Wednesday, July 30, 2008

Back in Jozi



I'm back in Johannesburg. Strange that a city so foreign can feel so much like home. I'm psyched to be back! Kenya was great but it's always nice to feel at home. The picture is the Ponte Tower...an apartheid-era redoubt for the yuppies of the day, now a mad African city in a towerblock. The scuttlebutt (used to be -- see Josh's comment) that the garbage in the former central grand atrium, discarded by various squatters, campers, and n'er do wells, now reaches to the 11th floor.....

I don't know if that's true (Ponte is a particularly scary place to visit..but maybe I'll find out this trip) but I like the imagery.

A Note on Backpacks

I’ve always had a thing against them – associating them with filthy feet in run-down sandals, Let’s Go travel books and raucous laughter in overcrowded train compartments.

My bias has cost me over the years. In the late 1970s, when a high school friend and I went to Europe, we decided we weren’t going to join the backpack crowd – and went instead equipped with two huge duffel bags, which over the ensuing months cut huge gashes into our shoulders with their single straps.

Roller bags, which I later moved to, are fine for airports but not so good when you are running through markets trying to catch a bus or walking miles to try to find the weirdly isolated B&B you booked.

In both cases, the contents end up a jumbled mess and mornings were devoted to frantic grab-bag searches to look for clean underwear, my passport, or whatever else I needed.

You’d think I’d learn. But vanity persists and I reverted to a duffel bag for this trip – one of the most intense packing/unpacking sequences of my life. But I’m saved! Before leaving the U.S. I bought a set of “Eagle Creek Travel Gear” packing envelopes – Velcro and cloth sleeves that zip up into neat little packages. Into one go socks and underwear, into another shirts and t shirts, and into the largest go pants, sweaters, my raincoat and whatever else I stupidly overpacked on the trip. Then, one by one, they slide into the duffel, making it a convenient traveling dresser.

I’m usually sceptical of “organizational breakthroughs” – doubtless the sign of a terminally disorganized mind. But these damn things have made a real difference. Thank You, Eagle Creek (I’m not a paid spokesman but I would be in a second – Eagle Creek, call me).

Now, back to packing.

Tuesday, July 29, 2008

Books for an African Trip

African taxi drivers are usually pretty nice and often offer to help put your bag in the car – but when they take mine they grimace.

My trusty red duffel bag weighs a ton, and most of it is reading matter. Along with my notebooks and an ever-expanding file folder of copied articles, I’ve been lugging around a little mini-traveler’s library to keep me occupied on the many nights when the TV reception is bad or the language incomprehensible.

Here’s what I’ve read so far:

“The Invisible Cure: Africa, the West and the Fight Against AIDS” by Helen Epstein. This is depressing in more ways than one. Epstein does a masterful job chronicling many of the missteps and bad judgments that have marked the world community’s response to Africa’s AIDS crisis. She’s got a bee in her bonnet about U.N. agencies and Western aid groups and she marshals the facts to show that in many cases the “AIDS establishment” has done more harm than good. For a reporter, it is both thrilling and daunting so see someone else tackle the subject so well.

“The Scramble For Africa” by Robert Pakenham. Clocking in at around 750 pages, this is a blow-by-blow account of Europe’s various colonial enterprises in Africa during the latter half of the 19th Century. He delves with equal passion into better known sagas (Stanley and Livingstone, the Boer War, Cecil Rhodes) as well as tales perhaps less familiar to English-speaking readers including the formation of French Equatorial Africa, the revolts against the Germans in East and Southern Africa, and Italy’s war with Ethiopia. It is, perforce, more about diplomatic dealings in European capitals than about the impact these had on African states and peoples, but it’s an amazingly comprehensive and often thrilling account of what happened.

“After the Party” by Andrew Feinstein. Feinstein is a former MP for South Africa’s ruling ANC who grew increasingly frustrated and disillusioned with Thabo Mbeki’s government. Here he sets out what he thinks went wrong (paranoid leadership style, blind eye toward corruption) and calls for a “new politics” to revive South Africa’s great experiment. Probably too much inside baseball for most readers, but a heartfelt analysis of where one semi-insider thinks things went wrong in the post-Mandela era.

