A Few Pictures.

Here's what you missed:

Uganda: Jump off of me.

Lake Nakuru, Kenya

To clarify -- This is a Rock Hyrax.

But they're so cute....

And I probably don't have rabies.

Orient yourself. You're still in Kenya.

And enjoy the view.

Chase a Giraffe into the forest on foot.

Don't scare the flamingo.


And move on to Ethiopia...
Lake Tana and its monasteries...

You heard what the sign said!

9 century old bibles hand written on goat skin, displayed by adorable monks abound...


Gondor, Ethiopia -- The Camelot of Africa, as they say.

The Simien Mountains.

Ethiopian Angels.

Lalibela, Ethiopia and it's rock hewn churches...
These churches were carved directly out of bare rock. Ground level is at the top of the picture.

Yup. Carved out of a hillside.

The church interiors are carved from the same single stone.


Look for the people at the left side of the picture for scale.


This nun paints Ethiopian Christian religious imagery on small patches of goat hide from her monastery atop this mountain...


Feeding the hyenas in Harar, Ethiopia. Because I probably didn't have rabies yet.

Malawi.

Northern Mozambique


Rwanda. Gorillas and Genocide...

It's kind of how you picture The Jungle. Right Max?


Yup. We're that close. That's a silverback.

Please take a moment to appreciate the relaxed attitude of the baby on the left. It's good to be king of the Jungle...

Elsewhere....

Church Genocide site.


The near sign marks the place where French soldiers played volleyball while 50,000 bodies were thrown into mass graves (marked by the further sign).

Spain.
Meanwhile, at the Alhambra, in Granada, there hasn't been a genocide since ... the Inquisition.

Take a look at that white wall in the foreground. Closer...

Closer....

Close enough. Now remember that.




and now?

A New World.

Want to hear something frightening? Someone in a bank -- who seemed to know what they were talking about -- told me today that I was pre-approved for a $160,000 mortgage. Seriously -- someone is foolhardy enough to front me a hundred and sixty large. Kind of a sea change from African street hustlers trying to bilk me out of an extra 13 cents.

So yeah -- things change fast when you hop a few intercontinental flights, and get a diploma that says MD.

I'm afraid that I became rather delinquent in my blog updates during the last month of my trip. Now, sitting in one of my future co-resident's living rooms, a few days into my search for a new home in New Haven, Connecticut, the adventures seem rather distant.

I still haven't gotten the cable out of storage that can connect my camera to my computer, so you'll have to wait a bit longer on pictures, but here is what you missed in the rest of East Africa. For details, give me a call, my number hasn't changed:

Scuba-diving in northern Mozambique -- real fun.
Being qualified to rent scuba equipment, and head out in a boat with a buddy -- real foolish.
Having to eat a raw egg, including shell, as part of an awkward PADI-Scuba initiation ritual -- real not fun.
Hopping a flight from Northern Mozambique straight to Dar es Salaam, Tanzania in order to skip 5 days of arduous overland travel -- real smart.
Finally getting rid of the body lice infestation of questionable origin that you picked up a month prior in a hotel in Ethiopia, and which proved resistant to the "All-Natural Lice Shampoo" that you found in Nampula, as well as the pungeunt homemade disinfectant mixture with which you later washed everything that you owned, including your body in Pemba, but was susceptible to the 'Not-Natural' (read: effective) Lindane lotion which you bought in Dar es Salaam and applied in Arusha, in the shadows of Mt. Meru -- real satisfying.
Laughing at Max when he finally lotioned himself 2 denial-frought weeks later -- also satisfying.
Being back in Tanzania -- homey.
Taking a bus directly from Arusha, Kenya to Kampala, Uganda -- really long; improved by overnight self-medicating; worsened waking up and finding that your headlamp was stolen while you were deep in a medicated sleep somewhere near the Kenya-Uganda border.
Kampala -- bustling.
Deciding to go to Rwanda to see some of the few remaining Mountain Gorillas -- smart.
Rwanda -- good infrastructure, easy to travel, and oddly pleasant for a country only 15 years out of a genocide.
Seeing 35 year old Rwandan men on the street and wondering: what were you doing when you were 20 -- disconcerting.
Going Mountain Gorilla tracking and being touched by a Silverback -- real real naughty. (that's a good thing, mom.)
A variety of Rwandan Genocide memorials containing everything from polished informational exibits, to gnawed, abandoned clothes covering the pews of a once-church-refuge, to the twisted bodies of adults and infants, exumed from shallow mass graves, covered in lime powder, and pkaced in room after room after room of a once-school once-site of 50,000 killed, set upon a hilltop surrounded by lush tropical hillsides and a view as incongruously beautiful as the smell of the memorial was memorable -- difficult to fathom.
The trip back to Nairobi and a farewell to Africa for a while -- bittersweet.
Waking up in Nairobi and going to sleep in Madrid -- stisfying, especially if the first thing you do is buy a bunch of wine and bread and cheese (which we did).
Couchsurfing -- always an adventure.
The Alhambra -- not too shabby.
Two weeks in Spain -- exceedingly pleasant.
NYC, Gradutation, relocation and residency -- the capital of the world, fine, ongoing and we'll see.

