The following entries describe Zac and Sam’s (Z&S) travels in the Northern Hemisphere and Karl and Fatima’s (K&F) travels in the Southern Hemisphere. They would travel by foot, plane, taxi, rickshaw… and even by Boda Boda.
July 29, 2007 – August 2, 2007: “The Boda Boda Diaries”
Boda-Boda: n. a bicycle that can be hired to transport two or more people usually for the price of 10 Shillings.
Day 9 (Z&S)- Sunday, July 29: Busia Bound
After an abrupt departure from their teammates at the Kisumu airport, Zac and Sam found time to relax in the comfort of a hired Toyota Corolla. They had prearranged a pickup by their new best friend and taxi driver, Paul, from Busia who claimed to be “best friends” with Zac’s contact (fellow UC Berkeley Economics grad student and MIT’98 alum Owen Ozier who was stationed in Busia for the summer). Paul is a 28 year old native of Nambale who enjoys listening to Reggae music and has a deep chuckle that seems to be his response for everything. The two hour drive to Busia involved navigating a one lane, pothole strewn highway with Paul maintaining a solid 110 kph, honking at all bicyclists in the way (there are many) as well as every person we past that he knew (pretty much every matatu driver and truck driver in the western province). Paul’s gregarious nature would later be a strong asset in our hospital and dispensary visits as he not only knew the location of every health center in the western province but sometimes would even know the people working there. They headed toward the Northern Hemisphere crossing the equator at a town call Maseno (mostly rainy, not as hot as they expected). Zac and Sam checked into the Blue York Hotel in the center of Busia (1 Km from the Ugandan border) and promptly met with the contacts they had made over the past few weeks.
Lucie Heinzerling is a MD, PhD from Munich who just finished her MPH at Harvard. She has been in Busia for the past month assisting the graduate students at the Innovations for Poverty Action (IPA) group with a medical study that is tracking the effectiveness of AIDS education among local students. She really liked the idea of our project and went out of her way to schedule three meetings for us on Monday and Tuesday at various health centers in the area.
Day 10 (Z&S)- Monday, July 30: Busia to Bungoma and Back
After waiting around his office for over an hour (while Lucie concluded her morning meeting), we are finally introduced to Dr. Ahindukha, the District Medical Health Officer (DMHO) at Bungoma District Hospital. George Wanzala, the man in charge of immunization logistics in the Bungoma district, also comes in along with a nurse who brings in a cooler box. We are given a run through the standard set of KEPI vaccines:
Measles (in powder form, stored in 10 dose vials)
BCG (in powder form, 20 dose vials)
Penta (DPT liquid plus Hep/HiB powder, 2 doses per vial)
Oral Polio (liquid form, single dose container)
Tetanus Toxoid (liquid form, 20 dose multi-use vial)
Vitamin A supplements (liquid, single dose)
George is very helpful, and actually seeing/handling the vials that KEPI healthcare workers use in their daily routine was exactly what we needed. After being given a tour of Bungoma’s Maternal Health Clinic and the long line of mothers and babies waiting for their free vaccinations, George sends us on our way to a dispensary in Kabula with a better idea of how vaccines are delivered and a personally written note in hand, authorizing those at the nearby dispensary to work with us if possible.
As we pull up on the dirt road leading to Kabula with our driver Wesonga, we witness a scene that would become strangely familiar over the course of our trip.
As a crowd of nursing mothers and babies waits outside (sitting on the ground), we are quickly shown to the front of the line. The public health officer on duty is named Leah, and she pretty much drops everything to talk to us. We felt bad and asked her if we were disturbing her work- “If you are busy, we can come back later.”
“Its okay” she says.
I almost want to say “Please, don’t do this”. But I don’t and they do. Almost everybody does, and they go out of their way to help us.
Back in Busia that night, we have dinner with most of the IPA crew, which usually involves too many chips and lots of Tusker. I know that we’ve come here to learn from the locals, but I can’t deny that its really fun and comfortable to hang out with Americans again - to talk about what’s happening back at home, to drink beer and to share stories (even if they would never get published in an economics journal).