“Dinner with Mugabe” by Heidi Holland. Holland, a South African journalist, is a friend of mine and had amazing timing with this book, a sort of psycho-biography of Zimbabwe’s Robert Mugabe. She was the last foreign journalist to get an exclusive interview with him before this year’s disputed election. She concludes that Mugabe is a spurned Anglophile with mother issues – an interesting take if perhaps of little comfort to Zimbabwe’s suffering people.

“In the Footsteps of Mr. Kurtz” by Michela Wrong. A former Reuters journalist who went to work for the Financial Times, Wrong’s book takes us through the rise and fall of Zaire’s Mobutu. No mother issues here, just a lot of excessive greed, bad taste, and thirst for power. As they say in the trades, “rollicking”.

“The Wizard and the Crow” by Ngugi wa Thiong'o. This is a great fictional counterpoint to the two books cited above, and all the more interesting because it is by one of Africa’s most prolific and interesting writers. Wa Thiong'o paints a lengthy, magical realist fable of a mythical African country where “The Ruler” sets his people to building a new Tower of Babel. His chief advisor, meanwhile, grows enormous eyes to better see the Ruler’s enemies while the number two in the cabinet sets about growing enormous ears the better to hear of plots against him. Weird, wonderful (and long).

I’m going to be sticking all these books in the mail when I get back to South Africa and sending them home – so I hope my bag will be a bit lighter.

Not mentioned above was the three day British “chick lit” binge (“Confessions of a Mad Housewife”, “Lessons for an New Divorcee” etc) that occurred in Lamu thanks to the leavings of previous guests. I don’t remember anything about any of them except a vague feeling of queasiness

Autoclave and Destroy




There’s a freezer full of dashed hopes at the AIDS vaccine clinic in Kangemi, one of Nairobi’s crowded slums.

The freezer, kept under multiple lock and key, contains vials of the vaccine prototype that many researchers hoped would mark the next big step forward toward preventing new HIV infections.

But like other trial sites across the globe, Kangemi is now under orders to destroy the vaccine following a decision by U.S. sponsors not to proceed.

“It will be autoclaved and incinerated,” said pharmacist Jennifer Kigera. “We are still hoping for a new product one day.”

They will have to wait a while.

The cancelled PAVE trial has left few immediate prospects for large-scale human testing of HIV vaccine prototypes, with the U.S. National Insitute of Allergies and Infectious Diseases now saying it will focus on small, focused trials and basic lab science to better understand HIV.

The cancellation of PAVE followed the mid-way halt of a similar trial using a vaccine developed by Merck (see my entries on Phambili), a double blow.

Kangemi, which like many other sites had been set up expressly to prepare for big Phase II and Phase III trials, now has to repurpose itself – looking at basic epidemiological studies on HIV incidence in the region as well as tracking the early progress of infection among volunteers who recently rested HIV positive.

Gaudensi Mutua, pictured above, is the research physican at the site – which is made out of converted shipping containers stacked outside Kangemi’s municipal clinic.

“We all felt crushed and a little bewildered,” Mutua said of the PAVE decision. “It was the hype. Everyone had such high expectations.”

Kangemi hopes its work on HIV infection will feed into studies of two select groups of people – the “Long Term Non-Progessors” and the “Elite Controllers”. The first represent people who have been infected with HIV but take a very long time to develop any symptoms of AIDS. The second, a much smaller group, never develop symptoms at all.

By studying how their immune systems work – and particularly the role of “cell mediated immunity” which keeps long-term infections under control (think chickenpox), scientists hope that they will come across a key to disabling or even eliminating the HIV virus.

“It is these two groups that keep alive the hope that a vaccine is possible,” said Prof. Olu Anzala, the head of the Kenya AIDS Vaccine Initiative.

