I'd like to note

Growing up in California, I never had the snow days you see in movies, where kids anxiously listen to the morning radio for school cancellations and then joyfully bound outside to frolic and sled before coming home to a warm mug of cocoa.

I don't think many Kenyans have had this experience either, though last night I had dinner with someone who's school had been cancelled due to "lion in the yard."


The food in Nairobi, particularly the variety, has been much better than I probably would have expected (if I had had much time to develop expectations in the whirlwind before I left). And, as I like food, I'm keen to tell you all about it and post delicious pictures. Yet that seems irresponsible, not to mention insensitive, in the face of multi-national famine and drought in East Africa (the worst in 60 years). The areas of Kenya that have been most severly affected are in the north, bordering on Ethiopia and Somalia. This includes the Marsabit vicinity, which is where I will be working in October-December. That area has been assigned the UN food security classification "Emergency," which falls in the middle of the scale between "Crisis" and "Famine."

I'm currently fielding and returning a small volley of e-mails between here and UW regarding how this crisis will affect my fellowship work and perhaps redirect its focus. And I will likely have much more information on and exposure to this spiraling situation once I head up north.

Until then, I would like to crib a sentiment from Ruth Reichl, oft invoked by those who fear appearing cavalier: That it is our moral responsibility to respond to disasters as best we can; yet, in the face of ongoing tragedy, it is also a moral responsibility to appreciate and enjoy what we have. (Though I suspect Paul Farmer would be apt to disagree with this definition).

And to that end, I will be posting delicious food pictures in the near future.

In the meantime, I'd like to note my appreciation and many thanks to the people who made my life easier in these past transitional months. My parents, for helping me navigate a missed connection/re-routed flight through Oakland and for convincing me to take the large bag of chocolate-covered almonds (which I enjoyed the other night with a mug of tea while it thundered and rained outside). My grandmother, who's fore-thinking about local currency allowed me to survive and buy food my first week (which is about how long it took to find an ATM that accepts Mastercard (it's a Visa city, apparently)). Tom, who gave me a last-minute ride to the airport and also performed manual labor on my car in the final minutes before we left. And Alastair, who set up my new computer, talked me through a myriad of problem-solving challenges, and whose enthusiasm buoyed my own when anxiety began to take hold.

And least specifically, though not least important, to anyone who experienced a rare Kara's-come-unhinged moment and handled it with unwavering grace and aplomb, many thanks.

Today

I started this morning by finally killing the mosquito that's been sharing my bedroom, and ended tonight with a 20-person Korean BBQ outdoors.


Today was a success.

Jerafes

So much to tell from the past few days! Like all of the amazing food I’ve been having, or my burgeoning “command” of Kiswahili, or how nice it is to explore Nairobi with friends, or why I ate a piece of chocolate with Kathleen Sebelius’ photo silk screened onto it.

However, anyone who knows Anjuli and Laura already knows the photo-op highlight of my weekend: kissing giraffes. Or “jerafes” if you are a cute little French kid. So I best post these first, lest they become old news.


Laura got to Nairobi last week, and Anjuli bused out from Bando for a weekend of friends, fun, and slumber parties. On Sunday, we went to the Giraffe Center where they breed endangered Rosthschild giraffes and then re-release them into the wild. There was a baby who was only 5 days old, and he was HUGE (at least, larger than each of us 3 full-grown people). I asked one of the staff what a pregnant giraffe looks like since the babies are so large, and he said “BIG. Like a pregnant woman.” I could type some more details, but I think the pictures are pretty self-explanatory.

Feeding!


Kissing!

And, don’t worry: the saliva is antiseptic (to help heal their tongues when eating thorny acacia twigs).

And what do I do?

Seems like some people are interested in hearing a bit more about my job and work, which isn't totally off-limits to discuss (it's not like I work for the Gates Foundation), just the details relating to participants/results. So:


This is the outside of our offices at Kenyatta National Hospital, where we do our admin, non-clinic-based work. I think the colors and setting are simply lovely. Now, pretend to pivot about 150 degrees to your left. See that large gray building in front of you? That's the morgue. Really. On my first day of work, my boss said, "I'm sorry about the smell; it's just the morgue next door." Luckily, growing up with years of allergies seems to have stunted my olfactory development.

But all kidding aside (I'm actually not kidding; our offices are really next to the morgue), after a week of training, I feel a bit more equip to talk about the scope and background of my work. My job is that of assistant study coordinator/research assistant on a study regarding treatment of cervical neoplasia in HIV+ women. It’s a randomized trial comparing Chryotherapy vs. LEEP (Loop Electrosurgical Excision Procedure) for the removal of CIN (Cervical Intraepithelial Neoplasia) grades 2 & 3, and CIS (Carcinoma in Situ). The outcomes being evaluated are HIV viral shedding in the month following treatment and recurrence of lesions in the 2 years following treatment.