Day 11 (Z&S)- Tuesday, July 31: Alupe, Tanaka and MSF
Leonard Khalumi Chibole is a nurse who works at the Alupe District Hospital. When we visit on Tuesday, Leonard is kind enough to take some time out of his busy morning to show us around, to demonstrate his immunization technique and to answer our questions. Soft spoken but strong, Leonard has a quiet determination that underlies his work and a similarly impressive depth of knowledge regarding both immunization and general medical practice. He knows how important it is, and it’s people like Leonard and George Wanzala who have really impressed us during our time in Kenya - with their professionalism, with their hearts, and with their knowledge, as well as their willingness to help out a bunch of grad students.
That same afternoon, we conduct our first interviews on the grounds of a private hospital. This one is called Tanaka Nursing Home, and the child and maternal health nurses here (consisting of 2 senior nurses and 3 younger nurses) make up an interesting group to give feedback on the microneedle device. At the same time, we also learn some things about the nation’s private hospitals, and this has helped us gain a broader perspective of Kenya’s healthcare system. Before we can leave the head nurse can’t resist asking us our opinions on Barak Obama. We ask them what they think and her response is, “He is our son.”
As a last item of business on this day, we make a visit to Medecins Sans Frontiers (MSF) headquarters in Busia, where we meet Rafael and Paul. Rafael, the logistician for this Spanish team tells us that their MSF team is mostly focused on HIV/AIDS projects, and so they are unable to do much more than give us phone numbers for other MSF teams in the country and wish us good luck. Still, it’s pretty interesting to watch this remarkable organization in action and see firsthand how Doctors Without Borders runs their ship.
Day 12 (Z&S)- Wednesday, August 1st: Busia District Hospital
Sitting around a table with a group of nurses at the Busia District Hospital, Zac and I are running something like a focus group. The nurses here are older, more experienced than the ones that we met at Tanaka, and they have names like Rose and Flora. Some of them wear glasses or little white hats. When we introduce the microneedle technology, the group is somewhat skeptical and they have lots of questions for us:
So how do you remove a needle?
Why are there 900 of them?
And it takes 30 seconds to deliver the vaccine?
A contagious laughter spreads across the room. These nurses are exactly like the kind of people that we came to Kenya to learn from, and it seems like there is much that remains to be learned. When they laugh, it’s difficult not to laugh along with them, even if you are not sure what the joke is.
Day 13 (Z&S)- Thursday, August 2nd: Outreach program and Nasira
Thursday is the day that we say our goodbyes to Busia and drive back to Kisumu with our favorite taxi driver, Paul. Our friend Connie comes along for the ride, and soon we are off bumping down the country roads with the windows open, booming reggae music in kiswahili.
We make a stop along the way at the Nambale Health Center, where we receive a pleasant surprise when they invite us to go with them on an outreach clinic. Joining us on this trip today is a friendly group of young medical students from Moi University, located nearby at Eldoret.
Leonard Khalumi Chibole is a nurse who works at the Alupe District Hospital. When we visit on Tuesday, Leonard is kind enough to take some time out of his busy morning to show us around, to demonstrate his immunization technique and to answer our questions. Soft spoken but strong, Leonard has a quiet determination that underlies his work and a similarly impressive depth of knowledge regarding both immunization and general medical practice. He knows how important it is, and it’s people like Leonard and George Wanzala who have really impressed us during our time in Kenya - with their professionalism, with their hearts, and with their knowledge, as well as their willingness to help out a bunch of grad students.
That same afternoon, we conduct our first interviews on the grounds of a private hospital. This one is called Tanaka Nursing Home, and the child and maternal health nurses here (consisting of 2 senior nurses and 3 younger nurses) make up an interesting group to give feedback on the microneedle device. At the same time, we also learn some things about the nation’s private hospitals, and this has helped us gain a broader perspective of Kenya’s healthcare system. Before we can leave the head nurse can’t resist asking us our opinions on Barak Obama. We ask them what they think and her response is, “He is our son.”