Friday, July 25, 2008

Lucky (?) Pluckers



Ok, it looks like a Teletubby encampment but this weird little village of round red cement houses is actually corporate housing for James Finley Teas, one of Kenya’s biggest tea exporters.

In many ways it appears idyllic – groups of these houses are set in rolling tea fields which, from a distance, look like the frozen emerald froth of some great sea. The workers (“pluckers”, locally) are actually in pretty good shape by working class African standards. They are given free health care, their kids go to company schools, and the little round houses come with the job.

Still, tea plucking is backbreaking work and at 7 shillings a kilo, a good day’s take home would be only about $5. That’s better than the $1-per-day benchmark that the U.N. has set for the poorest of the world’s poor, but it’s not exactly easy money.

The tea plantations have worked with the U.S. military’s HIV program and many of these workers have been among the volunteers for HIV vaccine studies. From a researcher’s point of view, it’s a great “cohort” – a large group of people with relatively similar living patterns in a controlled environment.

Ironically, the pluckers are almost too good. They are generally seen as at a low risk for HIV, so discovering whether or not a potential vaccine would work is that much harder – is it the vaccine working, or is it simply that these workers are too bushed to get up to much risky behaviour?

For that reason, the Walter Reed program (like the IAVI group in Mtwapa I mentioned before) is gearing up to bring a high risk group under study – commercial sex workers who make their living in the trucker bars and hostels along the main highway. This group will be harder to find, harder to enlist, and harder to track – but may, in any future vaccine study, be the ones with the answers.

I’m leaving Kericho and the Walter Reed program today. On Monday, I’m hoping to do another IAVI site in one of Nairobi’s many slums.

Wednesday, July 23, 2008

Lab Work



The Walter Reed lab in Kericho began as a makeshift workspace in a rented living room.

"I came out here and took one look at the place and thought I would take off..Kericho is pretty small," said lab director Rukiya Kibaya, remembering her first foray into the new world of scientific support for the AIDS effort in rural Kenya in 2003.

"But the enthusiasm of everybody at the site caught up with me."

The Walter Reed lab is now one of the best in Kenya, the only one in the country to win the prestigious College of American Pathologists (CAP) certification and one of only a handful in Africa with that designation -- which means its procedures and results are on par with the best labs in the world.

This minor miracle -- brought about with a lot of investment from the U.S. military and a lot of hard work by dedicated Kenyan scientists like Kibiya -- now operates from a suite of rooms in the Clinical Research Center at Walter Reed's headquarters in downtown Kericho. Reaching it is like moving through a series of airlocks leading from the developing world to the front lines of science.

Just off Kericho's main drag, where minibus taxis jostle and hawkers congregate selling everything from bananas to cellphone minutes, you walk down a quiet alleyway to a large metal gate. Behind it, the CRC is a freshly-built, stone building surrounded by manicured lawn and "keep off the grass" signs. A reception hall leads to a landscaped inner courtyard that wouldn't look out of place in Silicon Valley. And around it are arrayed quiet, airconditioned offices ranging from IT to pharmacy, and well-equipped laboratories where the exacting work of testing, measuring and reporting the biomedical ravages of HIV in the region are carried out.

Lab workers in blue coats work quietly and quickly, surrounded by the metallic gleam of state-of-the-art machinery enabling them to do everything from basic urinalysis to complicated tests to assess patient HIV viral load -- an increasingly important signpost for AIDS-related illness.

In the cold storage room, a row of locked refrigerators gives way to massive scientific freezers - set at -74 degrees Celsius -- which preserve samples and are backed-up and failsafe-d to keep the both the samples and the data reliable.

While the CRC lab was originally set up in line with Walter Reed's "primary mission" in Kericho -- the thus far fruitless hunt for an AIDS vaccine -- the lab is clearly realigning itself with the new realities and new priorities of PEPFAR, the U.S. AIDS treatment aid program. Much of the work now is devoted to new studies aimed at assessing how and when to intervene with anti-retroviral treatment, and in training lab personnel from other nearby facilities on how to handle the scientific backup required for a program that is enrolling tens of thousands of local Kenyans on AIDS drug treatment.

