Mount Kenya

12,467 feet above sea level and this was just the beginning.  Onwards to waterfalls and caves, but Mugi Hill already gave me my daily calorie expenditure and then some.  We left Chogoria the night before and stayed at the Meru Mt Kenya Lodge on the Chogoria Route of Mount Kenya.  This was one of those trips that attitude made all the difference...Only a couple hours out of town our Land Rover came to a thrusting halt.  Engine turned over, transmission is grinding, and the gear shift lever breaks off! All we could do was laugh and jump out into the blistering sunshine.  Time for a nature moment in the Mt Kenya National Park and our first visitor dropped from a branch above.

One side of the dusty two-track was a quasi-impassible bamboo forest that called my name.  I've seen bamboo growing but this was a symphony of plants living under protection of the park, so there were no more vertical shoots than there were horizontal and diagonal.  Their music was magical, each clap of one bamboo shoot on another in the wind created a different tone based on the plants' age- the older, the hollower. 

In the bamboo forest; my new African do

Our guides figured out a way to set the transmission selector in 1st gear and that would get us all the way to the lodge.  Still one more stop en route though, for a quick sandwich and mango juice box.  A couple truacol's were communicating our presence to the rest of the forest.  The small red bird was native to the higher altitude.  As we ate, our guides laid in the shade, one of them was picking mihai, a medicinal berry fallen from the towering tree above us- good for the common cold when made into a tea. 

Camp, or bandas, was a cozy wooden cabin with a bedroom, living room with a fire place, bathroom, and kitchen.  Our shower was supplied by a tank behind the cabin being heated by firewood!  Quite luxurious for some.  A quick swim was in order at the nearest "river".  Quotation marks because we had to help our guides learn the difference between that and a creek.  Bathing wasn't really possible in 2-inch water, but wait, we can forge through animal dung and clay up the creek to the "Fishery Falls."  Here the water had dug out a 4-ft wide, 3-ft deep swimming hole we just couldn't resist after such a journey!  And there were leeches, yea.  Dinner on the fire consisted of roasted chicken, cooked cabbage, and white rice.  Before retiring, we sat under the stars and listened to the nocturnal creatures awake.  Most notable was the marmot-like tree hyrax that first made an obnoxious clucking call then a eerie, high-pitched screaming.  A fellow student stayed up later and had the opportunity to hear the hyena's whooping in the distance. 

Frozen toes woke me at 4am, so 7am breakfast and 8am departure couldn't come soon enough.  Ascending Mugi Hill seemed impossible to us amateurs as we packed our bags and slopped on the sunscreen.

We did it in about 4 hours but that included a stop at Lake Alice, behind the mountain to the west, the drinking water source for camp and beyond.  I'm proud to say, me, da only Yooper, was the only one able to swim in the frigid mountain lake...coming out after numbing my entire sunburned-speckled body was just shy of excruciating against the brisk gusts.  A quick nap in the sun and we were off to the peak of 3,800 meters.

Christine, Jen, Aimee, Dave

Little did we know how much hiking we still had ahead of us...our guide said the nursing students he brings every February do this itinerary in two days.  So over the foothills, bushwhacking through a shortcut, and another liter of water later, we've almost made it to Nithi Falls.  You hear the cracking of branches- those same black sooty branches that loved to tear across our thighs- as the only indicator of animals in the distance.  A buffalo ran just over a ridge out of sight and moments later a small herd of waterbuck clear way for us.  Swimming in the lake was a little crazy, but swimming in the falls would have been insane.  Just sitting at the base of it you felt an arctic blast of mist that would quench any one's thirst for water or adventure. 

Nithi Falls

 

Making the way back to the bandas was all downhill and dusty, time to let gravity take over and get us home!  My leg muscles were jelly by this point and picking flora was a great escape from the pace.  Flowers for pressing, lemongrass for cooking, and mihai for my next cold.  Just a few minutes from home I heard the crashing of branches again and knew we were close to the resident elephant's range.  An old, male named Mitwa Kinyori, was up on the hillside opposite the road from where he had been in the morning.  I'll end on his note, an amazing animal, solid and smooth moving.



