Categories
Kenya

Trout Tree

 

Good restaurants are thin on the ground in rural Kenya. The two doctors who were here in Embu before me would drive two hours to a restaurant outside Nanyuki called the “Trout Tree”, just for Sunday lunch. Well, anything is better than rice, beans, cabbage and chapattis after a while. We had already planned to stop here for lunch on our way back from our safari at Ol Pejeta.

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We got there quicker than we had anticipated at 11.30am, too early for lunch. A large group of safari tourists were already moving down to the restaurant. “Why don’t we go for a walk until 1pm and reserve a table once this group has moved on?” I suggested.

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The restaurant is built into a massive tree. It overlooks the trout farm. In the forest surrounding the farm, there were troops of colobus monkeys. The staff of the restaurant fed the monkeys at midday so they would come for lunch at the same time as the customers. They were a good tourist attraction. A few tree hyraxes (about the same size as a large rat) visited the diners on the top floor of the restaurant.

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The maitre d’ was rather flummoxed by our request to be shown some walking trails. “There are none here. This land is all owned by farmers. Why do you want to go walking anyway? Why not sit in the bar and wait for your table?” We didn’t believe him and walked up the steep drive to the main highway. Across the road, we could see a rough track.

We followed the track up to a radio tower on the hillside, enjoying the clean air and sunshine. We could hear voices in the woods but no one came to chastise us for trespassing. By the time we got back to the treetop restaurant, it was 1pm. The big group of Safari tourists were just leaving. I quizzed them about the food and they recommended the trout. Well, they would, wouldn’t they?

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We settled into a prime location and waited for the waitress. Service was extremely slow. It started off badly when my Danish colleague saw Carlsberg beer on the menu and ordered an ice cold bottle. It was not available, so he had Guinness, but was concerned about its provenance as the label had come adrift in the ice chest where drinks were kept. He wasn’t impressed by the smoked trout pizza, either. He kept us amused by reading out bad reviews from TripAdvisor as we waited for our food.

I asked for plain tap water and the waitress refused to give it to me. She said, “If tourists drink our water and get sick they will blame the food at the restaurant.” I told her that I live in Embu and drink the water from the tap, but she still refused to serve me. However, I had some wholesome vegetable soup, followed by the grilled whole trout with garlic butter and chips, which was very tasty.

We ordered tea and coffee with home-made biscuits but were given fresh fruit salad instead. After pointing out the mistake, the waitress said we could have it on the house, free of charge. But what about our tea and biscuits? It took a long while to get lukewarm water and tea bags. By this time it was almost 4pm, time to get back to Embu before darkness fell.

Categories
Kenya Medical

What am I doing here?

I often ask myself the same question.

We are supporting the Kenyan Ministry of Health’s policy to improve the management of chronic non-communicable diseases (NCDs – hypertension, diabetes, asthma and epilepsy in the first instance) in rural clinics and health centres. Before we started work in Embu in August last year, most people with NCDs went to the local district hospital for treatment or attended a private clinic. We think that highly trained doctors working in hospitals should be treating more complicated conditions, and leave the simpler stuff to primary care. If this scheme is implemented throughout Kenya, it will save the Ministry of Health billions of shillings.

Eleven months later, almost 2,000 patients with NCDs receive their treatment at their local health facility, where local health workers have not just been trained, they have been mentored to improve their knowledge, skills and attitudes.

The usual approach to training rural health workers is to get funding from an aid agency to run a course in a hotel conference room. After eight hours of death by PowerPoint, the health workers get a certificate and are considered trained. We are using a different approach, mentoring.

Our 12-strong team of highly trained clinical officers, nurses and health promoters have been trained to mentor health workers in five rural health centres and two dispensaries. The cycle lasts for six months, with weekly visits, a structured learning programme, one-to-one teaching, observation of clinical practice, etc. The mentoring team uses a set of disease-management guidelines which have been specifically designed for rural Kenya. These can deal with over 90% of the patients we see, but when the guidelines don’t seem to fit, the mentors ask for advice from the expatriate doctor.


