So I got out of bed to at least do some writing while I freak out and the first thing I see in the kitchen is....wait for it....yup....a cockroach. I nabbed it with a dishtowel and decided to forego the midnight snack. On my way out of the kitchen, another little bastard was greeting me right in the doorway to the living room. I'm not sure what my deal is. I was so ecstatic to sleep on a flat bed and sleep through the night and here I am with my eyes bugging out of my head. Geez, I really need to toughen up. Alright, must sleep. Oh yeah, and PS. Mom don't worry. I'm sure I'll be fine.