On the Balance

I am not so good with numbers. I am a terrible accountant. (Don’t tell the NIH, which trusts me to account for large grants!) Some days, it is not clear to me how I became a physician-researcher given all the math and statistics I have survived to get to this place.

Some days, though, I find myself struggling with a different kind of accounting. Counting up recent deaths vs. lives saved. That kind of math doesn’t work, Rachel. Accounting for lives doesn’t make sense. There is no way to balance these figures. And yet, some weeks find me counting…


At the end of last week, I lost a patient for whom I had fought really hard. When he left the hospital after a serious illness and a lot of struggle to keep him alive, I believed he was going to make it. I thought he was ok. And when he came back to the hospital and died last week, his death caught my heart off guard.

Today, we had another patient die, a girl who had been enrolled in our disclosure study and whose family was followed closely by my team. She had been sick for quite some time, but now the world will never see her sweet smile again. Her mother and her younger sister mourn.

Our children are dying. It is impossible to account for a life on a spread sheet.

But, day-to-day, the balance shifts from sorrow to joy, from joy to sorrow. Even as we wrestled with the unexpected death on Friday, another little boy for whom I fought hard to get a surgery to repair his heart went home and I rejoiced. Arthur was as recovered and strong as I could possibly hope for, and his smile was brilliant when I reassured him that, yes, he was going to grow now. The same day, we celebrated the birth of baby Vreeman, and I marveled at the honor of this beautiful baby namesake. Losses and gains. Our children die, but our children also live.

Three weeks ago in one of our rural clinics, I was incredibly frustrated by a teenager who was not taking his medicines. Brian wanted to stop his HIV treatment entirely. The clinic staff had pretty much given up on him. He had not opened his medicine bottle since the previous month when he came to clinic, and when questioned about it, Brian just shrugged. His father says that the medicines for HIV are not worth taking, and the boy had accepted what his father said.

I can’t force Brian to take his medicines, as much as I might like to. There is no court system or hospital in Kenya where I could exert my medical will over his father’s misguided thinking. As I walked with him across the clinic compound, the boy tried to ditch his medicine bottles and just slip out of the gate. He tried to escape again a little while later as we waited for a social worker.

I didn’t let Brian run off, but I felt like there was little I could do. I marched him over to my office to give it one last shot. In my mind, I was gripping him by the ear. I drew out my pictures to talk him through how the medicines worked and why he needs to take them. I even tried to convince him why he should keep coming to the clinic even if he stopped the medicines altogether. I tried and tried, but Brian’s face was still as a stone and he gave no indication that anything I was saying was getting through.

He took my drawing with him, though — my drawing of how the virus was fighting against the soldiers of his body. And, with my drawing, went my words about how much I wanted him to grow and be strong and healthy. And the medicines – please take the medicines. I had tears in my eyes when I looked at him, but it didn’t seem like he noticed. Deep down, I thought I had lost this one too. I counted him as a loss.

As part of the new study we launched this month, we are holding focus group discussions about the stigma experienced by families and children with HIV. We gathered adolescents for a discussion group at that same clinic where I had been three weeks ago, and who showed up but Brian. Brian, taking his medicines every day and telling my team that he was going to stay with the treatment.

“Vreeman: 1, HIV: 0,” said my study coordinator. Then, she adjusted it to “Vreeman: 1,298,372,397,398, HIV: will never win!”

I like that score better! We mourn, we rejoice. We count the losses, we count the victories. Most of all, we fight on.

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Adventures Along the Rift Valley


In a lot of ways, Kenya feels like home. I am very accustomed to how my life and work here operate. I feel comfortable with my friends and adopted family here. I am even pretty used to the roads (as comfortable as one can be with the constant threat of collisions, massive holes in the pavement, and all manner of weaving, crazy traffic.)

But then, you have some days where you are driving along and the incredible, unique beauty catches your breath and makes you stop and marvel at the wonder of this particular part of the globe. Days when there are zebra grazing beside you. Days when you drive along the long expanse of the Rift Valley. Days when you almost hit two giraffes with your car because they are in the middle of the road and it is raining and dark and you were not expecting giraffes.

The American women of my study team and I had a few days of adventure driving across the country, with stops at Lake Naivasha, Hell’s Gate National Park, and then a different kind of hell which is the department of immigration in Nairobi. (I’ll spare you those insanely frustrating details. Let’s just say it is a miracle that anyone ever gets any sort of work permit or visa from this place. I, of course, am still without a work permit almost 9 months after my last paperwork was filed.)

But anyway, we are driving along, and then there are giraffes…. Wow.


This is not when I almost hit the giraffes with the car. This was another encounter, when their grazing allowed me to get out of the car and take a photo of my trusty blue beast and the twigas…


A long bike ride is a lot more fun when you have zebra onlookers.


Hello Zebras!


Baby. Boooch.


My all-star team! They put together music playlists for the drive that even included theme songs for each one of us. Mine was Beyonce’s “Diva”, but they assured me that they meant it in the best way possible… because I can get things done.




An unexpected zebra stampede behind Amy.




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Baby Vreeman

In honor of me and my family, my study coordinator and her husband gave their new son my family names…

Welcome, Manuel Gerrit Vreeman!