All that wheezes isn’t necessarily asthma.

The mentor asked me about a 65-year-old lady with rheumatoid arthritis who had a year-long history of expiratory wheeze, nocturnal dry cough and chest tightness. She said she had cooked for years using dried cow dung in a restricted kitchen area. She didn’t smoke, but her husband had done in the house for years. A few months ago, she had started taking 10mg prednisolone (steroid tablets) for arthritis, which had helped to improve her wheeze. The steroids were stopped and her wheeze came back.

Examining her she had widespread expiratory wheeze. Her peak expiratory flow doubled after salbutamol inhalation. I concurred with the mentor that the diagnosis was adult-onset asthma, which is pretty rare.

Contrast this with a 45-year-old man who had attended the health centre with shortness of breath and a cough a week previously. The nurse (not on our programme) had treated him with two different intravenous antibiotics, oral antibiotics, salbutamol tablets and antihistamines. The nurse had diagnosed asthma and asked him to come for review when the team attended.

On closer questioning, the patient said he was feeling much better. He had similar episodes once every two or three years. Clearly, this was a chest infection, not asthma, as the unmentored nurse had thought.

Another lady with a 20-year history of asthma treated with salbutamol tablets (we stopped using these in UK general practice when I was in medical school) had enrolled in our NCD programme a month ago. She had been prescribed a reliever (salbutamol) and a preventer (steroid) inhalers instead of tablets. She told us that she had only had one attack during the past month when she had been caught in the open by a cold rainstorm while she was farming. It became apparent that she had been using the steroid for relief and the salbutamol for prevention (the wrong way round). Still, even so, she felt better. She will improve even more when she uses the inhalers properly.

It is really important to spend time with patients to understand how to use their inhalers. We don’t have any placebo inhalers to demonstrate technique (I am working on this). When observing our mentor in the consulting room, I saw one lady who managed to use her salbutamol inhaler upside down. When she eventually managed to fire off a dose, the gas was unable to get out of the closed mouthpiece and came up alongside the aerosol canister for her to inhale.

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Categories
Kenya Life Thursday Doors

Thursday Doors – the Mother Lode

While visiting the Ngong Road Racecourse watching the Kenya St Leger, I messaged my father in England (who has an uncanny knack of picking winners). He replied, warning me of a storm forecast for 5pm. We called a taxi and left the track at 4.30pm. There was a traffic jam on Ngong Road. There is always a traffic jam on Ngong Road. The first juicy raindrops fell just as the taxi arrived at 5.20pm.

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On the way home, we passed the birthplace of doors. Still being held up in the jam, I was able to take some photographs from the taxi.

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These are for the rich folks. The poor people get by with doors like this.

Categories
Kenya

Shops at the Roadside 2

More photographs of colourful shop fronts. Here’s a Guinness harp.

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Cape Jolly is a great name for a hotel, even if it sells batteries and Selfies, as well as meat and choma 24 hours a day.

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El-Bethel Ministries International God Rescue Church – it’s all there in the name.

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New Luck shop is next to Wamuria Salon, selling cosmetics.

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Uptown (as opposed to Downtown) Pool Table, next to the Pork Centre (scratchings between frames?).

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And there’s always a casket maker. Nanyuki Coffins Place also sells flowers, which is convenient. There is pink coffin just inside the door.

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Bumps View is a strange name for a Bar & Restaurant. Overlooking the antenatal clinic? The annex (sic) is not the shelter next door.

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Mathy’s Shop continues the gold and green colour scheme of the Travellers Park Pub.

Categories
Kenya

Shops at the Roadside 1

Driving along Kirinyagi County’s dirt roads is a colourful experience. The first photograph shows the first-floor decoration of a pub, advertising Tusker Beer. Below it, there is a butcher’s shop and a restaurant providing choma, or barbecued meat. The white box with a red stripe is used to transport meat. For sale in the small market, there is maize, cabbages and carrots.

duka is the Kiswahili word for shop. This one is dedicated to the memory of Amos Ndata. I am sure he would have appreciated the pink, brown and duck-egg blue colour scheme.