As a last item of business on this day, we make a visit to Medecins Sans Frontiers (MSF) headquarters in Busia, where we meet Rafael and Paul. Rafael, the logistician for this Spanish team tells us that their MSF team is mostly focused on HIV/AIDS projects, and so they are unable to do much more than give us phone numbers for other MSF teams in the country and wish us good luck. Still, it’s pretty interesting to watch this remarkable organization in action and see firsthand how Doctors Without Borders runs their ship.
Day 12 (Z&S)- Wednesday, August 1st: Busia District Hospital
Sitting around a table with a group of nurses at the Busia District Hospital, Zac and I are running something like a focus group. The nurses here are older, more experienced than the ones that we met at Tanaka, and they have names like Rose and Flora. Some of them wear glasses or little white hats. When we introduce the microneedle technology, the group is somewhat skeptical and they have lots of questions for us:
So how do you remove a needle?
Why are there 900 of them?
And it takes 30 seconds to deliver the vaccine?
A contagious laughter spreads across the room. These nurses are exactly like the kind of people that we came to Kenya to learn from, and it seems like there is much that remains to be learned. When they laugh, it’s difficult not to laugh along with them, even if you are not sure what the joke is.
Day 13 (Z&S)- Thursday, August 2nd: Outreach program and Nasira
Thursday is the day that we say our goodbyes to Busia and drive back to Kisumu with our favorite taxi driver, Paul. Our friend Connie comes along for the ride, and soon we are off bumping down the country roads with the windows open, booming reggae music in kiswahili.
We make a stop along the way at the Nambale Health Center, where we receive a pleasant surprise when they invite us to go with them on an outreach clinic. Joining us on this trip today is a friendly group of young medical students from Moi University, located nearby at Eldoret.
Together the outreach group will give a talk to mothers on the importance of vaccinations, weigh babies (using a fish scale hanging from a tree), administer vaccines and offer discounted mosquito nets for 50 Shillings ($0.75).
Nelson Bigambo rides alongside with me and Connie in the backseat of Paul’s car as we follow the ambulance on the way to Nasira Primary School (where the outreach is to be held). Nelson is also a student, in training to become a public health officer in this region and it is his first day at the outreach as well. With his friendliness, helpfulness, determination and enthusiasm, Nelson belongs to the same class of people such as Leonard and George, who have impressed us so much.
As our car pulls up to the school, the children stop and stare, pausing in the middle of their volleyball games to gather around the curious sight of three emerging mzungu. The initial reaction is like a mixture of suspicion, curiosity, and delight. There must be at least 100 of them (maybe 200?) and the gathering crowd helps you understand what it might be like to become a celebrity - an awkward self-consciousness mixed with a strange desire to smile. However, after a few moments, both sides feel more comfortable with each other, and Connie, Zac and I take pictures with the kids and kick around a makeshift soccer ball.
Actually, most of the soccer balls we’ve seen here in Kenya (that the children play with) are simple bundles of cloth, paper and plastic bags - held together and tied with string.I just want to give them all real ones. If it were possible, I would travel back through space and time to Berkeley, California, July 17th 2007, and dump everything out of my luggage. Fill it with deflated soccer balls and a pump.
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MEANWHILE IN KISUMU:
Day 10 (K&F)- Monday, July 30: The plumbing is killing me softly
Starting out in the city of Kisumu involved all of the usual settling in and getting accustomed to the new surroundings. Kisumu is the third largest city in Kenya, and definitely seems less bustling than Nairobi. There are a variety of fresh markets selling everything including the daily catch of fish and freshly picked fruits. Karl and Fatima are staying at the Novelty Guest House, and it appears that a working toilet is apparently a novelty at this establishment. The toilet currently can only be flushed every 2 hours, and continues to leak water as it refills. While the guest house staff has said that it will be fixed, that remains to be seen. We have managed to negotiate a lower rate for the room, since it does not have a working flush. The water only works at night, because the water source to the room must be turned on and is limited because of a water shortage within the area. Karl bullied Fatima into showering at night instead of in the morning, and reluctantly she agreed but consoled herself by singing “Killing me Softly” in the showerDuring down time away from microneedle work, Karl has taken a liking to the talkshow Tyra, starring Tyra Banks, which is on daily from 5-7pm. While this may be surprising, consider that there are only 3 television stations available, and only 2 of them are in English. This leaves very little choice in programming, and so Karl must be excused for partaking in this guilty pleasure. In addition, Tyra is not afraid to tackle major issues facing society (both American and African) today.