Pictures soon...

mulanje to pemba: a variety of transportation - Guest blog by Max

Hello! Inasmuch as I've fallen far behind on all my electronic responsibilities, and I started traveling with my roommate Max two weeks ago in Malawi, the following blog entry is brough to you by Max. I'm still working on the entry about Ethiopia (the prior few weeks), so forgive the out-of-chronological orderness. Anyway, the trip has been Ethiopia, meet Max in Malawi, overland northern Mozambique, and now in Dar es Salaam, Tanzania. My old stomping grounds. More soon... Now, from Max:

________________

ben and i arrived at mulanje, a border town on the malawi/mozambique border on tuesday morning, april 7th following an overnight trip from blantyre. the date is easy to remember because it's our new favorite holiday- women's day in mozambique. at the border we were welcomed by rowdy, boisterous, and saucy women drunk at 11:30AM. they implored us to come back to one of their homes to have lunch and we accepted. it turns out that that woman runs a restaurant out of her home- whoops. sumptuous lunch and and too many beers in, i cut myself off from the barley hops at 3; dancing all afternoon was the complementary remedy. dinner was served, and we were fast asleep on a mattress by 8.

430am out the door to walk into town and head to mocuba by public transport (this was a small lorrie, but we were offered the cab). bumpy road, one short break down and 6 hours later we arrived. at the bus station we inquired about transport to nampula- this was the long leg on the journey to the indian ocean. in the manner of minutes we found a group of guys, in a huge lorrie, who could take us. after using our spanish as broke-ass portugese to understand destination and price, we agreed- this time in the bed of the truck. after filling the bed will other passangers on the way out of town, we were on our way.

and then it started raining. hard. and the roads were horrific. about, i'd say, 10 minutes into the trip, we were soaked to the bone and our packs were water-logged seat cushions. the conditions were pretty nasty. rotten fish was the dominant scent whenever we slowed down. sometimes the group haphazardly pulled a grimey tarp over us, creating a hot, wet, fetid atmosphere underneath. about 4 hours later we stopped at a town to fill the bed with bags of corn- human and agriculture transport now. 2 hours, 2 beers, and a fiasco trying to dislodge the truck from the mud, we were back on the road. now it was dark. the rain had diminished, but the threat loomed and a chill sunk in. one silver lining was a beautiful tropical savvanah countryside illuminated by a full moon.4 more hours and then we arrived at another town. we quickly filled our stomaches and heard that there was now one spot in the cab. we looked at each other- rock paper scissors? the loser was gonna be PISSED. so, we inately implemented the sad puppy dog guilt-trip technique. layed it on real thick. next think we knew ben was on my lap in the cab. PA-REESH. 4 hours later we pulled into nampula at 3AM. good lord. 14 frickin hours. 14 hours. we were in a state of hazy distortion- fatigue, lack of shelter, damp nastiness. thank god the hotel we found was nice.

