Where Is Annie?

I never thought I’d fall in love with a slum.  When we got to Nairobi I was scared of going out there. I knew it would smell bad, that the sewers would open, and the people would be destitute.  Indeed, all that is true, but still I fell in love and I want to go back.

Korogocho started as a settlement sometime in the 70’s.   All of the land in Korogocho is owned by the government.  The people are merely squatters on this land.  They moved onto the land as they moved into Nairobi for jobs.  Most homes are shanties made of corrugated steel.  They’re tiny and packed in practically on top of each other.  There are some real buildings made of cinderblocks in the slum, some even two or three stories high, built by industrious individuals and owned by slumlords.  There are also homes made of daub and wattle, ie rows of sticks held together with mud.  None are well made.  Almost all of them leak in the rain, have no running water, and have no heat (yes, it gets cold at the equator sometimes).

Korogocho is made up of nine villages with varying degrees of planned development.  Some of the villages have wide roads, the sewers deep ditches along the sides of the roads.  The homes in these parts are made of bricks and often have central “courtyards” with the different homes opening out onto the courtyard.  This adds a bit of privacy and protection.  Other villages are just corrugated steel homes put up slipshod with narrow paths between them.  The sewers here are shallow and cut through the middle of the path.  A communal toilet is often a shack made of a patchwork of steel with a platform placed over this sewer.  During rains the sewer is not deep enough to hold the water as it tries to wind its way down the hill.  If there is no hill, the water just stagnates.  One of the villages is actually built just below the city’s sewage treatment plant, with its open settling ponds and treatment tanks.  Between the village and the treatment plant is a market selling goods and produce.

The sewer adds to the smell, of course.  So does the garbage.  There is a garbage service for some of the villages.  Youth groups collect the trash and charge households about 20 cents a week.  The youth collect the garbage and dump it in the ever increasing piles on the side of the road or really on one side of the road.  Cars and motorbikes need to drive around the garbage pile.  In some villages the trash just carpets the ground.  As the rains soak the garbage the stench of rot fills the air.  There are often children searching through the garbage for goods to resell.  Rarely (some say just before an election) those piles of garbage are moved to the city dump.  The large city dump borders Ngomongo, one of the villages of Korogocho.

So how in the world could I love this place?  It’s certainly not the scenery.  But it is the people.  They are happy and optimistic and willing to share their enthusiasm.   They’re loud, and they’re playful.  I fit right in.  Many are working hard to make their community a better place.  I went there originally to help my boss, Jake Sinclair, with his organization, Ujamaa.  Its mission has evolved from aiding AIDS orphans to aiding a community that is helping its orphans and itself.  Most of the people I met through Ujamaa were from the slums.  These were people who embraced their lives and embraced me as well.  Literally.

Everytime I walked into a room, almost everyone made an effort to come shake my hand.  It wasn’t just a handshake.  Their hand would start out two feet from my own and then make a loud clap as it met mine.  The grasp was always firm and long.  During the handshake I’d be often pulled in for a cheek kissing and a hug.  It was always accompanied by a grin.  I made so many friends, from health workers and guardians of orphans to the teachers of self defense all supported by Ujamaa.  They welcomed me into their group as a lifelong friend.  I have many new numbers in my phone.

I was welcomed into many people’s homes as well.  All the homes had a similar layout.  It started with the doorway without a door, just a sheet or a blanket to keep out the wind and to provide a bit of privacy.  The front room always had at couch (bench with foam cushions) and at least one chair (bench with foam cushions).  The corrugated steel roof let in a little light because of all holes, but the ceiling was softened by a sheet of lace or a modified mosquito net hanging under it.  The back room was the bedroom.  I rarely saw this as it was separated by a sheet from the front room.  In these small homes seven or eight people would often live, sleeping on every surface, cooking over a small charcoal stove on the floor, eating and socializing around the table.  The homes varied in their wealth; some had more space, nicer furniture, and more decorations.  I was an honored guest in all of them.  And like the handshakes the welcome was almost always enthusiastic.