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Mopers hard WARE has three children moping about outside. It had been raining in the night, so it was not surprising to see two of the boys wearing wellington boots.

At the Stage Butchery next door, some adults are also moping about. The girls in the doorway are wearing their frilly dresses for church, but it is so cold that they have donned woolly hats and jumpers. You can just see haunches of beef hanging up behind the window bars.

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According to “Rise Up” enterprise, Toss detergent and Golden oil form our shopping heritage. The artwork is good, but on the Shaker’s Bar, it looks as though the artist was paid in beer. Butterflies?

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More butcher shops, more great illustrations and gaudy colours.

Categories
Kenya

Swimming Pool

One of the things I find difficult about living overseas is not being able to get enough exercise. I love to swim, so I was delighted when I found several swimming pools in Embu. When I arrived, I asked my Kenyan colleagues about which was the best pool for swimming lengths, but no one knew. I asked a taxi driver, who came up with half a dozen. I made an arrangement with my colleagues, whom I had infected with my enthusiasm, to do a “pool crawl” in the taxi on Sunday. Unfortunately, my colleagues preferred to have a lie-in on Sunday, so I decided to go exploring for pools on foot by myself. The weather was perfect, warm sunshine and cotton-wool clouds in a blue sky.

I found the Royal Minni Inn, which had a small pool with a boom across the shallow end to keep non-swimmers boxed in. This left about 15 metres to swim in, which isn’t enough. One kick off from the end wall and I’d be at the boom. It had a gym with some basic equipment and a mirrored room for aerobic dance classes accompanied by thumping drum N bass music. A sign on the wall read, “No Idle Sitting”. It was cheap, but I didn’t stay to loiter.

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Some of the pools were in hotels on the outskirts of town. My idea was that I would go to a pool after work at 5pm and get home by 6:30pm, so I’d prefer a central location. The best I found was the Panesic Hotel’s “L-shaped” pool, about 20 metres long with a children’s area off to the side. On the poolside, there were small circular tables with parasols where people were eating.

I thought it was promising, so I telephoned my colleagues who had taken a taxi to the Mountain View Hotel, a couple of kilometres out of town. I decided to join them, but when I arrived it began to rain. I joined them at the poolside. I thought it was rather comical all the people in the pool got out as it rained more heavily. After all, they were already wet. Then there was a peal of thunder and I realised it wouldn’t be safe to be in the water if there was a lightning strike.

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The curved, shallow pool was divided in two by a rope, with children on one side and cavorting adolescents on the other side. It wasn’t suitable for swimming lengths, though if I fitted a rudder between my buttocks, I could have swum in circles.

One of my Nordic colleagues had not applied sunscreen and he looked like a boiled lobster. I told him he needed to cover up and stay out of the sun. We ate lunch under a parasol (masala chips, pizza and fish and chips) but the service was slow and the food mediocre.

It took about three weeks for his sunburn to heal. One doctor suggested that he take a cold shower and it would be better in a few days – she had never had to deal with Scandi-skin before. I offered to get him some hydrocortisone cream, but he’s a big lad and there was a lot of sunburn. Searching the internet came up with spraying menthol shaving foam all over his body, but we couldn’t find any in town. And his skin was far too sensitive for it to be shaved.

Eventually, he was able to venture out during the daytime at weekends without being in pain and we walked down to the Panesic Hotel. A large notice outside the changing room said, “Pay here before entering the pool,” but the booth was empty. On the far side of the pool, there were half a dozen young men dressed in black trousers and white shirts, sitting around, chatting. I asked them if I could pay them, but they said that they were waiters. “Shall we wait with you waiters until the manager comes?” I asked. They thought this was very funny. One walked off to the main reception and eventually, someone came to take our money.