after head to ilha de mozambique the next day, we had transportation paradise from there to pemba. ridiculous. by complete dumb luck, an opportunity for a pricey (by our standards) by not unreasonable private van fell upon us. after some back and forth with the driver and hastily assembling our packs we were on the road. feet up on seats that faced each other, the only two in the entire back seat of the van with and ipod to dj with. hehe, this was a beautiful, beautiful thing. gorgeous, expansive country side, our music, a book, lounging in padded seats. oh yea, there was a sunroof! paradise really, especially after the nastiness that had proceeded it.

k, off to the beach.

word.

max

Ethiopia

Alright -- so this is the long awaited blog on Ethiopia. Started writing it about a month ago and am finally finishing it up. In Arusha, Tanzania, right now. It's been nice to be back in Tanzania, speak some swahili and know my way around. Tomorrow though it's the overnight bus through Kenya direct to Kampala, Uganda -- we're going to work on seeing some Mountain Gorillas. Also, we're picking up Big Ben (my other former roommate) in Nairobi. It's a little Tower III, 21E reunion. We'll be sure to do it up right.
____________________
Greetings from Lilongwe, Malawi.

I've left Ethiopia behind and arrived here yesterday to meet my friend Max, with whom I'll soon head for the abandoned beaches of Northern Mozambique and head back north up the coast to Swahili country, which by now feels like home.

What can I say about my time in Ethiopia? Ethiopia is Unique. Ethiopia is incredibly interesting -- one of the most interesting places I've ever traveled. Travel in Ethiopia is also incredibly difficult, trying and tiring -- amongst the most difficult places I've been. I was fatigued and ready for a change when I boarded the plane in Addis.

Let's start with what's interesting. In terms of poverty, Ethiopia is very much like many other parts of Africa that I've been -- worst than most, actually. And poverty is always the same, to some degree. But beyond the similarities of mud and stick huts, thatched roofs and dirty streets, Ethiopia is a place wholly it's own.
The Amharic peoples -- the dominant cultural group of the central Ethiopian Highlands -- are unlike most africans, and pride themselves on this difference. They speak Amharic, a rather opaque semitic language that is spoken nowhere else in the world. They are different in appearance. There is a huge variety of complexions, facial features and body types. I suspect that Ethiopians elsewhere in the world are often mistaken for people of mixed origins -- half white and half black, or half black half arab, or some such combination. Ethiopian food is unique. The majority of Ethiopians practice a unique brand of Orthodox Ethiopian Christianity -- a type of christianity which was not introduced by missionaries in later years, but rather directly from Jerusalem during the initial spread of Christianity, and therefore has evolved it's own flavor over the millenia. Indeed, Ethiopia's location at the horn of Africa and on the cusp of the middle east, in addition to allowing the early introduction of Christianity, also made it an important way-station on ancient Arab trade routes, connecting Ethiopia's storied dynasties with world affairs in a manner unlike the rest of sub-saharan Africa.

The ruins of these ancient kingdoms, and the displays of ancient Ethiopian Christianity are what now constitute the majority of Ethiopian tourist sites. And as a tourist, I was not disappointed.

I visited Bahir Dar, a city on the shores of Lake Tana, the source of the Blue Nile, and took a boat trip to ancient island monasteries, where creased monks leafed through the goat-skin pages of 900 year old hand-scripted bibles. I visited Gondor, and walked through the ruins of the Gonder castle, a medeival construction of the Gonder kingdom that would be be equally at home in western europe (though when I exited, and was passed by a train of donkeys loaded with charcoal, there was little ambiguity as to my location). I visited Lalibela, where in the 12th century, emperor Lalibela oversaw the excavation of 12 Rock Hewn churches -- impressive monolithic buildings carved out of the featurless stone of the hillsides, and designed to symbolicaly represent Jerusalem and function as an alternate (and rather more accessible) pilgrimage site. I visited Harar, a historically strongly muslim town in the East, where there is nightly ritual feeding of hyenas outside the old city gates -- hyenas which then wander around the town like stray dogs, whom you can feed by hand (don't worry, I've already had my rabies shots....).