Hiking

As during our morning jogs, setting out for a hike draws quite a bit of attention.  Equipped with water bottles, backpacks and wearing tennis shoes instead of flip-flops, we must look like a bunch of clowns going out to look at nature as if we'd never left our American suburbs.  But just like in any place, you get accustomed to the views and extraordinary features of your landscape, until someone shares their amazement with you.  As soon as we got off the main roads and into the countryside, we acquired children who knew we were out to explore.  It's a good thing John had nothing better to do this Sunday afternoon, without him my friend from the clinic, Caroline, would have taken a few wrong turns.  Although I think we got the most direct route possible to the falls and that meant descending trails with much more caution than the kids floating ahead of us.  We were headed to the waterfalls of the Mara River and caves in the vicinity.

 John was 13 years old but much smaller for his age in American standards. He was in the 8th grade and could tell us the species of every tree or bush we passed, in English and kimeru- the local dialect, still similar to Swahili.  He told us stories about seeing "indians" kill a lion years ago in a neighbor village and about how he has seen elephants near his house and maybe he could take us their one day!

John

From here we make our way back up the hillside and further down the river to where he remembers the caves being.  The trail is about 6 inches wide as we clumsily descend to the river again.  Only once we were down there did John tell us we just walked across the river on a huge land bridge.  I can't imagine the size and speed of the rapids that once carved out this passageway (shown below).

Caroline, Timo (med student from Germany), Christine, Dave

This was the caves right? Of course not, we had to cross the rapids to get there! John tears off his shoes and wades over with ease, expecting his little ducklings to follow without pause. We scrambled up and down the riverside looking for the most comfortable route to take across the slippery, hidden boulders beneath the water's surface. There was a huge vine extending from the top of the land bridge down to the river and trailed off in it for several meters, now there's a tempting way to cross! Water up to our thighs, we made it safely, and didn't even consider if aquatic predators were near. Under another section of the land bridge was the entrance to the caves. Water dripping from the black roof a foot above our heads was so refreshing on our necks. John crouched as he neared the entrance and said the water had risen too high, it had obstructed the narrow passage. No caves today, but I ventured around the edges of this cavern and before I noticed the other entrance a swarm of black butterflies zipped past my head from their secret crevasse. This too was another dead end, so we called it a day and prepared ourselves for the treacherous climb up.

A Positive Paradise

Again, the HIV mobile clinic this week was a memorable one, and overwhelming to say the least.  I knew the village was called Nchiru and we'd be seeing lots of children, so I imagined something similar to last weeks clinic in a rented cabin.  Ai ai ai, after an hour and a half drive in the loaded up SUV, the road finally narrows to two, packed dirt peaks the tires try to stay on.  After riding through a lush, green tunnel it came as a surprise to pass through the compound gate into an expansive view of mountains, near and far.  We had just arrived at the "New Hope HIV Orphanage," founded by AINA onlus of Italy- "Italian Association of Nomads of Love."  The Polish director came to greet us and invite us for tea and bread.  Recognizing the new member of the team, he gave me an introduction to the project.  After he said that 84 children live at this site and are all HIV positive, my heart sank into this reality and my attention was gone.  Eight-four.  It was too much, yet a small portion of the country's orphaned children.  From the gates, the orphanage spread down a soft hillside, with their livestock down at the bottom.  Three different sleeping quarters and the dining hall created a "U" shape, hugging the central play area.  A jungle-gym, flowering bushes, and green grass gave the children their own safe and loving space.  Some were being wild and crazy, digging holes and riding the swings and others were laying in the grass in total peace.  So much to see but strangely it all started to blur together like a Monet painting.  The beautiful faces and flowers swirled together and I closed my eyes.  I didn't need them to feel the grace here. 
After tea we set up clinic in a room dedicated for us and the children's medication cubby holes.  Over half of the children were due to be seen so we had our work cut out!  Youngest to oldest.  The three-year-olds fluttered in and each sat neatly on a tiny wooden seat, waiting to be seen.  With no parents' hands to hold, they look wide-eyed at the buzzing line-up ahead of them, first height and weight, then another nurse to take their vitals, next the waiting chair in the corner, then on to see Caroline and I, then either out the door or on to the lab tech in another corner for a CD4 count blood draw.  Not a single child complained except when asked to describe their complaint...a rash, bumps, belly ache, etc.  Any serious complaints were brought forward by one of the seven "house mothers."  This newer generation had very different names compared to what I have noticed so far: lots of Ann's, Mercy's and Agnes, Beatrice, Glory, Valentine, Purity, Nimrod, Fridah, Moses, and my favorite, Perpetual.  Moses is one of the two HIV-negative children here.  Usually they would be taken from the home and placed in a foster home, but they are trying to construct a separate sleeping quarter for them.  Moses is only 7 months old.  He was rescued from a car accident here in Chogoria a few months ago in which the car had ended up in a river, he was the sole survivor of a matatu-full of people.  I think he was accepted because his mother was HIV+ and his status was unknown at the time.  Definitely a cutie and pretty chubby, it showed how much this disease can affect growth. 
Only a few had to get their blood drawn, at least that I noticed, none of them cried so I practically forgot it was going on beside us.  Until it was Erick's turn.  HIV+ but healthy in all other respects, his immune system was doing well with the help of antiretroviral meds.  I think they called him back after we were finished with the rest of the kids for a reason.  Four years old, gabbing away, he acted like he was the boss of this clinic and if he wasn't examining something, he was asking questions or showing you his stuffed Tiger.  The first attempt at drawing his blood was unsuccessful, the holding team was upped from 2 to 3.  He wasn't crying, he was screaming and as soon as he saw the second needle and syringe it was no longer pain that fueled his lungs, but anger.  He pleaded for them to stop, kicked, pushed the syringe away after it was already in his skin.  A third time and we were all as desperate and anxious as he.  Then he let out one last plea and I had to leave the clinic in tears.  He screamed "But I'm not sick!  Please don't subject me to another injection!  I'm not sick!"