"We're spreading our risk," Kibaya said.

Monday, July 21, 2008

Cute is not a word



that springs to my mind when I imagine a U.S. military installation -- but here I am in one of the cuter ones. This is the guest house at the U.S. Military HIV Research Program in Kericho. It is set amid lush tea plantations in Kenya's cool, wet highlands that mark the southern edge of the Rift Valley. It takes about an hour and half to get here from Kisumu, juddering at 120 km/hr across some hilariously pot-holed roads navigated by frighteningly self-confident drivers.

The cute ends here, though, and real work gets done not too far away. The USMHRP office in downtown Kericho sits atop a stubby block of converted flats, backing up onto an intensely busy gas station which seems to be a major transit crossroads for minibuses and everybody else.

Despite its military affiliation, there's no camouflage fatigue around. The USMHRP site in Kericho appears entirely civilian run, and in fact there is only one American -- the director Dr. Doug Shaffer -- working here, while the rest of the staff, from senior scientists to data entry monitors, is Kenyan. Administratively, it's a joint effort of the U.S. military and Kenya's KEMRI medical research institute.

The USMHRP has been involved in HIV vaccine work here for several years, and was due to have been a site for the next round of large scale tests before they were scrapped last week out of lingering safety concerns. They are still "cohort building" looking for the next possible trial, while research into other areas of HIV goes on.

One fascinating study they've got underway involves looking at the actual cost benefit of putting tea plantation workers on ARV treatment. While its not news that people get better after starting on the drugs, the genius of this study is that there is a very basic -- and very measurable -- way to measure the economic difference made by the treatment: how much tea the workers are able to pick. Apparently its the first study of its kind to attempt to put a $ figure on productivity gains associated with the widening ARV roll out.

The PEPFAR program for AIDS drugs seems to be playing a big role here -- in essence, the availability of free public treatment is opening ethical doors to study proposals which would have been impossible before when treatment itself, offered through a clinical trial, might have been seen as an inducement.

Sunday, July 20, 2008

On Lake Victoria


I'm on the other side of Kenya now...in Kisumu, the country's third largest city and chief outlet on Lake Victoria.

I just arrived so have nothing wise to say except Kisumu on a Sunday afternoon is QUIET. But the hotel has surprise wireless Internet....a first for me in Kenya so far.

Kisumu's chief claim to fame is that it was almost strangled by a voracious explosion of water hyacinth in the 1990s. The alien invader hobbled shipping and nearly killed the local fishing industry, laying Kisumu low. Apparently they've beaten it back (how and with what I don't know..will have to investigate) but like all kinds of third-tier places, it now seems to have its hopes set on bigger and better.

I'm here for one night on my way to Kericho, Kenya's tea capital and home to the Kenya division of the U.S. Military HIV Research Program. They've been involved in vaccine studies, and were getting ready to participate in the PAVE program that the NIH just formally stopped.

We'll see what they say!

Thursday, July 17, 2008

Ok I admit it




I’m not exactly “roughing it”. But wait (I swear) there’s a reason!

I’m now in Shella, a village on Kenya’s Lamu Island. It is hardly undiscovered – the construction/reconstruction around here is amazing. That is all thanks to Lamu’s reputation as a get-away-from-it-all destination for various jet set stragglers (bonjour, Princess Caroline).

This is, of course, Kenyan winter and therefore off season, so no ramshackle Royalty to be seen. But the weather is great and Lamu is a spectacular place, enough to have been named as one of the U.N. World Heritage Sites – if you give that any credence given the politics involved there.

