Kenya

I returned to Samaria with a Clinical Officer, Waweru, in tow to staff Samaria for the week in Susan’s absence. Susan has an obligation to attend training and program review for her participation in Tunza the family planning program supported in part by USAID. If Susan is not able to find a substitute during her absence, then she must close her clinic. In this case it would have been for 4 ½ days, difficult on the patients and Susan’s income. Even so, engaging a substitute adds costs to clinic expenditures, that may or may not be recouped from leaving the clinic open. This underscores the difficulty that private clinic nurses have in taking time away from their practice if they are the sole practitioner. It is difficult to engage in continuing education, a must for any clinical practitioner, if the economics and finding a trusted substitute are onerous.

So off Susan went Monday afternoon to a suburb of Nairobi for her meeting. And then the rains began! Waweru and I were busy with patients until it was time for him to head home to Nyeri. I realized that this relative “city boy” came to Samaria without gum boots or an umbrella. He trudged out in the rain in his dress shoes for what turned out to be a 4 hour commute back to Nyeri. This trip in dry weather is about an hour. Happily Waweru showed up the next day despite the rain and the convoluted travel requirements to avoid impassable roads.                                    

Gum Boots

 Waweru and I established a good rhythm in seeing patients and had time to share reflections about our respective training and commonalities and differences, which I will address another time. It is still raining!                                                                                            

Eight am the next morning I am called by Waweru that due to a family emergency he would have to go to his family home in Nakuru. He was trying to find me a substitute but to no avail. Hmmm. Given my knowledge of Kikuyu, it was going to be a real challenge alone in the clinic. Susan made some noises about coming home but in the end, it was me with the frequent  translating services of her sister Nancy for those patients  who remained perplexed by my words. There is nothing like being thrown into the deep end to bring you up to speed. Oh yes it is still raining, so realistically Susan would be hard pressed to make it home.

Fortunately no real emergencies arrived at the clinic. Patients were gracious and patient with my attempts at Kikuyu and communicating with them. Others were forced to use their English skills that otherwise might not have had Susan been there. Oh yes, it is still raining- I introduced the term “raining cats and dogs” to the local colloquium that week. It is very impressive rain.The first two days alone were busy despite the rain and while I tried to establish a rhythm of seeing patients, assessing for health complaints, being the pharmacist to fill the medications I prescribed, collecting payments, and entering patient visit information in the various registers, as required by the Ministry of Health.                                                                        

The MOH required registers

The “Well Child Visit” crib is a good perch after a long day.

 

I did use the early morning re-reviewing the MOH guidelines for managing childhood illnesses for under 5 years and various reference books on treating worms, amoebas, malaria, and typhoid. I was very glad that I also brought my Sanford Guide to Antimicrobial Therapy. During nursing school I did not fully appreciate the wealth of knowledge this guide supplied, despite its impossibly small 4 point character font! My roommate during the summer also recommended a midwife’s pocket guide that proves to be illuminating for this family nurse practitioner.

Susan returned home Friday night after an adventurous travel home that required hitching a ride with an ambulance on the main road which in fact got stuck and required 13 young men to push it out, after Susan promised to pay them each 50shillings the next day.

I was asked by one of my male blog readers what do the men. Well, in this area many young men wait along dirt roads waiting for vehicles to get stuck. Once stuck the men negotiate a fee, usually 50 shillings, and then push the vehicles out of the mud and muck. Kenya’s unemployment is estimated at 40% (of 39M) of which a large percentage is “youth”, resulting in many idle young men. As you may recall, I was told by more than one man that the construction work on the dirt road that was causing all the stuck cars was too back breaking to be worth the 250 shillings a day for men, however apparently not so for women. Pushing vehicles pay more with less effort. Others are using motorcycles to provide taxi service for people and goods in the smaller communities, that has improved some men’s income. I have asked whether there are co-ed groups or men groups engaging in micro-lending projects as an alternative. In this area there is beginning to be interest by men but it is a challenge I am told to build trust among the male participants. I see lots of entrepreneurial opportunities for men and women, however, there perhaps a lack of mentoring by successful men or men in leadership roles to pursue some of those opportunities.