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We got changed in a dingy male toilet with a bench and no lockers. There was an audible gasp of astonishment when the Kenyans sitting at their shaded tables had the double shock of seeing a pink man and a white man wearing budgie smugglers walk to the poolside. We commandeered a table and got into the water. It was about 25C, cooler than an indoor pool in the UK, but pleasant in the sunshine.

We had just started to swim lengths when a crowd of young men joined us. Some decided that they wanted to practice diving from the side, others wanted to race. I waited till the activity died down and resumed swimming laps.

The water was slightly cloudy and there were no markings on the bottom of the pool or the wall, so when I was swimming fast, the wall loomed very quickly into view. I had to be on my toes in order to avoid crashing into the wall. At about 5pm, it began to get windy and I could see thunderclouds across the valley. It was time to get out.

I didn’t use the tap in the changing room to shower off the chlorine; I felt safer with the chlorine still on my body. We chatted to the gang of waiters who had not budged since we had arrived. I asked when would they be serving food, and what was it like. One man replied that it was the best in town. “Really?” I asked. “Yes, but I have to say this because my job depends on it,” he replied. Honesty.

Since then, the weather has been too cold to go swimming in an unheated pool. It is winter here in Embu and although today the temperature hit 24C, it rained heavily last night and it was cold this morning. Perhaps by Christmas, it will be perfect for swimming.

Categories
Kenya

Buses with Attitude 2

Some coaches have been converted from trucks, like this green one. Others sport the livery of soccer teams, usually from the Premier League – Arsenal, Manchester United and Chelsea being the most popular. Others are named “Compliant” or “Reliable”, aspirational targets perhaps, relying on the power of prayer and other spiritual messages.

But sometimes, as in the last photograph, it all goes horribly wrong.

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Categories
Kenya

Buses with Attitude 1

The buses of Nairobi usually have extravagant paint jobs to make them more attractive to paying customers. Some feature celebrities or famous figures, such as Muammar Gaddafi. Graffiti style is popular. And there is always some Christian iconography.

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Categories
Kenya

Nairobi National Museum

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I had to cross eight lanes of traffic to get to the Museum, but it was worth it. I had to sign in at the gatehouse, show my residence permit (I have diplomatic status, but not like Boris) twice and pay the US$6 fee. This got me into the museum and the snake park. Viewing the dinosaur in the gardens was free.

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The main galleries are arranged around a central hall. This has an artistic pile of calabashes, a map of Kenya made from butterflies and a remarkable necklace made from feathers. On the ground floor, there is an exceptional collection of East African stuffed birds in glass cases. The note cards giving the name of the bird, its habitat and snippets of information have been typewritten. This makes the presentation look dated, but the exhibits are phenomenal. Look at all these different types of hornbill, for example (and I only photographed half of them). There are almost a thousand specimens on display.

I could have spent an hour scrutinising the birds, but I had to attend a meeting in the afternoon, which was the reason I was in Nairobi. Also on the ground floor, there was a collection of mammals and a fascinating exhibition displaying skulls of hominids found in the Rift Valley. The oldest human remains found at Baringo date from 7 million years. Kenya was the place where apes evolved into humans. I stopped to watch a flickering video loop showing how scientists investigated the surface of teeth of different hominids using a scanning electron microscope to find out what they had been eating.

On the gallery of the first floor was an exhibition of the life and paintings of Joy Adamson (“Born Free” the book describing how she reared Elsa, a lioness). These showed flowers, fish and fierce warriors from different tribes.

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George and Joy Adamson – typical colonial picnic, with HP sauce and big cat

I enjoyed reading about how a traditional healer used goat’s horn to store herbal remedies, keeping all his paraphernalia in a satchel rather than a Gladstone bag.

There were glass cases containing children’s toys, masks and skeletons. A large part of the upper floor was occupied by an exhibition of the struggle for Kenyan independence, with photographs of the mau-mau commander, General China. The exhibits were quite outspoken, openly criticising corruption.

Finally, there were a couple of galleries devoted to modern art – colourful, a bit derivative, pleasant, but nothing I would want to have on my living room wall.