HIV Bush Clinic & Khat

Part of the battle against any treatment for illness is compliance.  And that can include issues of finances, belief systems, transportation, etc.  The HIV clinic in Chogoria (and anywhere in Kenya for that matter) is given the name "Comprehensive Care Clinic", or CCC, I think to decrease opportunities for stigmas.  The CCC has a mobile clinic that goes to four different villages, each once monthly.  Medications, records, our tea & bread are all loaded into a hospital 4x4; as well as two nurses, the PA, and a tech from the pharmacy and laboratory.
It was about a 45 minute drive, first on the highway then a dwindling dirt road through encroaching banana plantations.  The countryside looked a bit familiar since this was the way to Meru, the city we traveled to last weekend.  Despite this familiarity, something was different and it squeezed my chest.  Soon, Marcilio was there.  His presence was not joyful, but worrisome and it made me breath faster and tears started falling.  Against my good judgement I tried to fall asleep and was out.  I woke up during the steep climb up the clinic's driveway.

We were able to refill everyone's meds for a month, take CD4 cell counts via blood sample, and do immediate testing for HIV on the infants at least 6 weeks old.  Both children we tested were 18 months old and tested negative, thanks to the education by the CCC about the importance of taking antiretroviral meds during pregnancy and if breastfeeding, making sure the infant is taking a drug called nevirapine.  My joy was pretty obvious unlike the mothers', to some its just part of life and others there is a little expression of relief, but overall my perception of the Kenyan people is that they are more reserved with their emotions, especially around "mzungos" or white people.  Regardless of that, they are very welcoming and sincere about making your time here enjoyable, even too much at times.  Clinic is closed up and the spiders begin their reestablishment of webs. 
The trek home begins and I hope to nod off again.  It's hotter now and the window's breeze just cakes my face with dust.  But eventually I nod off, the pharmacy tech, a young guy named Kevin sitting in the back of the SUV on top of the medications, probably thinks I'm lazy or easily fatigued but oh well!  Who knows how much time goes by, and I'm awakened by the shouting of the driver of some profanity in Kiswahili.  There's burning branches and boulders forming a barricade across the main highway in front of us.  Only seconds have passed but in my waking I blurt out "what's going on?" and expect people to already know.  Everyone sits up straighter in their seats to peer out and the mob of people we are approaching.  I guess we have to investigate right?  Our driver pulls to the side of the road with all the other abandoned vehicles and leaves us to go find out what has happened.  I see two police officers with their rifles just standing amongst the crowd not showing their concern.  Word is a khat, or miraa, transporter came flying through this community and caused an accident, although their were no casualities.  But the civilians were outraged and determined to not let them continue on their way.  So of course, the guys in our car jump out to go observe the action and us three, sensible women stay in the car and watch from a deceiving safe 20 meters away.  We all know things like this can go bad very quickly.  The miraa driver runs out of the crowd, comes back with a machete, and starts slashing through the miraa bags piled on his pickup truck.  There are different stories going around, if they are trying to move it by hand into another vehicle or giving it to the village members as payment.  Here he is in action...

