Embu Market

After four days of intensive briefings, my head was bursting with data. And more questions. I needed some time for the information to bed in. I needed to put some flesh on the bones. I needed to get to know Embu. And the best way to understand a place is to visit the market.

Early on Saturday morning, four of us jammed into a taxi and drove down the hill to the market area. There are four markets in the centre of town. The first is the fringe of the matatu (bush taxi) bus station. There are shops –  butchers, hairdressing salons, restaurants, general stores – and stalls selling snack food, huge hands of green bananas and leafy vegetables.

We worked our way through the tangled mass of matatus, already jammed full with people and produce but waiting for just one or two more passengers to maximise profits. “Never trust a man with a smile,” proclaimed the logo on one taxi. Maybe that would be good advice for buyers at the market.

In the centre of the matatu parking area, there stands a massive billboard advertising cane spirit. This is potent stuff, but costs just a bit more than a bottle of Tusker beer. There is a big demand for spirits in Kenya. On the television news this morning, Diageo / East African Breweries announced it was stepping up production. Meanwhile, illicit stills produce cheap rotgut which occasionally causes methanol poisoning.

At the corner of the parking area, there is a small muddy snicket leading to the covered market area. A first glance, this looks like a sea of jumbled produce and people. There may be an underlying logic to the arrangement, but it was lost on me. Sellers pile their tomatoes, aubergines, potatoes, avocados, bananas and whatever else they have, on their stalls. There appears to be no demarcation between one stall and the next. Indeed, some stalls don’t have scales, so they pass baskets of food to their next door neighbour to be weighed. And if they don’t have the correct change, they will “bum a few bob” from an old lady across the aisle.

Never buy what you see at first is a good maxim. Take your time and cruise the market, looking for the best quality produce. Avoid the temptation is to buy lots of stuff at one stall, spread your shillings around the community of producers.

There is another covered area, past the fishmongers, perhaps selling better quality goods. Up the hill, there is an open area selling massive cabbages, maize and bulky items.

I am always a bit wary when the price of items on a stall is always 100 shillings (equivalent to a US dollar). If I want to buy something there, I will try to bargain a discount or get a few extra items added to my shopping bag for free.

What did I buy? Courgettes, avocados, black and green, papaya, butternut squash, potatoes, sweet purple onions, green beans, carrots, tomatoes, oranges, tangerines, watermelon, pineapple and passion fruit. The stallholder explained that the green passion fruits are good for indigestion. It transpired that they are sweeter and less acidic than the darker variant, so they don’t provoke indigestion so easily.

Plastic bags were outlawed in Kenya last year, so I brought cloth carrier bags with me. We lugged our purchases back to the taxi so they could be dropped off at the house with two team members, while I explored more of the town with N.

Road trip

“What goodies shall I bring to the project?” I asked Dr E. She said, “The staff like sweets.” I thought that this was not such good advice because my new mission deals with chronic diseases, such as diabetes and hypertension. Sugar is the enemy! But I found I was wrong when I had my briefing in the office.

“What we want is Quality Street! Not Celebrations. As children we found out where my father hid the Quality Street and we ate them,” she said.

“Even the green ones?” I asked.

“No, they were our least favourite. We liked the red and yellow ones.”

“What about the purple ones with the soft toffee and the brazil nut?”

“We liked them too. When he discovered what we had done and he asked us if he was the father of thieves!”

My departure to the field was delayed by an enormous traffic jam caused by a lorry and trailer jack-knifing on the Mombasa Road. It had been loaded with cement, which was tipped over two carriageways of the highway. It had been raining since midnight, so the cement must have been setting. In my mind’s eye, I could envision workers chipping away at the hardening cement of the road surface, trying to clear the way.

We set off and joined the traffic jam. Some roads were raging torrents of orange water. Our twin cab Toyota Pickup truck ploughed through the flood, creating a bow wave. A truck passed us on the inside lane and drenched my side of the vehicle with a tsunami of muddy water. Unfortunately, I had left a crack of window open to prevent the glass from steaming up with condensation…

As we left the city en route to Embu, the rain stopped and we were able to make good progress. I sat back in the passenger seat and drank in the atmosphere. I made some notes:

Most locals use minibuses called matatus. Some matatus were named after Manchester United. Another was called, “Addicted to Jesus”. The message on a truck’s mudflap was “Almighty Leader”.

The side of a bus was painted with the Nike swoosh and the slogan, “Jesus did it.”

Motorbike taxi riders wore yellow tabards, advertising their sponsors. Some bore the name of the President. To shield passengers from the rain, a few motorbikes sported elongated umbrellas which must have limited their speed. But not as much as one man with a two-seater sofa balanced across the pillion seat.