The enthusiasm was carried onto the street as well.  The slum is full of life.  It’s full of people.  It’s full of industry.  There were businesses lining the roads: businesses in buildings, in stalls, and on blankets laid out by the side of the road.  People were selling repaired bicycles, used shoes, axes of all shapes and sizes, and green beans and carrots cut up for an instant meal at home.  There were food stands selling mandazi, chapatis, beans, and greens.  Nothing was expensive.  Delicious bananas were five cents a piece.  Lunch was no more than 50 cents at the stalls; $1.20 at the restaurant was a splurge.  It was bustling.  It was thrilling.

And the children.  Their poverty is disheartening.  But like their parents they were infectious in their enthusiasm.  They always greeted me, loudly yelling, “How are you?”  They often ran up to touch me and shake my hand, smiling and jumping up and down.  Hank and I walked by a group of preschoolers and kindergartners one day during their recess.  They all raced to grab onto our hands.  We had to peel them off when their bell rang to go back into their school.  I was filled with joy and fell in love with Korogocho.

We had a week for safari.  It was the perfect amount of time.  It was wonderful.  We explored the Masai Mara, Lake Nakuru, and the Samburu.  We saw almost everything we were supposed to see, plus some extras. There were, of course, the big five: lions, leopards, rhinos, elephants, and cape buffalo.  As well, we saw zebras, wildebeest, and giraffes.  And birds, birds, birds.  Hornbills, weaverbirds, sunbirds, storks, eagles, hawks, and grey-crowned cranes were just a few.

Our first evening in the Masai Mara we watched a pride of lions.  We watched the cubs play and play and play.  The jumped on each other.  They jumped on their parents.  They jumped on moving blades of grass.  We laughed and laughed.  Over time one of the young adult lions started to irritate the others.  The females around started snarling.  Then snipping.  All of a sudden we heard a massive roar, and a large male with a huge mane came climbing out of the bushes.  He didn’t run, he lumbered.  With only a snarl he chased off the annoying lion and then laid down in the grass as if he had used just enough energy for his job of keeping discipline.

We didn’t see the wildebeest crossing the Mara River, avoiding the jaws of crocodiles, dashing and splashing.  Still we caught a herd as they walked single file down a creek bank.  Dust began floating up from the creek bed as they walked and then suddenly dashed across the small stream.  With dramatic leaps they bounded over the lip of the opposite bank as they reached the top.

Lake Nakuru is famous for large flocks of flamingos (or as Catherine has dubbed them, flaming-o’s).  We saw the lesser and the great flamingos, both pink, of course.  Unfortunately, the drama of millions of flamingos filling a lake had migrated just a week before to another lake.  We did get to see a rock hyrax.  There was a picture in our guidebook of a rock hyrax on the exact same rock above the lake.  We couldn’t find the polka dotted ant Catherine saw crawling around the rocks above the lake.

The lake has been a destination for the endangered white rhino.  The wildlife service has moved several to the national park there.  They’ve been making babies and population is growing.

In the Masai Mara we needed an armed guard to explore the river bank where the hippos and crocodiles co-exist.  He taught us about hippo poo.  Their poo (mavi in Kiswahili) is important for marking their territories.  There are piles of half digested grass littering the river bank.  We got to watch a demonstration of how a hippo poops while the beast was still in the river.  As the poo is excreted the hippo waves his tail back and forth across the material spreading it in all directions.  Pooing in the water makes for more drama as the splashing water is mixed in.

We ended our trip at a relatively touristy resort, The Ark, which has viewing platforms and a turret next to a salt lick.  We were treated to milling with the elephants only meters away.  First a large male came toting his huge tusks of ivory.  He used the tusks to dig into the dirt.  He then picked up clods of dirt with his trunk and blew them into his mouth.  He was joined later by a herd of five to six female and juvenile elephants filing onto the delicious dirt single file.  Eventually, after some eating of dirt, playing, and fighting, the small herd left again in single file with the matriarch in the lead.  The large, lone male continued to eat dirt.