Back to Susan’s journey: Susan was dropped off by the ambulance to walk about a mile up a hill across farms and along the so called road to Samaria without gum boots. She made it by 10:30 PM. And yes,  it is still raining.  In fact, I was to return to Mariine Maternity Home and Josephine on Sunday the 3rd and was delayed until Wednesday because of the rain.  I did manage to take advantage of a break in clouds on Saturday and Susan volunteered to add a little color to my hair.                                                                                                                


                                                                                                                             

Courtney Massaro
Frist Global Health Leader

Reporting from Les Cayes, Haiti

December 28
 
As I mentioned in my last post I’ve struggled with practicing as I’ve been taught and believe is best while also trying to respect how my Haitian counterparts were taught and what they believe is best practice.
 
There was a woman who came in in labor this week and when the doctor examined her he said that she would need an episiotomy (cutting the perineum to make the vaginal opening bigger) in order to give birth (this was long before the baby was even close to being at the perineum when something like that could really be evaluated). I had labored for most of the evening with this woman and thought of her as “my patient”, and was more than a bit frustrated at the prospects of her having an episiotomy. I told the nurses I was working with that I didn’t think she needed an episiotomy—and explained that in the U.S. the literature shows repairing lacerations is better than repairing episiotomies—and that if I caught her baby I wasn’t going to perform one.  Needless to say, I was not allowed to catch the baby and she got an episiotomy (and actually had quite severe post-partum bleeding, I believe in part as a result of her episiotomy).
 
I know that the nurses where just doing what the doctor ordered them to do (as is appropriate), and that they believed that performing an episiotomy was best practice, but it was still very hard for me to watch. I however, see no easy way to reconcile our differences in practice. Although I’ve tried to talk to the nurses about why we in the U.S. don’t perform episiotomies (and various other practices), at least in this type of society behavior change needs to come from the top (i.e. the OB/GYN chief) and not the bottom (i.e. night nurses). And although I feel very strongly about the issue I’m reticent to go to the head of the OB/GYN department and try to lobby for such a change. Part of that that is me being scared and non-confrontational, but it’s also hard given that this is what is believed to be best practice and still taught in the medical/nursing schools, and I’m “just” a visiting foreign new midwife lucky enough to have been allowed to work at HIC for these 2.5 months. So, I’ve done nothing—except never perform an episiotomy and have had many moms with no lacerations (when I was told an episiotomy would be needed) or well repaired ones. I know that’s not enough and that I’m not serving my patients as best I can, but it’s all I feel comfortable with doing at this point.

Courtney Massaro
Frist Global Health Leader

Reporting from Les Cayes, Haiti

December 22
 
As the providers at HIC (i.e. the nurses) have become more comfortable with me and my abilities I’ve slowly begun to help teach the nursing students who are present during my shifts. This week I got to help a couple of the students do deliveries, which were rewarding experiences, though ones I’m not (yet) totally comfortable with. In many ways I still feel like a student myself—I graduated from nursing school in May 2012 and this is my first job practicing as a “real” (as opposed to “student”) midwife—and so it’s a bit odd for me to already be put in a teaching role. That said, I really do enjoy guiding the students and helping them grow more confident with and skilled in catching babies.
 


Nursing students in uniform before their graduation


One of the hardest things about trying to teach here is that there are some birthing practices that are standard in Haiti that aren’t viewed as best practice in the U.S./developed world (i.e. they always clamp and cut the cord immediately, in the U.S. it’s recommended to typically wait at least 2 min, they perform perineal massage while pushing, in the U.S. that’s not recommended, they perform episiotomies very frequently, most midwives in the U.S. perform them very rarely). So although I may be coaching a student through a delivery, advising her using recommendations from the U.S., often times one of the nurses will “correct” the student and tell her to do something very different than what I’ve just said. So that is sometimes frustrating for both the student and me. I’ve now started saying, “in the U.S. we do this” and trying to explain why I recommend doing something “my” way versus the “Haitian” way. And after hearing my explanations and watching me practice, some of the providers/students are slowly adopting at least the delayed cord clamping, which I’m happy about.
 