Lamu’s claim to fame is that it is the best-preserved Swahili town left standing, better and more authentic (so the experts tell us) than Zanzibar’s Stone Town. It’s a medieval agglomeration of squat buildings built out of stone and coral, all facing an estuary that gives out to the sea. The waterfront has a few Victorian-era monoliths – the District Commissioner’s Office, the Museum – but behind that the streets quickly shrink into a dark, confusing rabbit warren of alleyways and bypasses. None is wider than 8 feet, so cars are out – the only mode of transport on Lamu is the donkey, which are here in abundance. Local mahouts jockey them around, sweet-eyed beasts that let out the most heart-rending bleats at all hours (I know…they woke me up last night).

The Muslim heritage is strong here – many of the women are veiled, and alcohol is verboten except for a few, touristy places. But on the whole it is extremely relaxed and friendly. Everyone, and I mean everyone, pipes up with a friendly “Jambo!” (hello!) on the walkways, which can be exhausting.

My excuse for being here is twofold. The KEMRI malaria people in Kilifi could only see me last week, and the U.S. Military HIV programme in Kericho was only free next week.

Voila, a few days to spare.

It also dovetails with an ongoing interest of mine, which is the triangular relationship between the Sultans of Zanzibar (the source of Swahili culture), Kaiser Wilhelm’s Germany and late Victorian England in the latter 1800s. It’s colonialism with a capital “K” – the Zanzibari rulers were Arabs from Oman and the African population suffered from all hands. Still, it’s a fascinating glimpse of one of the early encounters between Africa, the “Muslim World” and modern Europe.

More about that, if I ever get my act together, later.

Meanwhile, back on Lamu, everything is pretty good. Shella has one world-class hotel – the Peponi, frequented by the above mentioned royals, clapped out rock stars and site of the only decent Internet connection, from which I will post this– but also a lot of very nicely set-up B&Bs. I’m staying in one (thanks Andy Meldrum!) called Banana House, run by a Dutch woman named Monika and her Lamu husband, who goes by the name of Banana.

Monika is a yoga master, and I hear her doing athletic yoga breathing just as the sun rises. She’s also a specialist in the “Art of Living” (apparently a recognized qualification?) so we’ve got a Wellness Center attached to the hotel. I slept through the yoga class this afternoon – too much sun and heavy thinking – but will be bending my heart out tomorrow, I promise.

There’s a lot of construction around, so days are not quiet. But it is a beautiful place – and, for the moment, empty so I am the sultan of my surrounds, sitting on an open terrace with the fullish moon now mottling through the flowering vines overhead (I can’t spell bougainvilla but that’s what it is). In the garden, where the guys are digging by hand what promises to be a pretty cool swimming pool, there are frangipani, which give off the sweetest honey scent as the sun goes down.

So that’s where I am right now. But I’m still focused on global health, don’t get me wrong. More about that soon.

Sunday, July 13, 2008

Exploring

I'll be off exploring for a few days next week and probably won't be able to post for a while.

I'll recap when I get back.

Friday, July 11, 2008

Procedure

It was, I imagine, like trying to interview Madonna.

Crouched on a rickety wooden folding chair, I had my notebook out. Dzame Kitti, whose guest I was, was sitting cross legged in the doorway of her small, mud-walled house. The sun was shining bright, and chickens pecked at the ground near a round rattan mat where corn kernels lay out to dry.

I began to ask a question, and was immediately stopped. Procedure. My companions – Dzame’s handlers – swung into action. Dr. Ally Olotu, who had overseen the early malaria vaccine trial which Dzame’s daughter Jazmilla participated in, brought out a sheaf of papers and began to speak to her in Kiswahili.

The papers were the consent form we had worked out for the interview.

Informed Consent is a key element of clinical trials. Participants are asked to sign forms that indicate they have been told all of the details of the trial, including risks and benefits, and have agreed to take part voluntarily.

The informed consent process extends to interviews. I had come with a Kiswahili translation of a consent form that had been worked out by malaria workers in Tanzania. It was modeled on a form drawn up for an earlier visit by a TV crew, and apparently had some jarring language – “universal distribution rights”, “all media” etc.