The rational is that, with the fairly recent roll-out/scale-up of antiretroviral treatment in Kenya, people with HIV are living much longer than they were in the days prior to ART access. However, this new life longevity opens the door to an array of other health complications, including cervical cancer, which is more common among HIV+ due to a suppressed immune system, and is the most prevalent cancer in Kenyan women. Chryotherapy and LEEP have both been shown to be effective treatments for pre-cancerous lesions, but have never been evaluated in an HIV+ population, where the immune response differs from the general population. Furthermore, treatment poses a form of trauma to the cervix, potentially resulting in increased viral shedding and increased infectiousness in the subsequent weeks.

Thus, this study is a public health evaluation to inform PEPFAR recommendations for the most effective treatment of precancerous cervical lesions among HIV+ women.

And what do I do? So far through training I’ve gotten the chance to sit in with every segment of the study team (reception/recruitment, screening/nurses/pap-smears, lab/specimen processing, doctors/treatment, data analysis/management). I guess I’ll be doing a bit of everything coordination-related… running meetings, compiling quarterly reports and IRB updates, communicating with investigators and staff, analysis of adverse events, etc.

And, to date, that’s what I know!

Another problem with boiling water

A view of the lake at Uhuru Park in the city center, with lily pads, footbridges, and families in paddle boats. I walked down here last weekend to explore the city and ended up sitting on a grassy knoll watching a dance performance while a lady told me that I was her Jesus Christ and savior. (Crazy is a little harder to ID across a language and cultural barrier, but that was a pretty good tip-off).

But this isn't a story about attracting loony people; it's an exploration of water. Water sanitation methods, to be precise. Which may bore people not interested in water sanitation methods. Just a fair warning.

The advice is so simple: Don't drink the water. Or, as the travel clinic brochure says, "Avoid both tap water and drinks or ice made from tap water, unless you are advised by a reliable fellow foreigner that they are safe."

Coming here, I was actually kind of excited about trying out different purification techniques: Bottled, boiled, chemically-treated (iodine tablets), SteriPEN, solar disinfection.

I started thinking about what kinds of studies I could do to test out ease and effectiveness of each method. Given that my N=1 (me), the answer was none. I couldn't even do an extremely poorly powered crossover study on myself because I would need at least one person for each of the different ordered options (e.g. Bottled then boiled then chemical, vs. chemical then bottled then boiled) in order to account for the development of immunity/bacteria familiarity over time.

Still, I want to try them out. However, things have ended up being more complicated than I thought:

- The SteriPEN was about $90 from REI, so that got scratched.

- Bottled water is pretty much exactly like you'd expect, but it's hard to sustain. I buy 5 liter jugs because that's the heaviest I can carry home from the store, and that probably lasts me up to 2 days (depending on if I'm using it for brushing teeth or just drinking).

- Boiling water seems simple enough... but most recommendations say to boil for at least 5 minutes (although the CDC gives a liberal 3min), and the electric water kettle here has an automatic shut-off when water reaches boiling. So at first I tried to manually override the system by just holding the switch down in the "on" position (until I got burned with steam, and amended this procedure by holding it down with several hand towels). And then the kettle broke. Apparently, manual override is frowned upon. So I've started just doing it in pots on the stove, which is much slower and is starting to tarnish the pots. Logistics aside, there's another problem with boiling water: it's really really hot. Which is great for tea, but not so great for brushing teeth. So, if I want a supply of tepid, boiled water, I need to make it several hours in advance, pour into another receptacle, and store in the fridge (away from things like eggs that might spoil).

- SODIS (solar disinfection) is really exciting, and I can't wait to try it! But... I don't have a corrogated tin roof (or similarly appropriate locale) to put the bottles. And it's not really sunny. Mostly overcast with a tinge of smog. And sunbreaks (like Seattle, but warmer and no rain).

- The iodine tablets, I'm saving for an emergency, or perhaps when I head up north to Marsabit, as my supply is limited and I don't want to waste them when the 5 liter jugs of bottled water are just a short walk away.



The other issue is hand-washing. Easy enough. Wash hands with antibacterial soap before eating to kill the bacteria. But since the water is also likely to have bacteria, rinsing off the soap will just leave you with another layer of creepers, right? Perhaps the bacteria is water dies when it's dried, but how long do your hands need to be dry for before you can touch your food or mouth? And what about the the lack of towels in most washroom facilities?

The logic eludes me!

I did not pet this cheetah.

Hungry hungry... rhino:


My first weekend in Africa, and we got a new country. I spent the morning watching the only English-language TV channel I get, which had live coverage of the independence declaration and people singing in the streets. I heard music in the streets here as well and asked Richard if it was related to Southern Sudan, but he said it was just because it's Saturday. I guess weekends are celebrated worldwide.

This afternoon our study driver (henceforth to be known by his actual name, Richard) took me to the Nairobi National Park, where we went to the animal orphanage for abandoned or injured youngsters. They raise them before either graduating them to the adult area or re-releasing them into the wild.