Thankfully, our driver hears about an alternate route on another little dirt road.  He manuvers the vehicle with urgency and too much confidence now, all fired up.  His muscular hands wrap around the steering wheel practically crushing it.  The alternate route eventually winds us back to the main road and what is that up ahead, a bridge.  Blockaded by motorcycles and men.   We have to wait for the others to come down the winding trail before we can head up it again.  Another ten minutes in the bush and we make it back to the highway probably only a 1/4 mile down it.  All is well and Mr. Macho doesn't hurry us home but takes his time at every speedbump to share the news.  Back in Chogoria the news really wasn't noteworthy, but mobile clinics might just be out of the question for the rest of the students!  My angel was there all along :)
Ok, I have to throw one more picture in, this was when I jumped out of the SUV before it made an insane decent.

 * A word about khat (miraa locally)- it's a plant that has been chewed by people in Africa and Asia for thousands of years, it contains an amphetamine-like substance that causes euphoria and is classified by WHO as somewhat addictive (less than tobacco) and is legal in Kenya. Thank you Wiki. 

Tuberculosis

Nearly on a daily basis, we have a patient with an entirely new presentation form of tuberculosis.  This is mostly due to the fact that patients with immunosuppression from HIV have a different set of characteristics of a TB infection- basically it can cause pathology anywhere in the body, not just caseating granulomas in the upper lobes of the lungs.  Yesterday a woman presented with left flank pain (HIV+).  Once a urinary tract infection was ruled out and physical exam showed hip flexor weakness, it was diagnosed as psoas abscess caused by TB and a four drug regimen was initiated of INH+ethambutol+PZA+rifampin.  Extrapulmonary lesions in HIV patients increase as their CD4+ cell counts drop below 50.  The xray below demonstrates miliary tuberculosis in the lungs- a peppering of the middle and lower lobes.  A third example: an HIV+ woman presented with persistant diarrhea, night sweats and anemia, her chest xray was normal.  Other causes of anemia were ruled out and thus "unexplained anemia in an HIV patient" was attributed to TB.  Unfortunately, HIV increases the risk of reactivation of tuberculosis by 100x, as illustrated repeatedly here.

Miliary Tuberculosis (sorry very poor detail)

Tuberous xanthomas: on elbows, knees and extensor surface of wrists...

caused by hypertriglyceridemia (lipids/fats), a side effect of one of his HIV medications.

A Kenyan clinical officer, or physician's assistant, performing a lumbar puncture on a patient with suspected cryptococcal meningitis.  After ten pokes we were still unable to get any cerebrospinal fluid and let the 26 yr old rest... maybe because it was a needle half the length we needed?

A Short Time Here

Although it seems that time is flying by, I've only spent three days in the HIV Clinic of Chogoria Hospital so far.  There are too many moments that I have been reminded how little time some of us have here.  I'm meeting children who know no life without HIV, whether they are seropositive or have a parent that is.  One of our patients was admitted over the weekend because of blindness and limb weakness that has developed over the past 2 weeks.  She is in her 30's and most likely this is an opportunistic infection that she will succumb to.  She is no longer able to coherently answer our questions and her muscles are flaccid.  At the end of each day, the other four medical students on this trip convene with our preceptor, Dr. MacIntosh, for discussion of interesting cases.  Each student is stationed in a different ward and luckily some stories are more enlightening than mine.  It's hard to shake it off at 5:30.  More detailed medical cases to come, it's 11pm and I have a run scheduled for 6am up the main road- literally up- the Chogoria route to Mount Kenya.