This had raised red flags in the KEMRI social research group, which felt that perhaps that Kenyan participants would be signing away too much. So Ally helpfully drew up a new, simpler form, stating that the interview was for Reuters news and was voluntary. This had been cleared by the KEMRI social research team, one of whom was with us and watching with the eagle eye of a Hollywood publicist.

We were good to go.

Dzame – wearing a t-shirt supporting Louisiana State University -- listened carefully as Ally read through the form, and bashfully nodded her assent. I began to ask my first question, and was immediately stopped by the social research worker.

She hadn’t signed yet.

Dzame – rail thin, with two-year-old Jazmilla clinging to her legs – didn’t know how to write. Discussion ensued. We had forgotten to bring the ink pad for a thumb print. Would an “X” suffice? No. More discussion. Eventually Dzame allowed the social research worker to use a ballpoint pen to coat her thumb with ink. Pressed against the consent form, it yielded an acceptable “signature.”

We began. Dzame didn’t have much to say about the malaria vaccine trial, it turns out. Inexpert translation flattened her comments and left me with the feeling that it had all gone well – but no sense of her personality, or the real considerations that went in to her enrolling Jazmilla in the vaccine study.

This obviously is due to my inability to speak Kiswahili, and my ignorance of the local customs and attitudes. A better informed local reporter would have a sense of what was really going on.

But I’m equipped as I am, and this is my project, so we continued.

Toward the end, I asked if I could take a photograph. The social research worker frowned. Photographs had not been mentioned in the consent form. If I wanted to take a snapshot, the entire process would have to be revisited. Dzame has not released visual rights. Would this be for publication? If so we might have to refer to the ethics committee in Nairobi.

I put the camera away.

At the end of the interview, Dzame gathered Jazmilla up in the billowing folds of her colorful wrap, strapping her tightly against the maternal back to get ready for the day’s work. Jazmilla looked at me with a fathomless stare as Dzame offered me some fresh corn from her fields.

Sitting on the stoop of a peasant farmhouse in rural Kenya, the elaborate protocol to get to a simple interview seemed absurd. But I understand why it is there – the KEMRI researchers have, as their paramount responsibility, the welfare of their trial participants. And their main objective is to obtain data on the vaccine – not to publicize the project, or to trot out helpful “spokespeople” for the vaccine enterprise.

Dzame waved as we set off back toward the KEMRI landrover through thickets of corn. Jazmilla had already scrunched the consent form into a ball. But we had followed procedure.

Thursday, July 10, 2008

You Gotta Have Faith


Faith Okuma, 25, sits behind the reception desk at the International AIDS Vaccine Initiative (IAVI) trial site in Mtwapa, Kenya.

On her desk is a huge bowl, overflowing with condoms. In her pencil jar is a large wooden penis.

With her wildly tousled hair, brilliant smile, nose stud and hot pink high heeled sandals – pink spaghetti straps snake up her long legs – Faith is a great advertisement for the 24-hour party people of Mtwapa, locally known as the Sin City of Kenya’s coast.

Thanks to Faith and other volunteers like her, the IAVI center in Mtwapa is reaching out to some of the most marginalized – and most at risk – populations in Africa: female sex workers (FSWs in global health speak), and men who have sex with men (MSMs).

“I’m MSM friendly – it means I have a lot of friends,” Faith said with a low laugh.

Acceptance and understanding are hard for both of these groups in Kenya, where prostitution and homosexuality are illegal on the books and widely stigmatized by political and religious leaders.

And both groups are seen particularly at risk for the next wave of HIV, in large part because existing public education programs and interventions ignore their existence.

Not so at the IAVI center.

Mtwapa, despite its rock’n roll reputation, is a pretty gritty little town. About 60 km north of Mombasa, it has an aura of fun because its bars are open 24 hours a day, there are beaches and hence tourists, and the taxi system works thru the night. But the reality of Mtwapa is a collection of ramshackle dives, blaring music, set up next to day traders peddling everything from car parts to DVDs and salted with a lot of dubious hotels promising “excellent service” and “superior meals”….