(In case you don’t realize, the Gerrit Vreeman parts are the Dutch parts. This baby is named after me/my father/ my father’s father)



Although I had the privilege of welcoming him at his birth, our whole study team got to celebrate and welcome him with a baby shower — complete with a beautiful cake that officially declared the arrival of this newest Vreeman.





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How I Draw/Talk About HIV

“Your drawings help patients and their parents understand this disease.”

After a morning seeing patients together in the HIV clinic, this was the lesson the pediatric resident remembered from our clinic together.

I do like to use drawings while I am explaining to a family how HIV attacks the body or counseling an adolescent on why it is so very, very important that they take their medicines every single day. The resident saw me draw the same picture over and over again (with slight modifications to make the child in the picture look more like the child in front of me.)

And my patients here seem to really like the drawings. They always want to take them home. This may be largely the novelty… Too often, the other clinicians do not take the time to explain these ideas to them. Plus, in a setting where much of the learning is done by rote didactics, lecturing and demanding memorization, learning with something visual — something that I keep changing as we talk — stands out. Of course, I hope that it improves their understanding too.

Tomorrow morning, I am training pharmacy technicians on how to counsel families and children about HIV medicines, so I have been giving extra thought to my usual drawings and words. They don’t need to make a drawing like I do, but they do need to be able to use words and concepts that families understand well enough that the families can grasp why we want them to take these medicines in the way we do.

Here is my spiel and what I would draw for you on the back of a lab request form….


This is you! Otieno! And this is how I want your body to look – healthy and strong and growing. I want you to be healthy and strong so that you can do anything that you want to do. I want you to be able to run and play. I want you to be able to go to school. I want you to become an adult and have a family if you choose. I want you to have a good job.

DSC_8877germs copy

For all of us, we must be concerned about the germs that are around us. We sometimes call these germs “bacteria” or “viruses.” Germs are tiny little things that can come into our bodies and make us sick. It is germs that cause problems like diarrhea, pneumonia, malaria, and TB. We don’t like these germs that can make us sick!


Thankfully, our body has soldiers to protect us against these germs. These soldiers are very small, but there are many of them throughout the body. Our body has an army of soldiers to try to protect us against the germs that want to make us sick. This is called your immune system. These are the soldiers of your body. We will give the soldiers guns that they can use to kill the germs. We want your body to have many, many soldiers to protect it and to keep you healthy and growing. The name that we call these soldiers is CD4 cells.

DSC_8877the snake

Unfortunately, as you know, your body does have one virus living inside of it that cannot be killed by these soldiers. This is the HIV virus. I am going to draw it as a snake because I hate snakes. You do not have a real snake living inside of your body, but we will think about the HIV virus like a very bad snake that is inside the body.

This snake is so bad because it wants to kill the soldiers of the body. It tries to kill the soldiers, and then you have no army to protect you from the germs that can come in and make you sick. This is how the snake tries to defeat you. It is very, very sneaky in how it tries to kill the soldiers of the body. When it destroys the army of your body, then the germs can make your body weak and sick.

We do not have medicines to kill this snake. We do not have treatment to remove this snake from the body. I wish that we did, but there is no treatment anywhere in the world right now that can remove this snake from the body. If scientists find such a treatment, I will try to bring it to you right away.


What we do have is sleeping medicine for this snake! We have medicines that will keep this snake sleeping, so that it cannot kill the soldiers of the body and so that your body’s army can become strong again. This snake is so bad that one medicine cannot keep the snake sleeping. Even two medicines cannot keep the snake sleeping. But when we use three medicines, we can keep the snake sleeping.

If the snake is sleeping, then your body will remain healthy and strong. You will grow. You will be able to do all of the things that you want to do – go to school, become an adult, get married, have a family. We must keep the snake sleeping so that you can be strong and healthy.

These medicines that keep the snake sleeping, they only last for about 12 hours. But we want the snake to be sleeping for all of the day and for all of the night. So, we must take these medicines in the morning to keep the snake sleeping during the day.  And, we must take the medicines again in the evening to keep the snake sleeping during the night. I know that it is difficult to take these medicines every day and to take them in the morning and then again in the night. I know that this is a challenge for many. But this is how we keep the snake sleeping. And we want to keep the snake sleeping so that you can be healthy and strong.


If you miss to take the medicines in the morning or in the evening, the snake can wake up. Whenever the snake is awake, it starts to kill the soldiers of the body.  If the snake keeps waking up again and again, then sometimes it becomes stronger than the sleeping medicines. If the medicines can no longer make the snake sleep, then your body’s soldiers will be defeated again. We want to make sure that this does not happen. (We call this the virus becoming resistant to the medicines) This is why it is so important for you to take the medicines in the morning and in the night. We want the sleeping medicines to continue to work and to keep the snake sleeping.

I have high hopes for YOU. I want you to be healthy and strong, Otieno. I want you to be able to live positively. I think you will be able to meet this challenge of keeping the snake sleeping. I think you will GO FAR.

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Wordless Wednesday: Kenyan Fashion

blue skirt

Green skirt_1

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