This week I was doing the admitting paperwork on a woman who came in in labor. I know how to ask some basic questions in Creole (How old are you? What’s your name? How many babies do you have? etc) and so went through those with her.  For the more “complicated” question (Where were you born?) I switched to French, hoping she knew how to speak it—which she did. Her reply—Jamaica—surprised me, and prompted for me to ask her if she spoke English—which she did also. So throughout my night laboring with this woman we had conversations in a mix of Creole, French, and English, which made me smile. I know for Haitians and most people around the world speaking multiple languages is nothing exciting—and I mélange French and Creole normally with all my patients—but having that English thrown in (with her great accent to boot) was a treat.

Elizabeth Harris

Vanderbilt University

Samaria, Kenya

So I have moved temporarily for the week to the Mariine Maternity Nursing Home outside of Nyeri to work with Josephine Gikunja. I will go back to Samaria next week while Susan attends a training workshop. Susan has enlisted the services of a Medical Officer (Physicians’ Assistant) to work with me and help with translation.

Josephine started Mariine clinic in 1963 and just celebrated her 77th birthday. Marrine means swamp because the location was called a swamp. For all my midwife colleagues, this clinic is like “The Farm” in longevity and success in maternal and infant care. Josephine, like Susan, is a midwife and a family nurse practitioner. As far as I can tell, Mariine clinic never closes. If there is a laboring or postpartum mother, Josephine sleeps on the ward.

Josephine

I am happy to report that a baby was delivered at the very last minute of Thanksgiving Day. No fancy scrubs at Mariine for a delivery. We donned plastic rain ponchos with hoods and long plastic aprons for the event. After a short and uneventful labor, this Gravida 1 mother delivered a baby that tipped the scales at half of what I weighed at birth, small but none the worse for wear. I was sure that with the labor we were in it for the long-haul. I couldn’t see much progress in getting the head out, but Josephine knew almost to the minute of when the baby was coming out. Although I was there for observation and moral support, I was put in charge of Oxytocin and Vitamin K injections and cleaning and swaddling the newborn. I was glad I paid attention to my day in Delivery at Vanderbilt hospital. I will spare the details of the delivery, but you midwives would have been impressed – good looking placenta.

It was an unusually quiet week at Mariine for patients and deliveries. Patients come for all parts to see Josephine with much the same ailments I saw at Samaria. Josephine lives on the compound of the clinic. I now have electricity and plumbing “amenities”, which surprisingly I did not miss much at Samaria except when I needed to charge my computer or write at night. Josephine’s  compound is home to two rather grand avocado trees which I am offered  fruit  from most morning noon and night. It is one of my favorites.  The compound is about a kilometer from the main road and only about 10 minutes by car from Nyeri center. I took a walk to the “shopping mall” about a mile away in the other direction with Josephine’s son, Peter to get the lay of the land. I created quite a stir, but only one boy was brave enough to come up to shake my hand. I continue to startle people with my few words of Kikuyu. Hardly a day goes by when a school age kid is reduced to fits of giggles when I talk to them, and that is when I speak English.

The view up to the clinic from Josephine’s home

I return to Susan’s on the 26th but return to Mariine on December 2nd for a few weeks. There is a professional nursing society meeting for private clinic nurses on the 7th and Josephine will take me to meet and talk with other nurses. There is supposed to be a nurses’ strike starting December 3rd, but it is not clear if the private nurses are being asked to participate. Regardless, Josephine will be open to do deliveries.

Courtney Massaro
Frist Global Health Leader

Reporting from Les Cayes, Haiti

December 13, 2012


First off, an update on the two abandoned babies: they were not there when I went to work after my three days off. I was told that the girl (who was very cute and term) had been adopted, while the boy (who was a premi, but seemed very healthy—though of course small—to me) had died.