The IAVI center lies down one of Mtwapa’s rutted, muddy roads. Go through its gates and you enter the world of international AIDS enterprise – clean, new furniture, decent computers, and in the labs up to date equipment. The IAVI center was one of many in Africa that was gearing up to test the next wave of AIDS vaccine candidates – until hopes came crashing down with the disappointing results last year of South Africa’s Phambili trial, which cast doubt over the current basic premises of AIDS vaccine design.

The work goes on, however.

In Mtwapa, they are doing what is called “cohort building” – trying to attract and retain people seen at particularly high risk for contracting HIV, such as MSMs and FSWs. While the point initially was to enroll participants in vaccine trials, the outreach now is about education. And research: the more we understand about how HIV is transmitted, by whom and to whom, and under what circumstances, gives us more weapons to halt its spread.

Faith says the people who are brave enough to walk through the IAVI Center doorway are often not brave enough to stay.

“Sometimes they come in and I call a counselor, and by the time I get back they are gone,” she said. “We are trying to get them to stay.”

You Gotta Have Faith

Tuesday, July 8, 2008

The Therapeutic Misconception




I’ve spent the last few days at the KEMRI-Wellcome center at Kilifi District Hospital (picture from kid's ward above...am still negotiating to actually take pictures of the kids!). It is a joint project of Kenya’s Medical Research Institute – the country’s equivalent of the U.S. Centres for Disease Control – and Britain’s Wellcome Trust.

The “Unit”, as it is known, is a major research center on Kenya’s coast and the home base for a number of clinical trials including the coming Phase III large scale trial of the RTS,S malaria vaccine candidate.

Dorcas Kamuya is the community liason manager, who is in essence charged with sorting out the unit’s relationship with the local people who must consent to being part of a medical research project. In the case of most malaria research, this involves parents giving consent for their children – the infants who are the most likely to contract and possibly die from severe malaria.

Dorcas has a broad smile and a businesslike manner, and readily discusses the complications in the relationship between researchers – who are equipped with state of the art equipment and aspire to produce world class data -- and the researched, often subsistence farmers in one of the poorest and most unequal regions of Kenya.

Unit scientists have run into a series of problems, including widespread rumours that their requests for blood samples were somehow related to “Miyani”, a local version of the vampire legend. And the unit had to replace the familiar snake-and-staff logo of the medical fraternity on its vehicles after the serpents drew suspicions that somehow they were involved in devil worship.

But a more persistent problem for medical researchers is what they call the “therapeutic misconception” – the idea that parents get that somehow participating in the research will result in a better treatment for their own children, and that declining to participate may mean the children aren’t treated.

In any randomized clinical trial, there is at best only a 50/50 chance that a given child will receive the test treatment. And even then, there is no guarantee that it will produce any protective or curative effect – all the trial is aimed at doing is delivering data on whether or not the treatment might be effective in a broad sense.

In kiSwahili, there is no direct equivalent for the English term “research”, at least in a medical context. Various words including “utafiti” (study), “unchunguzi” (investigation) and “mradi” (project) may be used, but Dorcas said that none really conveys the idea of scientific research with its hard repetitive queries and often elusive conclusions. How do people really give “informed consent” for a process that is at least initially alien to them?

It is just one example of the weird collision of science and hope that occurs around here every day.

The KEMRI group says they are pretty sure that they are overcoming the culture gap – and point to rising numbers of people declining to enroll in trials as evidence that “they are learning that it is ok to say no”…..an ironic symbol of success, but one just the same.

Sunday, July 6, 2008

comments please

I'm new at this game so please bear with me...but I think I've finally got the comments enabled now. If anybody feels like venting, please do!

It's hard not to like



a town where the two main traveler's hotels are the Titanic and the Watergate.

Despite the catastrophic references, Kilifi is pretty swell. Built at the mouth of a deep water creek, the town faces the Indian Ocean on bluffs -- the pelucid waters of the creek slowly giving way to the surge and chop of the ocean.

It is quiet, and the Southern Hemisphere starscape burns bright.