Today was spent trying to hunt down the provincial medical officer (PMO) office. With only a small map courtesy of a donated lonely planet, and armed with an official letter for the PMO from the Director of Immunizations in Nairobi (Dr. Tatu Kamau) introducing our group we decided to track the PMO down. Since no one seemed to have any idea where his office was, we decided to first try the Provincial Medical Hospital at the edge of town. After walking there, at a fervent pace set by Fatima we arrived sweaty but motivated. As soon as we entered the outpatient area, we came across the area where immunizations were administrated. The hospital was packed, and it was clear that Monday mornings were busy. After talking to a few nurses, we were eventually directed to the office of the Medical superintendent. After sitting outside of his office for about an hour, and getting shafted by other people cutting in front of us, we eventually got an audience with the superintendent. He read the official letter we had from Dr. Kamau, and was very helpful. He suggested we visit the PMO’s office as soon as possible, to introduce ourselves, and make sure that he was aware of our presence in the area. He provided us with directions to the office and wished us the best of luck. While having to follow the top down structure of approval clearly present with Kenya can often be time consuming and frustrating, we understand its importance and value in protecting both the hospitals and their patients. Before leaving the hospital we were able to walk by the waiting area full of mothers bringing their babies in for immunizations, and it was an amazing sight. Like a factory, naked babies were being weighed, cards were being recorded, and immunizations were being provided.
After a short matatu ride back into the center of town (Karl decided he didn’t couldn’t maintain Fatima’s walking pace while carrying an 8 pound laptop) they made their way to the PMO’s office. This matatu had clearly been to “pimp my matatu”. There were plush red seats, and a TV in the front of the vehicle for passengers to watch music videos from the USA. These included “Gangsta’s Paradise”, and “Killing me softly”. Fatima almost didn’t want to get off at our stop because Lauryn Hill was doing her thing. If the PMO is trying to fly under the radar, he is definitely succeeding. The door to his building was squeezed between two banks, and had a small sign reading Provincial Medical Officer, Kisumu Province. After climbing 3 flights of stairs we reached his office, where the secretary was catching up with the daily newspaper. Apparently there was a power outage so she was relaxing in the waiting room. Unfortunately the PMO is out of town until Wednesday, but we were directed to the office of the district medical officer. After stopping for a brief lunch, Karl went to find out if the plumbing was fixed at the guest house, while Fatima went to visit the district medical officer’s office. Fatima found the district medical officer away from his desk, and so left a note with his secretary. Karl meanwhile found that the plumbing could not be fixed because we had taken the key in the morning at not left it with the front desk. Apparently, the guest house only has a single key for each room. While we think this is quite strange, we have decided that guarding the key with our lives is imperative for our future success.
In the late afternoon, we made our way back to the provincial medical hospital, to interview one of the nurses in charge. After chasing him down, his input was extremely helpful, and we found him to be very knowledgeable and insightful. Lastly, we were able to catch up with the district medical officer, who welcomed us to the region and put us in touch with the head nurse in charge of public health. Dinner consisted of an overpriced but surprisingly decent meal at a local Chinese restaurant. While some may ask why we chose to eat Chinese food in Kenya, Karl says there is only so much beef stew, french fries, and fish filet someone can eat in a 2 week period. Plus we wanted to make Sam jealous.
Day 11 and 12 (K&F)- Tuesday, July 31 and Wednesday, Aug 1: Tyra Time
Evenings in Kisumu bring heavy rains, and they last > 5 hours at a time. Karl and I don’t mind them. The gecko lizard sharing our room however, does not seem partial to this coolness at all. He crawls in every evening, falls fast asleep plastered to our window, and leaves sometime at dawn when all signs of rain ebb.
Our time in Kisumu, the district headquarters of Nyanza Province, is passing too quickly, and I find myself constantly asking myself (and Karl), ‘Are we doing enough? Have we met all the right people? Are their any major stakeholders in immunization delivery that we may have overlooked?’ My most romantic ambition here involves venturing out to the tea estates and interviewing health care workers who provide immunizations to employees at these farms (a major industry in Kenya).