Working at HIC has certainly taught me a great many things, none more so than how to multi-task. I’ve gotten used to—though certainly haven’t mastered—watching the perineum’s of two women who are pushing wondering who will give birth first and if I’ll have adequate time to change gloves to catch the second ones baby, to do the admission paperwork while making sure that a resuscitated baby is still breathing appropriately, and to triage patients while checking frequently for the presence of the baby’s head of a woman squatting and pushing on the floor. I’m forever impressed at what the nursing staff (as they are the main staff that run the maternity) do every day. As I say I’ve gotten used to this type of work environment, but it still stresses me out and makes me anxious. They however, are so used to it and so good at balancing multiple patients at once, that I don’t think they even notice it at this point. I think it’ll be a bit of a transition to go back to the U.S. and for each patient to have her own room (instead of an open room with three tables) and to have to certainly still have to multitask, but in a very different way.

This week I had the pleasure of visiting the Maison de Naissance (MN), a birthing type center about 30 minutes from Cayes. MN is located in a tiny town pretty far off the main road and provides much needed services to the women in the area (many of whom would never come all the way to Cayes to give birth and so would just give birth alone, or with a traditional birth attendant). MN had 7 post-partum beds, a two-bed birthing room, provides prenatal consultation serves, and birth control services (among other services). It was really nice to be able to visit MN and see a different type of birthing environment. Because MN is smaller than HIC, it was much calmer than the maternity ward I’m now used to—though I was told I visited on a very calm day. It was wonderful to see what good care the midwives were able to offer the laboring women and those who came for prenatal consultations.  High quality clinics like MN are invaluable—in my opinion—to Haiti as they provide skilled birth attendants and health care services to women in rural areas who wouldn’t typically make the journey to the nearest hospital, but nonetheless need/deserve such healthcare.

Courtney Massaro
Frist Global Health Leader

Reporting from Les Cayes, Haiti

December 6

My last three nights at the maternity were good, but really, really busy. I caught 13 babies (in 3 nights)—which even for our relatively high volume maternity is a good number of babies (since I wasn’t the only provider catching babies).  Most of the deliveries were beautiful normal births, which was really nice.

The worst part of having busy nights is that inevitably women have to sleep on the floors. It’s always so sad for me to catch a baby, and get the mom and baby all cleaned off and dressed, and then have to tell them to try and find a spot on the floor to sleep. But, that’s how it goes when you have 20 beds in the maternity ward and more than 20 patients (and no overflow beds). Luckily, the post-partum women don’t have to stay in the maternity for that long (I try to make them stay for at least 6 hours so I can monitor their bleeding, but that doesn’t often happen), so at least they don’t have spend days on the floor.

The one unexpected addition to my night shifts was two adorable, abandoned babies. One is a term girl, the other a pre-term, but healthy boy. Both had been delivered at the maternity and for whatever reason their mom’s had decided not to keep them. When I asked the nurses what was going to happen to the babies no one seemed to have a very clear idea (we evidently don’t have an orphanage in town). So the babies just hung out in our non-functioning baby warmer in the delivery room. Someone had gone and bought formula—and eventually diapers—for the babies, so in between seeing patients/catching babies I’d feed/burp/hold/change the babies as needed. Evidently HIC is the hospital in town where people come to abandon their babies, and Haitians looking to adopt know to come to HIC to try and get a baby (though I’m told adoption by Haitians is very rare, so I don’t think that happens very often).  I hope that when I go back to work tomorrow the babies aren’t still there, though I won’t be surprise if they are.

I had the recent fortune to experience the hospitality of one of Susan’s close friends who lives down the “road” from Samaria clinic. Esther is a farmer and has about 3 acres of land of which she farms about 2 ½ acres. She started off as a secondary school teacher but returned to her family roots of farming. She is married to a secondary teacher and has three children.       