I'm not staying at the Titanic or the Watergate, despite the attraction of the names. But don't cry for me -- my place has a huge pool overlooking the ocean!

Saturday, July 5, 2008

Dork on a Dhow

I should have known better!

Arrived in Mombasa yesterday. After Nairobi's smog and grit, this is a very agreeable city. The "Swahili Coast" elements are all there -- New Orleans style covered porches, elaborately carved wooden doors, and an Indian Ocean mashup of people all going about their business.

Some colleagues of mine at Reuters in Nairobi told me that THE thing to do in Mombasa is a dinner cruise on a "dhow" -- one of the old wooden sailing ships (refitted of course) which still sail up and down the East African coast and on to the Arabian Peninsula.

Dinner can be a problem when you are traveling alone. I can take the rest of it -- in fact I sort of prefer being a free agent during the day -- but at night you pay the price.

After a quick look at my hotel restaurant, I thought what the hell, at least it will give me something to do/look at during dinner, and it is THE thing to do in Mombasa.

So, even though the ticket cost almost twice as much as my hotel room, I splurged -- envisioning a sort of jolly putt-putt swing around the bay, a big sloppy buffet with crowds of noisy tourists, and a quick tourguide version of Mombasa history.

When I arrived at the jetty, I began having second thoughts.

There sat a splendid dhow, hung with lanterns. On its decks, however, were only about seven tables -- each kitted out in full "luxury dining" mode with a panoply of plates, glasses, silverware etc. While most were ready for groups of four or six, or romantic Honeymoon outings of two, one table was set majestically for one -- me.

A helpful waiter informed me that the cruise would take 4-1/2 hours.

So, under a fingernail moon, off we steamed. The point of this cruise was clearly the dinner and not the sightseeing. There was no guide, and within about 20 minutes night had fallen and it was hard to make out what was on the shore aside from a few twinkling lights.

I kept looking anyway, if only to avoid eye contact with my fellow passengers. Sometimes a single traveler can feel dangerous in groups of others -- a warning beacon.

Of course the other diners probably didn't give me a second thought. But the fact that my table was under the same spotlight as the band and the lady chanteuse decided to direct some of her more warbly numbers ("Midnight at the Oasis" -- oh yes) directly at me left me feeling kind of exposed!

On the upside, the food WAS delicious -- barbecued king prawns. And the 4-1/2 hours did pass. And I've now done THE thing to do in Mombasa.

Today I'm headed up the coast to Kilifi, where the malaria vaccine researchers are working, so I hope we'll get back to health-related stuff soon.

Right now, I'm going to go out and see if I can find Mombasa's most famous landmark -- giant metal tusks erected in arches over the main drag to commemorate a 1950's visit by Princess Margaret.

P.S. One of Nairobi's most popular (or at least most advertised) funeral parlors is gloriously dubbed "Montezuma and Monalisa Funerals". Aztec Renaissance?

Wednesday, July 2, 2008

Smog Birds

I don't think that's Kenya's national bird but it certainly should be Nairobi's.

You arrive at Kenyatta Airport, which is situated about 15 miles out of town. Then, in a rattletrap taxi with a grim-faced driver, its off along the "Uhuru Highway" into the city.

The highway quickly clogs with minibus taxis, private cars, huge four-wheel drives with diplomatic plates, and the weirdest odd-lot of trucks, tanker trucks, pick-up trucks, and what-have-you -- most of them spewing noxious clouds of greasy grey smog.

Strangely, as you come into Nairobi proper, the highway is quicky overarched with trees, their branches studded with the most amazing -- and huge -- birds. They look a bit like storks, certainly that size and with the same sword-like beak and long, spindly legs. They hang around nonchalantly in the branches above this seething cauldron of traffic and exhaust. Sometimes one will lazily take flight, with breathtaking wingspan, and come coasting in to rest on another branch, which bends dangerously down close to the traffic under its weight....

Anyway that's Nairobi so far. I've got a couple of appointments tomorrow and then head down to the coast and Mombasa.