Again, thanks to Bill for all the photos.  Hopefully, he’ll post soon at www.whereisbill.net.  Watch for more beautiful pictures.

During our three weeks on Lamu we rented two rooms from Majid and his family. We got full board, eating three meals a day with them. Zainab, Majid’s mother, normally lives in Dubai, but luckily she was visiting at the same time we were. She did most of the cooking, and her food was amazing.

Swahili cuisine has been influenced by the Arabs, the Indians, the Europeans (particularly the Portuguese) and, of course, the Africans. A starchy food is always the mainstay of lunch and dinner. There is the African specialty, ugali, a cornmeal cooked into a thick porridge. It tastes like a very bland masa harina unless it’s been cooked with coconut milk and then is slightly sweet. Rice is served often, either steamed or made into a pilau. Wheat flour is made into tortilla-like chapatis. These are often sold by the side of the road for 10 shillings (1 cent).  We would use them as a utensil, picking up our stews or vegetables with them.  And we ate potatoes, often in broth, as well.

Dishes served with the starch included goat stews, fried fish, vegetable stews, and beans. There was one dish of beans I could not get enough of.  The beans were ever so soft and flavored gently with chilies.  Everything was well seasoned but not as heavily as Indian food. Nothing was hot-burning spicy. The stews were accompanied by chutneys: date, dried mango, chili, coconut, or seaweed.

Goat stew one lunch was made from the goat slaughtered in the back yard that morning. Hank had watched the slaughter and couldn’t stomach the stew to follow. Admittedly, there were body parts in it we don’t typically eat in the States. Still by dinner, Hank was once again down with eating goat.  My favorite was a dish of chapatis filled with spiced, chopped goat meat.  It reminded me of the gözleme of Turkey, but with a thicker pancake and different spices in the meat.

For breakfast there were always mandazi, triangles of slightly sweet wheat dough deep fried. As well, John, one of their hired help, went out every morning for fresh fritters of ground beans with spices and herb, much like pakoras.  Occasionally, we had bhajia, lightly battered and fried potatoes.  I have to admit with all the fried food for breakfast, I loved when we added a banana to the meal. To wash everything down we drank milk tea, spiced with cardamom but unsweetened, or black tea with ginger and sweetened with sugar. I always combined the two to have a slightly spicy, slightly sweet, milky cup of tea. It was amazing how much that hot drink would make me sweat in the warmth of the island.

The people of Lamu use their hands to eat. Or more specifically their right hands. The food on the plate is mixed by the right hand and then a small bite is held, pinched between the fingers and the thumb. The thumb is then used as a squeegee pushing the food into the mouth from off the fingers. It is considered impolite to have the food reach beyond the fingers to the palm. Turns out there’s even an etiquette to eating with your hands. My family tried for about a week to eat with our hands. Turns out, we couldn’t do it. There were always utensils for us on the table. Eventually we all broke down and started using forks and spoons. Our hosts asked us if we ever ate with sticks. Why, of course, we exclaimed. They found it amusing we were more willing to make eating more complicated rather than less.  (One of the consequences of eating with their hands is they often have a sink in their dining room.  Makes for an odd decoration in the eyes of us Westerners who use forks and spoons.)

Zainab was incredibly thoughtful of my vegetarian daughter, always making a separate vegetarian dish and often a vegetarian variation of the main dish for Cat.  She would even cook the vegetarian dish before the meat dish so that no meat would contaminate my daughter’s food.  Few cooks are so thoughtful.  When Cat got sick and unable to eat, we could see that Zainab was a bit hurt by Cat’s refusal to eat.   When Cat likes her food, she’s so much fun to feed.  She relishes her food.  Zainab smiled from ear to ear when Cat was better and once again starting eating and complimenting the food.