A view from our foot path of a tea plantation.

During a morning hike, a little boy spotted us from a cliff above and on the way back he was in the same place with the yellow flower in outstretched arms, I motioned for him to come down and we made an exchange, of giggles first, then I accepted his flower and opened my other hand- there was a perfectly intact yellow and blue butterfly for him I had happened to find on the road.  His face opened up like the flower he had given me and he ran up the crumbly red dirt hill to his playmates.

Medical students house- still waiting on a shower and refrigerator but hey, we have a veggie/fruit garden in the back yard, an electric stove (2/4 burners work), and a normal toilet.

Chogoria's main road

Kids on their way home from school and slew of cattle and goats.



Transit via Embu

Tuesday and our whole group has arrived safely, Dr. MacIntosh and his wife Lorah, and four other 4th year medical students: Jen, Christine, Hope and David.  Mennonite Guesthouse breakfast consisted of a casserole of eggs, flour and bacon, fresh papaya and pineapple slices, and interesting little oat bars that had a hint of sweetness and disintegrated the minute you touched them.  I grabbed one for the road, not knowing what lays ahead.  Before we leave the capitol, we get directions to the nearest shopping area from a girl I met my first night here-Kim, a physician's assistance student from Ohio who will be working in Tanzania for the next three months...as soon as her luggage arrives from Amsterdam. 
Walking to the shopping mall was treacherous in the sense that cars, motos, and matatus (passenger vans) were whizzing by and their exhaust was suffocating.  With purchased internet access in hand and peanut butter and coffee, we made a sweaty walk home to catch our ride.  Since Kenya was a British colony until the 1960's, tea is more popular than coffee and I was warned once we leave a certain radius of Nairobi you may see it growing in the fields but it may not make it to the stores.
Stuffed into the matatu with our driver John, we head to Chogoria.  The first third consisted of construction and thorough ways of traffic crossing eachother with no supervision.  Crazy budabuda (sp?) riders- motorcycles- were transporting everything you could imagine and if they were up to date on the latest trend, were wearing fur coats and orange shin guards.  Long lunch break in a town called Embu at the Isaac Walter Inn- Kuku Kenya as my dish- chicken pieces with cooked carrots and greens. Then through farming country for a couple hours- tea, corn, coffee and rice mostly.  Lastly we made a short ride through the foothills of Mount Kenya, leading us into our one-main-road village.  Quick tour of the hospital and I beelined for bed.

Nairobi

Mennonite Guesthouse in Nairobi

Finally arrived in Kenya after two days of grueling airport life.  Quick disclaimer::: this blog will be simply a description of my experience, most likely I won't have time to be researching my findings so take it as it is and enjoy!

Nairobi airport was easy to navigate, got a visa for $50 in 5 minutes, and the declaration of goods department consisted of one person who was busy.  For the first time I got to look for my name on signs upon exiting the airport, how exciting to see someone waiting to drive me to the hotel.  Stephen, my driver was halfway through his 24 hour shift and had been waiting for 1 1/2 hours for me.  Still so kind and polite, he chatted away our 20 minute drive through the city.  Nairobi was fast asleep, no one out partying, no homeless in sight, everything was closed.  We made our way through a very developed industrial district, then a newer business district and out to a residential area.  It was eerily quiet and peaceful, and Steven said it would be like this during the day as well.  He reviewed with me the customary greetings here, hand-shake- no hugs or kisses!  Hugs are reserved for close family members. We did a little swahili lesson, my favorite word so far is "jambo"- hello.

Off to bed, I had no idea what time it was, a daze of exhaustion set in.  I climbed in my bunk and let my bones settle horizontally, not without some creaking.  And of course, the nighttime chorus begins...first the goose next to the compound gets startled and can't seem to shake it off for a good twenty minutes, a few lone honks from the nearest street, and then the best part, the canines.  There were a couple groups, each on one side of the compound, and I think all it took was a sneezing mosquito to get them going.  But, yes, hearing them made me feel more at home strangely, and I fell asleep thinking of my Lily and Jones.

Off for a 5 hour van ride to Chogoria tomorrow at 11am.

Peace