Hakuna matata, it's some warthogs!


There was a woman dissolved into giggles because she had asked her daughter if she knew what those animals were, and her daughter said, "puppies."

And an apt pairing, perhaps, but who says either of them get the right of way?


We also went on a "safari walk" on Robinson Crusoe-style boardwalk above the non-fenced, wild part of the park.


The raised boardwalk is, presumably, for keeping people safe from wildlife, but I'm pretty sure a hungry cheetah could jump it.


No, I did not pet this cheetah. Yet. But I saw other people doing it! Apparently, if you slip the guards something under the table, they take you in the fence and let you play with these guys.


Next time!

Which made me laugh

I bathed/washed from a tea-kettle twice today.

The first time was this morning when I woke up to find no running water in my apartment. Why? Who knows! Probably because it was my first day of work and life's teaching me flexibility and a sense of humor. Anyway, not wanting to make a smelly first impression, I had to pour some bottled drinking water into the kettle, heat it up, and pour it over myself. Yes. That plus some Neutrogena make-up removing towelettes = improvisation under pressure. Then I did my best to tame my Medusa hair and went on my way.

The second time was at lunch when our data clerk took me to one of the hospital cafeterias where there were no menus but three choices: Chicken, Beef, Sheep. I mentioned that I would like to ask the waitress for some water also (to drink), and he said, "Don't worry; she'll bring you some." Which I found rather peculiar since I hadn't yet ordered a drink, and how did she know what I wanted? But yes, she approached again with a kettle and bucket, and proceeded to pour near boiling water over my hands until they were thoroughly scalded (cleaned), and on we went.

I went to the store again this evening, mostly because I just enjoy walking outside and feeling my way around a new home. But the trip was a success as well, for I came home with dates from Iran, dark and spicy African honey, and a cheap bottle of white wine from South Africa. There are always hundreds of people out on the streets when I walk around, which adds a sense of community and electricity to the air, yet makes me feel extremely uncomfortable about taking pictures... someone is always bound to be in the foreground and think that I'm a larger idiot and sore thumb than I already appear to be. But I tried to lurk around a corner and wait for the crowd to disperse, until I could surreptitiously snap this shot of my walk to the market:


And the soccer players were all out again tonight:


The boy on my street was out with his friends tonight instead of his father, and their ball accidentally rolled to me when I walked by. As I kicked it straight into the bushes, he said, "I can tell you're very good," which made me laugh because it was so sincerely polite and not at all the sarcasm one would generally hear in that situation.

He also said, "Hi Karen." Which is just about as good as anybody in the U.S. does with my name at first-go. Though I suppose it's not too hard to remember the blond girl who walks around in the same pants all the time.

So I just sprayed some DEET on my ear

Hello all! This is the so-far-untold chronicle of my six-month stint living and working in Kenya. As Anjuli noted, work talk will be light due to the sensitivity/confidentiality factor of health care & HIV. I also feel obliged to state that this blog does not reflect any official opinions or positions of the University of Washington.

Today has been my first full day in Kenya. The first of approximately 168 days to come. I left my house in Seattle at 11:30am PST July 3 and arrived at my Nairobi apartment 9:30am PST July 5. =46 hours, about 22 on a plane. I won't recap too much of the transit, though there was an exciting moment with me throwing a hissy fit (not a good color on me) and demanding that the agent at a closed boarding gate let me on that plane RIGHT NOW because I need to catch that flight, and I can see it RIGHT THERE. To which he responded, predictably, "Nope."


But all's well that ends well, especially when it includes a beautiful evening in Zurich, and now I'm sitting here in my apartment, which is far larger and nicer than I expected. Several grade levels above the place I lived in Athens in terms of size, quality, kitchen (already stocked with spices and wine glasses), insulation, and plumbing. View from the balcony:


Other first impressions/vignettes:

I was woken sometime in the middle of last night by a mosquito's high-pitched buzzing but was too groggy to wage a full-scale attack, so I just sprayed some Deet on my ear so that he could go about his business without disturbing my sleep. Tonight I am permethrin'ing my bedspread as an extra deterrent.

Aside from unpacking and setting up shop, I've been to the store to stock up on food and necessities three times today, twice on foot and once with the driver. My first real non-granola-bar meal was fresh papaya and bread with "cheddar" (which is decisively not cheddar). I also bought something named "feta," so we will see how that goes.

Walking back from my third trip this evening, I passed a school yard with children, another field with adults, and a father and son in the street, all playing soccer. The weather was beautiful, and I wanted to join in.

The drivers here are as bad as Naples for aggression. But despite my preoccupying fear that someone is going to run over my foot soon, I feel at ease. The last month has been very difficult and stressful, and this has been one of the hardest moves/trips I can remember preparing for, for more reasons than I have the energy to enumerate now.

Suffice it to say, I am currently pleased with life, and am looking forward to learning more about my new city, starting my job, making friends.... So here we go.