Esther belongs to a micro finance group of woman farmers who work together to grow and sell snow peas, French beans, flowers, corn, carrots, spinach , garlic, onions, potatoes and kale. Although snow peas are not a vegetable consumed in Kenya, these women grow snow peas for export to Asian and European markets. The group used their resources to have their soil analyzed for optimum growing and have established some relationships with wholesalers for their produce and flowers. They also are working to provide direct sourcing for Nairobi supermarkets and hotels. As a result of their efforts, they have seen up to a four times greater yield and moving toward more control of pricing and understanding market needs.

Esther and I had an interesting discussion about prospects for the children and young adults in the area around Samaria and Ndathi.  I understand that the previous generation was squatters on the land and in 1992 or there about the government issued each family a half acre of land. Although that land may sustain the immediate family’s needs, a ½ acre cannot be divided among the children and their families in any meaningful way.  Many of the young adults do not have role models for education beyond the 8th grade, and this is reflected in their limited education level and aspirations. Ester agreed that the priority for this community needs to be education, so that the children have opportunities here and elsewhere. I try and ask the teenagers about their plans after secondary school and many have aspirations, but paying school fees to complete secondary school is a huge challenge for most of the children’s families.

Susan’s sister Nancy oversees a small library that was set up on the compound with the backing of a young friend of Susan. The Kubaru Library is open most afternoons after school and during school breaks also in the morning.                                                              

Nancy in the library with a student who is studying for end of term tests.

I spoke to a couple of kids who come after school to read and study. They would like to have access to more books that support their curricula and some novels about other places. School is now out for the term and even so there are a passel of students who come to this library. Sometimes they have to set up benches outside as 30 kids can be there at any one time. It is heartening to see how many kids want to have access to more and will take pleasure in what we would consider limited.                                                                        

I am struck with how much the women in this community look for ways to support their families. You can see it in the number of micro lending groups in the area and women participation in road projects. Susan’s daughter Njeri manages Kihiga Kirakana Foundatioon Company Ltd. (Burning Bush micro lending company)that has about 25+ groups of women (15-30 in a group) participating in the merry-go-round lending for projects that each group identifies. These women meet weekly to make payments to the loan and discuss opportunities and challenges of meeting the loan payments. The loan repayment among these groups is 99%+. The group meetings also is an opportunity to promote health education, children’s education, and family planning, as well as discuss other community issues.

Additionally, the women of the nearby communities are working on the road development, sadly not the road to Samaria! Instead of road machinery to do the work, the contractor is using local people. Although this produces income for some, it is felt by the men of the community it is too little to make it worth the backbreaking work, resulting in 90% of the workers being women. Hmmmmm.

Waiting for the screening.

Things at the clinic perk along. We had cervical screening day with free IUD insertion and contraceptive implants. Susan is part of a family planning network called Tunza and one of their nurses came to help us for the day. It was a busy day. I did the VIA/VILI screenings and Susan did IUD insertions and Joyce the implants. Women of all ages came and were eager to take advantage of the 60 cent screening and free IUDs and implant services. You may recall from my last entry that VIA/VILI screening is done to determine if PAP smears need to be. The VIA/VILI screening with white vinegar and Lugol’s iodine are used to identify any cervical epithelial changes. By the way, Zesta vinegar is the vinegar of choice! We saw a lot of cervicitis and unfortunately several abnormal findings that required referrals.  For many women this was the first or one of a few screenings that these women had ever had.

Courtney Massaro
Frist Global Health Leader

Reporting from Les Cayes, Haiti

November 30


Yesterday and today I participated in a training called “Helping Babies Breathe” (HBB). The training materials are produced by the American Academy of Pediatrics, and our training was put on by a number of American doctors who do HBB trainings all over the world. I was lucky enough to be able to also participate as a trainer in the training, which was a lot of fun. There were about 40 people at our training—mostly nurses, though there were also a couple of doctors (but sadly no midwives). I had 6 women (all nurses) within my small training group.