One of our last meals in Lamu was one of Zainab’s finests.  We had guests, eight in all, plus Zainab, Majid, and Thuweba, Sundus and Said, their kids, and the four of us.  There wasn’t room at the table for all of us, so we sat on the floor with a long table cloth to define the table.  There was goat stew with potatoes and chilies, rice pilau, bhajia, mandazi, greens, and my favorite pot of beans.  Of course, there was milk and black teas to drink.  And so much talk, in English, Swahili, and, yes, once again some German.  After the meal we all sang old rock and roll songs to a guitar.  The delicious foods of the Swahili cuisine had warmed our bellies, our voices, and our hearts.  We were very fortunate to have Zainab introduce us to the Swahili cuisine.  We were very fortunate to have her family to introduce us to Swahili culture.  Thank you, Zainab, Majid, and Thuweba for all your hospitality.

Munib Mafazy grew up on Lamu.  He went to Chicago to become a nurse and is now a PhD candidate there.  When he came home to visit he received a lot of visitors, not just wishing him well but wishing for their own wellness.  He took blood pressures and checked blood sugars.  He wrote prescriptions for all the medications needed to treat these patients, and then when he left, his brother, Majid, continued to take blood pressures and blood sugars of family members, sent the results to Munib who then sent back prescriptions.  With this experience the family realized there was a need for better access to preventive health care in Lamu.  Majid moved his workshop out of the first floor of the family’s house near the center of Lamu Town.  With new walls, new flooring and new paint the workshop became a clinic.  It opened its doors just a month or two before I came.

At about the same time as I came to Lamu, Aziza started working at the clinic.  As a clinical officer her roles are much like a nurse practitioner in the US.  She has worked in other clinics performing all services of general practice; she has treated chronic illnesses, delivered babies, and diagnosed surgical problems.  She grew up in Lamu and knows everyone and their circumstances.   My goal was to teach her anything I knew about taking care of kids with a focus on asthma.

The first day at the clinic was busy.  The Town Crier had gone around town with his megaphone a few days before I came.  He announced that an “asthma specialist” was coming to the clinic.  I tried to dispel that myth but quickly realized it just didn’t matter.  My limited knowledge was still going to be helpful to Aziza.   Aziza helped with my limited Swahili.

I started out seeing all the patients myself with Aziza interpreting.  Soon I realized I needed to learn from her.  I taught her about asthma; she taught me about malaria, intestinal infections, and jiggers.  After a few days, I knew the patients would be better served by Aziza making the diagnoses and treatment plans.  I acted as merely a consultant.

Much of the asthma we saw was bad.  There are a lot of triggers in Lamu for asthma.  Dust is everywhere.  The kids kick it up playing football; the donkeys kick it up hauling bricks.  It’s impossible to avoid.  Even worse than the dust is the smoke.  Most people cook over charcoal or firewood, often with poor ventilation.  Many of the men smoke cigarettes only adding more smoke to the environment of the island.  And then there’s the trash burning.  It seemed I could smell burning plastic everywhere.  Even my healthy chest started to feel tight.

With all these triggers many of the patients needed albuterol every day.  Some of the adults were still using oral albuterol.  It can’t be good having that medicine course through one’s body, only a fraction getting to its target, the lungs.  It has so many side effects including speeding up the heart rate. Having it work on an adult’s crummy heart in such doses can only lead to bad things.  These people needed a better delivery system.

When I was in Istanbul I had purchased a nebulizer from a pharmacist.  The guy was great.  He was excited to help me take something good to Africa.  He even gave me a discount.  I only wish I had taken his card so that I could send him a picture of one of the many patients to whom it brought relief.

Still the nebulizer could only relieve the symptoms while the patient was in the clinic.  So Aziza and I taught patients how to use an inhaler.  We also began inhaled steroids on numerous patients.  This required a visit to the local chemist (pharmacist).  What was available?  Turns out all sorts of things at various and seemingly random prices.  Prices were set by where the medicine was made.  Indian medicines were half the price of European and American.

Prices became the determining factor in what we prescribed.  There are inhalers of steroids only, but they cost twice as much as the combination of short acting beta agonist (albuterol) and steroid.  Aziza and I started prescribing the latter for most of the patients.  Here was the “preventative” part of Lamu Center of Preventative Health.  With this medication we could help reduce the inflammation in their lungs and thereby reduce the frequency of their attacks.  The cost of the daily medicine should be offset by a significant reduction in hospital visits.   As the lungs improve the patients will hopefully be able to reduce the amount of medication they use, and therefore, reduce their expense.