I walked down the hill to the snake park. It was looked a bit drab and needed some renovation, new snakeskin if you like. In glass cases built into the wall were black and green mambas, puff adders, spitting and non-spitting cobras. In the courtyard pit, a boomslang twisted around a sign which read, “Trespassers will be poisoned.” There was a massive African rock python in an open area and another which was housed in a shed. Its keeper brought it out to drape around the shoulders of brave tourists willing to pay a fee. Behind a fence of chicken wire were three Nile crocodiles, looking very bored.

On my way back to the entrance, I strolled through the botanical gardens. A group of workers clad in blue overalls were sprawled on the grass, sleeping in the weak winter sunshine. A park attendant walked past and threw a stick at one of the sleepers. He woke up, rubbed his eyes and went back to sleep.

There was an old, faded red postbox in the garden, overgrown with creepers. It didn’t look as though anyone would be making a collection from it.

Categories
Kenya Medical

Psychiatric Unit

“He dropped out of school because he was receiving messages from God,” said Lucy, the veteran nurse in the Psychiatric Unit in Embu. “But his family thought this was very strange because he didn’t even go to church.”

Just off the main Nairobi – Meru Highway, close to the Isaak Walton Hotel, is the only psychiatric unit in Embu County. It is a square building with an internal courtyard, built in “Public Works Department 1960” style. To gain access, one has to pass through a locked gate by the nursing office. It has two wards, one with twelve male beds and another with six female beds. Adjacent to the female ward, there is an outpatient consulting room. The seclusion room has a steel door secured with a large padlock. There is a recreation room with a caged television and a broken pool table.

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According to a national newspaper, there are only six psychiatrists working in the public sector in Kenya. One of them works here in Embu. Each time I have visited the unit, I have only seen Nurse Lucy, as the psychiatrist spends a lot of time doing medico-legal assessments for the courts. There is only one other psychiatric nurse, who manages the inpatients. Student nurses do placements here, but few of them want to make mental health nursing their career.

On my first visit to the unit in May, all the student nurses were huddled in the nursing office by the gate. No nurses were in the open courtyard where some patients were walking around in the winter sunshine. I asked why the student nurses were not mingling with the patients. It was suggested to me that they found it too cold to leave the office.

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Lucy told me that drug-induced psychosis was common. “Embu is the catchment area for khat,” she said. (I am not sure she got the right word; “epicentre” would have been my choice.) The shrub khat contains two mild stimulants which are released when the fresh leaves are chewed. It is commonly grown in East Africa, where it is known as “miraa“. To get the best price for the leaves in the markets of Nairobi, drug traffickers drive like maniacs from Embu down the A2 highway in the early morning.

Although amphetamine psychosis is well-recognised, I had never heard of khat causing psychiatric disturbances such as hyperactivity, mania, hallucinations and, with prolonged misuse, psychotic depression. I learned that khat is used with other drugs, such as cannabis, to calm down as the feeling of elation recedes.

Lucy regularly visits schools to talk about mental health and the dangers of drugs and alcohol. She supplements this activity by health promotion using social media. Sadly, outreach clinics in the community have ceased. She has no vehicle and there no community mental health workers. Many people think that mental illness is caused by being bewitched. Rural communities tolerate people with severe mental illness until they start breaking things or attacking goats. Then they bring the person to Embu for a psychiatric consultation. During my previous visit, I saw a woman whose hands had been tied with rope sitting calmly in the outpatient waiting area.

Lucy also said that puerperal psychosis, schizophrenia and severe depression were common in patients attending the clinic. If she could not manage patients suffering from these conditions, she would refer them to Mathare Mental Hospital (formerly known at Nairobi Lunatic Asylum) in Nairobi.

It was obvious from visiting the unit that the patients were cared for with compassion. Lucy was a true champion for people with mental health problems. Unfortunately, she has plans to retire in 2022 and at present, there is no one being groomed to be her successor.