Tuesday we met with an administrator at the Provincial Government Hospital and later had two more critical meetings with both the District Medical Office and with Aphia Nyanza. Both meetings solidified rural contacts for our research and the latter inspired further discussion between Karl and I that evening. Aphia Nyanza, acquiring 80% of its funds from the PEPVAR (the Global Fund) and the remaining 20% from USAID and PATH, teaching HIV prevention and provides support/counseling to patients. Their office was beautiful, they treated us to warm beverages, we indulged in bottled water they provided, their clean bathrooms and even a car ride home in their upscale SUV. Aside from the superficial impressions, the staff, including the director who met with us for an hour, were all highly qualified, eloquent, and received us warmly. Their work in HIV piqued our interest as well as it is interesting to see what people in power in HIV policy making think the money should be spend. Do patients need ART or supportive counseling: cotrimoxazole or education in prevention?
Highlights from Wednesday include a long rickshaw ride along the rolling green hills to Rabuor Dispensary. The nurses there serve thousands of local villagers in both routine and emergency health services. We were guided to a public health officer who agreed to take us with him on home visits this Friday. The purpose of the visits is to meet with children who are not getting vaccinated and to go and remind them of their importance.
Karl and I salivate at the prospect of this inside connection into communities facing difficulties in access. One major difficulty in analyzing qualitative data is the variation in reponses we hear from our interviewees. A first hand glimpse at the potential variables barring these communities from vaccination may help us grapple all the pieces of the story we have thus far collected. Hopefully it will also allow us to continue thinking on potential implantation schemes for a microneedle, if this device is suited for vaccine delivery.Best wishes and lots of love to everyone, from Kisumu. Over and out.
Day 13 (K&F)- Thursday, Aug 2: The boys are back in town
Thursday consisted of a very interesting experience on a rickshaw. With a planned meeting at a rural health clinic scheduled for 10am, Karl and Fatima headed out at 9:40am with plans to take either a matatu or a rickshaw. When they found a rickshaw driver, he stated that it would take anywhere from 45-90 minutes to reach the clinic which was apparently some distance away. While contemplating whether to take a rickshaw or not, the driver convinced the two unsuspecting travelers that a matatu would take much longer. Gullible as ever, the two hopped into the rickshaw and were off. But actually they weren’t really off. The lawnmower engine powering the rickshaw reminded Karl of the little engine that could. It was moving so slowly on the hilly road full of potholes. Meanwhile, streams of matatus flew by, engulfing Karl and Fatima in clouds of dust and exhaust. In addition the potholes made the ride quite bumpy, and Karl will need an examination of his ribs when he returns to the United States, to assess any permanent damaged. Karl did however manage to peel and eat a boiled egg in the rickshaw, which is a lot harder to do then it seems when you are also forced to hold on for dear life.
The health clinic was extremely interesting, and provided a stark contrast from the full service hospitals located within the heart of Kisumu. It was interesting to see the difference between services, and environments at the hospitals, rural health centers, and even more remote dispensaries.Thursday also brought the expect arrival of Sam and Zac back into Kisumu. They requested that Karl and Fatima book them a hotel in Kisumu. Deciding that the Novelty guest house with its lack of adequate plumbing and clean water was not the best place, Karl and Fatima booked Sam and Zac in the fairly nice Hotel Palmers for the following three nights. The clerk at the desk stated that the only thing available was a double bed in a fairly tiny room that would need to be shared. Karl knew that this was perfect setup for Sam and Zac, and also was quite certain that Sam would be eternally grateful to Karl for providing Sam the opportunity to finally share a bed with Zac.
Of note, dinner with the four reunited teammates in Kisumu, consisted of an interesting conversation about the levels and difference in poverty in the United States and in Africa. While all of the team members did not agree, it was interesting to see the different perspectives, and allowed us to reflect on what we had seen in the past few weeks.
With a few more days left in Kisumu and the surrounding area, the group has enjoyed the time away from Nairobi but seems ready to return to their home away from home.
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