I sortof ambushed Dr. Mamlin the other night, just before dinner- he's so busy running a compound and a blossoming health system, it seems to be the best way to set up a meeting.  He was on his way to feed the dogs prior to dinner, when I stuck out my hand to finally introduce myself.  Eating dinner together and discussing the Turbo experiment, he commented on me being a “hearty eater.” Given he’s from the Midwest, that probably means I was eating quite a lot.  It was about double what he had on his plate.  We spoke about Kelvin's, Otunga's and my visit to Turbo, and the potential points of failure in our setup. The clinic patients on the ministry side are treated sortof the way we the uninsured or those without primary care in the ED; it is simply episodic care, without any longitudinal follow up. Once the patient is treated, whether for malaria or acute HIV, the record is purged, and whatever chest x-ray taken as part of the visit is looked at by a physician’s assistant, never viewed by the eyes of a radiologist.

The goal of AMPATH is to change this model, offering longitudinal care which began as an HIV focused effort, now expanding to cover chronic conditions such as diabetes and hypertension.  Dr. Mamlin is concerned, because of the political and financial rift between the AMPATH and the Kenyan health ministry side, that our project may suffer from apathy, passive aggression, and failure.  We discussed possible solutions for problems which one could anticipate in the current environment. 

My other project is off the ground, and will need to be nurtured by the current registrars.  Since I wanted to have an image guided procedure focus, I strove to identify the barriers to providing image guided procedures, such as guided biopsy, drainage, and nephrostomy:  safe, effective and potentially cost- effective treatments for which there is a burgeoning need.  Currently, donated devices are pieced together for each given request.  

Our last patient for nephrostomy was extremely thin, and therefore the 7  cm access needle we had was adequate; however, a larger patient would not be able to undergo the procedure due to this limitation, despite the numerous locking catheters I brought. 

Since there is no consistent IR supply through MTRH, patients must have another option if these services are to be offered.  Orthopedic hardware, such as a hip replacement are stocked by pharmacies, so that patients who can afford it may buy it.  Our thought is that a similar setup could work for IR devices. So, I’ve e-mailed a number of distributors and am in the process of getting sample prices for the most important devices, including centesis catheters, guidewires, locking catheters, and biopsy devices, so that the registrars may pitch these devices to private pharmacies in the area.  Thus, patients who can afford the materials may purchase them, and the pharmacy can make a buck. 

Coming here, I heard the advice that one should pair up with a Kenyan counterpart to be most effective, and this fortunately happened for me quite easily.  Cornelius, a “part II,” or second year resident interested in interventions is the go- to  registrar for these kinds of procedures.  We got along seamlessly, and understand each other implicitly.  Over the course of the month, we’ve made a pact to get a consistent procedural service going at MTRH.  Since Cornelius plans to stay in Eldoret indefinitely, he also happens to be the person best poised for making progress in the department to this end.

Saying “kwa heri” to everyone in the department  was a several day process.  We had a dinner last week, when Val and Marc were on their way home.  We all went out to the edge of town for some nyama choma, or roast meat, the quintessential Kenyan meal out.  We had kilos and kilos of various kinds of meat, traditional greens, a mashed potato/ greens mixture, salads, chapati, and ugali, a tastless cornmeal I avoid, but is considered by most Kenyans a staple.  We got the registrars token gifts: jewelry for the female registrars, who are the majority, numbering 5 of a total 9, and stuffed animals for the guys, as they all happen to have multiple children.  We were showered with gifts, each receiving a soapstone sculpture from Dr. Abuya, from his native region, Kisi, as well as scarves, a dress for me, jewelry, paintings, and cards signed by all.  Everyone took turns to say what the visit meant to them and to thank us for visiting and contributing to the department.  It was truly touching, and we felt so appreciated.

Monday night, I was invited to Agnes’ home for dinner, where I spent the evening with her, her 3 children, and her housekeeper.  Her husband works in another region, hours away by car, so the family reunites on the weekends. It’s surprising to me how common that setup is in modern east African society.

I’m finally on my way homeward, and got a couple of marriage proposals in Nairobi today.  My driver gave me the hard sell all day; he only has one wife and one kid, and “wants a mzungu wife” because he “hears it’s nice.”  Despite awkwardly having to decline his offer, I had a great time seeing the National Museum, including the Hominids Exhibit, seeing the slums of Kibera west of town (life altering to see) and finally, having some more nyama choma and my final dose of Redd’s, a Tanzanian cider, while watching various Olympic events at a local pub near the airport with my driver and his friends.

There were hundreds of schoolkids at the museum today, all visually grouped by their uniform patterns.  Three beautiful little girls in uniform, probably twelve years old, all with buzzed black hair, came up to me while I was looking at some ancient skulls.  They wanted to shake my hand and say hello, as I was maybe the first mzungu they had seen.  I’ve become accustomed to this, and enjoy greeting them like they’re my new little friends.  These girls were not shy, however, and after shaking my hand reached up to feel my hair!  Two of them stroked the front of my head, smiling and saying, “smart!” which people use here in the British sense, meaning nice, pretty, what have you.  They got really excited, giggling and scampered off to join their group.

To anyone considering a trip to Kenya, it does not take much effort to gain kudos and appreciation for effort in learning Swahili.  Just a few words was enough to prompt people to ask where I was from, how long I was in Kenya, and when I will be back.