About halfway to Embu, there is a village which is famous for its catfish. I spotted saloon cars with fish hanging from their wing mirrors, presumably to keep cool.

The countryside was verdant and sparkling after the rain. Villagers were slashing the vegetation at the side of the road, to keep the verges clear. Some workers had tucked their trousers into their long socks, which gave them a “plus four” appearance. The privet hedging around some of the petrol stations’ forecourts had been clipped in a more careful manner, with topiary which would not be out of place in the Home Counties.

Some of the roadside hotels had great names. “Beach Hotel” and “Red Soil Hotel” were two that stayed in my memory. We arrived in Embu just before lunch. Across the road from the office is the “Kryptonite Hotel”. The sign above the entrance glows green. It’s fortunate that I am not “Superdoc”.

 

 

Thursday Doors Palma 2

Noma or Not?

WARNING – CONTAINS A GRAPHIC IMAGE WHICH MAY BE UPSETTING

October 2017, Kutupalong refugee camp, Bangladesh.

It began with a misunderstanding. I asked the Rohingya mother how her baby had developed an evil-looking purple swelling on the side of its nose. I thought the nurse translating said that it had been caused by boiling water. It seemed to make sense – fragile newborn skin being splashed with hot water during cooking, perhaps in a dark, plastic-covered hovel in the migrant settlement area. It looked superficial, it should have healed swiftly.

I misheard. The nurse translating the mother’s response actually said that it started with a boil on the face, a small spot, a furuncle. Over the next few days, the skin changed from the colour of a bruise to a dark patch of necrotic (dead) skin. Another dull red patch developed on the baby’s ear. The neonate had already been started on antibiotics but without much obvious benefit. The lesion started to ulcerate. We added another antibiotic specifically for staphylococci and yet another for fusobacteria. We even added an antifungal drug, in case the baby’s immune system was so compromised that this was an opportunistic infection.

 

I have crudely blacked out the baby’s eyes to preserve confidentiality.

 

There is a great online tool for doctors working in remote settings called Telemed, which allows us to seek the opinions of a group of specialists from all over the world. With the mother’s permission, I posted a photograph of the baby on the Telemed website and waited for paediatric dermatologists to give their opinions.

The infection got worse. We asked for help from the Memorial Christian Hospital, who thought that the baby had Noma, otherwise known as oro-facial gangrene (cancrum oris). This normally affects older children and is incredibly rare in the neonatal period. The hospital doctors thought the baby might benefit from a special antibiotic only used to kill multi-drug resistant bacteria. The ambulance was ready to take them for therapy, but the mother refused. She needed permission from her husband to leave Kutupalong.

Did he have a cell phone? No.

Was he going to visit her soon? No, he was looking after the four other children.

A nurse suggested sending the police out to find him and bring him to the hospital to get his permission. We dismissed this as too heavy-handed.

The mother said that she wanted to leave the ward, against our medical advice. She said she needed to discuss with her husband and that she would return if he agreed.

A day after she left, the Telemed paediatric dermatologists came up with another possible solution – a strawberry birthmark (capillary haemangioma) which had ulcerated and become infected. There is a cure for the birthmark, propranolol, though we would struggle to find it in Bangladesh. We’d probably have to improvise and use a different drug, which is not licensed for this condition. The baby would still need treatment for the flesh-eating bacteria, however.

The mother never brought the child back to the ward. I still think about this child. How could we have handled this better? Tragic cases, like this one, occurred every day in Kutupalong.

Thursday Doors in Palma 1

Thursday Doors at Joan Miro Museum

The Museo Fundacio Pilar i Joan Miro overlooks the port area of Palma, Mallorca. There is another museum dedicated to the surrealist painter, Joan Miro, in Barcelona, but Palma is where he lived and worked at the end of his career. His roots were in Mallorca. The museum contains over 5,000 artistic pieces – paintings, drawings, sculpture, collages and graphic works.

The doors featured here are from his studio, Son Boter, an 18th Century rural house.

To the side of the studio, there is a barn door and an ancient wooden wheel. 

There is a fantastic exhibition of his work, “Miro – a wild spirit” in the main gallery, which is well worth a visit. In the gardens, there are some interesting sculptures which are not in the scope of Thursday Doors. But I can’t resist sharing the anthropomorphic planting signs.

Thursday Doors rural Mallorca

This door has been well-used. I found it in a tiny rural hamlet of Alquieries in Mallorca, while I was on a cycling holiday last month. 

There were some other choice gates and doorways in the village. I think that the door of number 69 has been turned upside down. Many doors have metal plates to protect the lower part of the door from water splashed from passing vehicles. This door has the metal protection on top. Quite ironic.

I rather liked the street lighting, even though the metal gate is disappointing. I guess it replaced an ancient set of doors.

Here I am, struggling up a long pass.