I  saw more than asthma, of course.  Patients arrived with a multitude of problems that had nothing to do with their lungs.  The various and sundry complaints many of the adults brought with them reminded me why I’m a pediatrician.  In addition to my limited knowledge, my limited resources at the clinic kept me from treating all of the problems I encountered.  Still I felt I reached my goals in Lamu.  Aziza was creating treatment plans and teaching her patients how to control their asthma in their own language.   I’m keeping in contact with her, as a consultant and a friend.

Our hosts here in Kenya were excited when they were able to obtain tickets for us for the two nights of a Swahili wedding.  We were excited, too, but had no idea what would happen.  This was nothing like an American celebration.  Hank and Bill were not invited to the woman only party.  I had to buy a couple of dresses to fit in, dresses with lots of sparkles and ribbons, things I wouldn’t have worn at home.  Catherine was loaned some dresses that fit her perfectly.  We discovered when we got to the wedding dressing up was de rigeur.

The wedding was in the courtyard of the old fort here on Lamu.  Unfortunately, as outsiders we weren’t allowed to take pictures so I’ll try to paint the scene with my words.  A man guarded the front door taking the tickets as we entered.  He was the last man we saw for the next couple of hours each night.   We were greeted with incense wafting to our faces and rose water sprayed on our hands.  We were given a small plastic bag of food, one night meatballs and some gelled dessert, then next night cookies and soda.  One of the first times on the trip we decided to forego eating.

On the first night as we entered the courtyard arabic pop was blaring from the speakers.  As more women came in they sat down in an ever increasing semicircle in front of a stage.  Satin cloth of varying of white, gold and green was draped on the wall behind.  Some of the women danced.  They danced with partners swaying their hips and arms while walking forward and backwards at times turning around each other always smiling.  There were people finding friends and talking.  Finally, after a couple of hours everyone sat down.  An aisle was formed as women squeezed closer to each other to allow the bride to come in.   Her dress was green with crinoline beneath the skirt so that it stuck out two feet on all sides.  Sequins glittered on every surface of the cloth.   She waddled forward through the crowd.  It was an odd walk.  It looked as if the skirt was getting trapped beneath her feet, yet when she got up on stage she continued this back and forth swaying as if it was the traditional way for a the bride to walk the aisle.  Once she was on the stage all the women in the courtyard got up to take pictures and the party was over.  The bride was left on the stage posing for photos while we headed for the door.

The next night the party started again.  The women were again seated on the floor in front of the stage.  But this night there was a singer, a woman who had entered veiled was now in front facing the party singing Islamic songs in a high pitched nasal voice.  Girls sat around her beating drums and tamborines and singing along.  Women began bringing money up to the front, some they tucked into the singer’s scarf for her pay, some they threw to friends of the bride’s mother.  This money was folded into belts, crowns, sashes all to accessorize the bride’s mother.  As the night wore on the singing was more feverish and more penetrating.  As the excitement grew women began with ululations, also high pitched and feverish.  Finally the singing stopped, the crowd parted, and the bride entered.  On this second night of her wedding she wore a cream colored gown, again decorated with sequins and crinoline.   Again she waddled slowing as she approached the stage, turning a couple of times so the crowd could admire her beauty.  She climbed up the stairs to the stage.  And again this was the cue for everyone to get ready to leave.

Throughout the event women in black veils encircled the courtyard.  They only watched from the perimeter, never joining in.  According to our friend, Thuweba, some were probably unwed, some were probably just unwilling to show what poor clothes they wore underneath.  They gave me the sense of ghosts silently watching the festivities.  Yet it was one of these women on the second, more religious night who helped Catherine fix her scarf as it continued to fall off her head.  It was a tender, woman-to-woman gesture that meant the most to me during these two nights celebrating a rite of womanhood.