The HBB curriculum teaches participants how to resuscitate a baby in resource-limited settings (i.e. all of Haiti). Using a Neo-Natalie blow-up baby I taught my group the basic steps of drying a baby, suctioning his/her mouth and nose, performing stimulation, and using a bag and mask to perform ventilations—all in hopes of resuscitating a baby who is born not breathing.  We practiced various scenarios including: a baby born with clear amniotic fluid, with meconium, with the baby crying right after having been suctioned, and with the baby not crying or getting a high heart beat after correctly being ventilated for a number of minutes.  Each of the participants were given training materials to use back at their specific clinics/hospitals to train additional staff, as well as a number of bags/masks and bulb suction devices to now use to resuscitate babies.

It’s amazing to think that such inexpensive/relatively low-tech products like a bulb suction device and a bag/mask can have such a dramatic difference on a baby’s outcome. It’s also very sad to think that without the proper training even in the presence of such devices, many providers here don’t make use of them.

I’ve had to resuscitate a number of babies at HIC, and each time I’ve been the only provider helping with the resuscitation. Often the nurses have told me that a baby looks dead—and why should I try to save him/her? When I have responded that the baby has a heartbeat, and is in fact not dead—which is why I’m working to get him/her to breathe again—they have laughed and thought me foolish. That mentality however, I think—I hope—is slowly changing. As the nurses I’ve consistently worked with have seen the fact that with proper resuscitation a baby can be brought “back to life”, they are at least telling me that they now see the utility in not automatically giving up on a baby, but instead trying to work to make him/her breathe.



No one from HIC came to the HBB training—despite the hospital having received a number of invitations—which is sad, but the training has inspired me to use any downtime during my night shifts to train the nurses I work with. Hopefully with such training—and seeing my example of resuscitating every possible baby—the night shift nurses will learn the HBB techniques and will be able to pass it on to the other maternity nurses, and save lots of babies lives in the days/months/years to come.

Likewise, I hope that the providers who were trained in the past two days go back to their institutions and train others—or at least serve as an example and spark some discussion—and in doing so help babies who might otherwise not been given a chance.

Courtney Massaro
Frist Global Health Leader

Reporting from Les Cayes, Haiti

November 22

First off, Happy Thanksgiving. I have an incredibly blessed life and am thankful for many things—but most relevant to this post is the fact that I’m thankful for the Frist Global Health Leaders Program.  Because of it, I have been given this amazing opportunity to come to Cayes and work at HIC. It has been—and I’m sure will continue to be—an incredible experience, and I am so grateful for the Program and for having been selected for it.

HIC as a hospital is trying to improve its HIV testing rates (a goal that I think is true in most hospitals in Haiti).  As such, testing rates are now closely scrutinized, and it has become clear recently that the maternity has pretty low rates of testing women while they’re here to give birth (last month was about 25%).  That low rate is in large part due to the fact that most women who come to the maternity have already been tested once during their pregnancy—sometimes multiple times—and so don’t need to be tested when they come to give birth. (The women who have had prenatal consultations typically bring their prenatal card when in labor, and that shows if/when they were tested and the results.) There is still however, a portion of the pregnant women who haven’t been tested—typically those who haven’t had any prenatal consultations—who do need to be screened when they arrive to give birth.

Between the hours of 9am to around 4pm those women who haven’t been tested can easily get tested, as there’s a woman who tests pregnant women—typically it’s those women who are at the hospital for their prenatal consultations, but she happily tests ones here to give birth too (and I’ve sat in and watched her counsel women and she does a great job). The problem however, is that when this woman isn’t at the hospital the pregnant women who haven’t been tested, can’t get tested. So for most of the afternoon, and all of the night shift, we aren’t able to test women who haven’t been tested during their pregnancy. This is particularly difficult given the short amount of time that the women stay in the hospital after they give birth (an average of 6 hours). I had a woman on Tuesday come in, give birth around midnight, and then want to leave at 7am. I tried to convince her to stay until 9am to get tested—she sadly stayed until around 8am (I checked on her before I had a delivery and she was there, but when I finished with the delivery and went to see her again she was gone).



