Doctor V Goes Over The Sea

Yesterday’s adventures in the Kenyan countryside involved attendance of the funeral of the mother of one of my study coordinators, plus about 8 hours in the car to drive to and from this funeral. While our hours in the car were extended by the usual complications (detainment at a police checkpoint, running out of gas), the funeral itself was a pleasure to attend.

Funerals here seem to be surprisingly festive affairs, with hundreds of your friends, family, and village members in attendance. There are lots of speeches, including by local politicians who use the opportunity to campaign. There is also singing, dancing, a giant shared meal, and processionals with everyone in attendance. In many ways, the whole ceremony was a lot like a Kenyan wedding, except for the part where they bury the coffin and the lack of a bride and groom.

The church choir leads the processional.

Gathered around for the actual burial after the feasting and speeches.

Kids always find fun… pretending to be piki-piki drivers on the parked motorbikes.

It seemed appropriate to be at a funeral over the sea in Kenya since my own family was gathering in California for a memorial for my cousin, who died unexpectedly this week. She was in her early 40s, and in the midst of the Swahili speeches and songs, I could not help but think with sadness about this mother/wife/daughter/sister, the oldest of my generation of Vreemans, who died too soon.

And so, on both sides of the ocean, it was a day to embrace family, to send prayers and love, and to remember this gift of our one wild and precious life.

I began the day stuck in my room. Literally.

It was 6:30am, I had just gotten out of the shower, I had a long early morning to-do list, and I discovered that something had gone horribly wrong with the doorknob to my bedroom.  It would not open, and I could not get out. What began with subtle attempts to wrest the door open without waking my housemates soon disintegrated into me desperately pulling against the doorknob and making a terrible racket. Soon enough, my housemates living on my floor woke up and began to attempt to get the door to open from the other side.  After an hour of futile attempts, banging, prying with credit cards and screwdrivers, and the congregation of more and more people on the other side of the door, one of the guards finally kicked the door in!  At last, I was freed from the confines of my bedroom. This was a new one for me. A bit of a crazy start to a day that already promised to be very full.

In my own personal ranking, being stuck inside my bedroom until the door was kicked in was definitely worse than being locked outside of said-bedroom and having to fish out the keys from the 2^nd story window using a 12-foot pole and a coat hanger .  On the other hand, it was definitely better than being locked outside of my room in the open air wearing only a towel and better than being locked inside of a stinky, foul pit latrine. In my humble opinion.

Imprisonment in my bedroom was not the saddest part of my day. That came when the grandmother of the 8-year-old orphaned boy I was seeing in the HIV clinic looked across the desk at me and asked if I was the one who took orphans. “Will you please take this boy?” she said. “I cannot care for him any more.” Oh, Grandmother, I would adopt your boy if I could.

The day was full of lots of successes – even if they were not quite as dramatic as the moment when the door was finally broken open with the powerful kick of our favorite guard, Eli. We officially launched my new research study on disclosure of HIV status to children. At one of the rural HIV clinics, 10 adolescents gathered for a focus group to discuss what it was like for them to learn that they have HIV and to advise us on guiding families through this complicated process. The children were lively and talkative, and I cannot wait to analyze the transcripts of their discussion. How I love to learn from their stories!

My study measuring children’s adherence to HIV medicines was also very busy today. They evaluated 10 children at 2 different clinics, following up on all of the issues they have with taking their medicines. Working out of a small, hot tent, my team downloaded information from the special electronic bottle caps that record the exact time the bottle was opened and took blood samples to see how the drug is working in the child’s body. I so appreciate their hard work and how diligently they follow and care for these families.

In between the study activities, I saw children in the HIV clinic in Kitale. A 6-year-old girl with big eyes smiled at me shyly as I talked to her mother, then proceeded to decorate herself and her younger sister with the butterfly stickers I gave her. I found the right antibiotics for a little one with pneumonia and argued with the lab about missing results for a child who needed to start on HIV medicines and altogether felt pretty productive in taking care of the dozen children who came through my exam room.

A good day. Even if there is a hole in my door and I no longer have a functional doorknob.

(I also made these to thank my housemates.)

I have heard this story too many times.

Rotich is 3 years old. His father died just months after he was born. His mother spent most of his first two years of life in and out of the hospital. No one knew exactly what was wrong with her, but when she died a year ago, they told her mother that it was HIV.  Rotich went to live with his grandmother after his mother had died. She barely scrapes together enough for the two of them to eat one meal a day, but loves the boy and she asks her neighbors for help and she tries to provide for him. When he got sick with a bad, bad cough a few months ago, they learned that Rotich has this HIV virus in his blood too. Those were the bad times. She thought she would lose the little boy as well.

He was all that remained of my daughter,” she said. “And I did not want to lose him. But I knew he would die.”

In this case, thankfully, Rotich’s grandmother was wrong. She managed to get him enrolled in an AMPATH clinic. In our pediatric HIV clinic in the small town of Kitale, Rotich was able to receive a combination of medicines that could keep his virus sleeping. My study team started evaluating Rotich and his grandmother every month, going to their house and seeing them in clinic, and making sure that the little boy was getting all four of his medicines, twice a day, every day. They helped arrange for him and his grandmother to get a small monthly supplement of food to help them get a second meal each day. We all got to watch as this last remaining member of his family began to thrive and grow.

I have heard this story many times, for many many children. But it’s not really too many times. I don’t grow tired of the miracle.

In the midst of many hours of work and the countless complications of trying to get anything done in a resource-limited setting, I like to collect the things that make me smile, like I would shells on the beach. I take a moment to pick them up and to stash them away in the pocket of my heart. Today’s shells:

• A trip into downtown Eldoret reveals all sorts of options available to you, right on the sidewalk. Want to purchase new underwear? Weigh yourself on a scale for a small fee? Have your shoes shined or repaired? Buy some tomatoes or greens or dried fish?  You could do any of these things right on the street.
• One of my friends (a fellow pediatrician) made a home visit to one of my HIV-infected study patients. I was delighted to hear that this patient very eagerly and spontaneously told the other doctor all about how well she was taking her medicines and how proud I would be of her good adherence. She even showed my friend the special electronic cap that records whenever she opens the medicine bottle and talked about how it had changed her adherence entirely.  Love it.
• A broken system means SO MANY frustrations. Over one hundred texts, dozens of calls, evening trips to the hospital, offering supplemental funds out of my pocket… all to get a sick newborn the medicine that is needed to make sure he does OK. The shell that makes me smile in the midst of this? The baby is looking much better. Worth the hours of time.
• I have the best team in the world. The students and residents and staff that I have working for me amaze me daily. They are so talented and smart and hard-working. I have been immersed in a nightmare of paper revisions, working day and night this weekend, and my global health scholar has been working as hard as me, helping at every step. So great.