We’re trying to work on ways to address this problem—but as far as I can tell it comes down to the lack of money to pay someone to offer testing during “off hours” and the lack of motivation on the part of the nurses/doctors/midwives. Until a real solution is found I’m just going to try to beg women to stay until they can get tested in the morning (which I was successfully able to do on Wednesday).

Greetings

I have been with Susan for three weeks and have gotten a feel for how things work around here and the kinds of patients that come through the clinic. On Wednesday patients come in for vaccinations. Susan stores her vaccines at another facility because of lack of electricity and the cost of fuel to run a generator for the refrigerator. That has its costs as well since she has to pay transportation costs to go and retrieve the vaccines. Vaccines are provided free from the government and Susan charges a nominal fee for administering vaccines.

Last week it was announced that there was to be an area wide measles campaign for children less than five. We had about 200 little ones come through the door with various family members over 2 ½  days. It was an exhausting couple of days. We ran out of vaccine one day and many of the woman had walked far to get here. They were not very happy to have to return and have another a day away from farming etc.. We decided to draw straws for the last 4 vaccinations among about 30 women. There were very eager mothers to draw the right straw!

Open wide for a few drops of Vitamin A…before the injection

 

In the end I terrorized little ones, some because I gave them an injection and others because they have never seen a white person PLUS I gave them an injection. Susan and I did trade off making the kids cry.  

I did have the pleasure of meeting up with a cheerful four year old girl named Janet a few days later at a home of a friend. She announced to me that I had INJECTED her and showed me where I had committed the crime and the smudge mark we had made on her little finger indicating she had the vaccine. She seemed to forgive me.                                              

Janet showing me “the” arm

In the meantime my midwife friends would be happy to hear that I can actually find fetal heart beats and am batting about 50% in figuring out if the fetus head is engaged. I struggle with arms and legs and sometimes I think the head is the butt, but I am learning. The mothers seem tolerant of my role in their care and Susan tells me I am getting better at it. Note to my family practice friends, ante-natal care is a nice change from the sick patient. If you are in a rural area, it is a good skill to have, as long as you have a good referral network.

Warning for the squeamish, you might want to skip to the next paragraph or two.

I have now watched a couple of birth control “rod” implants in women’s arms. I am scheduled to do the next one that comes through the door. For those not familiar, a small incision is made in the underside of the upper arm and two flexible hormone rods about an inch long are inserted just under the skin to provide slow release of contraceptive hormones. No sutures required. The rods allow for five years of birth control or until taken out. It is one of the Millennium Goals for Kenya to emphasize long-term birth control options to improve the health of the woman and children. Spacing and fewer births are important for that goal. Both public and private clinics will be required to meet the goal.

Also, for all of us who are familiar with the PAP smears, the way that cervical cancer is detected here is definitely less costly and immediate. A sterilized cotton swab is soaked in household white vinegar, although I am told all brands are not alike. The swab is applied to the cervix. If the tissue reacts by turning white (VIA +), then you have a suspect case. Then another swab soaked in Lugol’s Iodine is applied the same way, and any tissue turning yellow is again suspect (VILI +). I had read about this method being used in India as well. Susan says she has found a few cases that were referred for treatment. Only one patient she referred died as the cancer was too advanced.

Otherwise we are seeing out share of respiratory infections, worms and amoebas, cuts, and rashes. There is no such thing as a text book case of any rash here! I recommend to my colleagues never leave home without an atlas of dermatological conditions and treatments. Furthermore, I was shown today a Nairobi fly that looks more like a long skinny beetle with longer antennae. If you are bitten you get shingle-like rashes. Having had shingles, it is one African experience I shall avoid.

Susan’s neighbor brought me Arabicum flowers and beet roots from her garden to welcome me to the neighborhood. The flowers are sold for export for about 10 shillings a stem (85 shillings to the US $). Consider that when next you buy flowers.

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