A real interesting place.

But also a pain in the ass. Max can attest that I spent the first several days in Malawi and Mozambique noting how nice everyone was and how much more pleasant travel had suddenly become (and this was despite the ridiculous lorry ride described by max).

So what was it about Ethiopia that was so difficult. It's tough to describe. Let me start by examples. You already heard the story of the Addis rip-off scheme to which I fell pray; coincidentally, it turns out that this is a CLASSIC scheme in Addis, actually described in detail in Lonely Planet Ethiopia (which I didn't have), and which fooled a few other tourists I met as well. Another unpleasant experience was in Gonder. I contracted (quotation marks probably necessary) with a gentleman to take a guided half day hike to a nice vista point outside town. The day was not without it's hitches (showing up in a taxi instead of a 4 wheel drive, trying to charge me for a guide I didn't want and had been told was included). But it was still a pleasant day. I was flying out the next morning and contracted with the same taxi-driver to take me to the airport. I made the mistake of paying him the partial fare in advance (as I was paying for the day's activities at the same time). I recognized my mistake shortly after and, as I feared, I was without a taxi in the morning and the cell phones of both the taxi-driver and the sketchy trip-organizer were turned off.

While in Ethiopia I traveled through a number of towns with a pleasant German guy named Cedric. Cedric also had not esceped the tribulations of Ethiopia. In Addis, he had wanted to make a quick international phone call. He was taken to a shop (in an alley -- though most shops are in alleys...) and placed a 1 minute phone call to Germany. He was told that it would cost him 250birr -- 23 USD. This is a ridiculous price -- it should have cost him about 4 or 5 birr. He refused, and they physically restrained him until he paid 250birr.

Perhaps the worst experience, however, was yet to come. Cedric and I were traveling together in Gondor. I decided to take skip the sometimes 2-day long bus ride, and take the quick domestic flight (only about 35$) to Lalibela, as I got a discount for flying into and out of the country on Ethiopian Air. Cedric did not get this discount, and was going to take the bus. He arrived at the bus depot one morning to find all the buses canceled - the ethiopian government sometimes confiscates them for it's own purposes. That day it was to relocate people from an overpopulated and under-producing agricultural area. While at the bus station that morning he met a nice Ethiopian gentleman named Daniel, who was going to be on the same bus, and explained the situation. He met Daniel again the next morning at the bus station (which now had buses) and they traveled together. Daniel was initially going straight to Addis, but had never been Lalibela, and decided mid-day, to make the itinerary change to Lalibela, where I met him when he and Cedric arrived.

He was an extremely interesting gentleman. He was a carpenter and worked for an Italian construction company (Italy has strong historical connections with Ethiopia and Somalia), which had taken him to jobs in Algeria, Kenya and elsewhere. He spoke English very well. He was funny and pleasant, and patently concerned with our comfort and safety. He always paid for himself (although we sometimes bought him tea or coffee or overpaid a bit at meals and let him pick up the remainder). We saw the churches of Lalibela with him, and took the rather arduous 2-day bus journey from Lalibela to Addis together. Every time the bus would stop, he would leap outside to ensure that our bags were secure on top -- something that even I do not do when traveling -- some things are beyond my control. I remember especially his story about the 5 months he had spent in Ethiopian prison, after his burgeoning interest in investigative journalism led him to publish an article about the untowards relationship between the ruling party and a certain well-known millionaire. All in all, he was the most friendly, genuine and interesting Ethiopian I had met.

When we arrived in Addis, as Cedric and I waited for our bags to come off the roof of the bus, he disappeared with Cedric's phone and mp3 player. He had been using the mp3 player intermittently on the journey, and just after getting off the bus asked to use Cedric's phone because his was out of credit. We never saw him again. As saddened and confused as I was, having not actually lost anything in the experience, except perhaps a little faith in humanity, Cedric was rather devastated. He felt quite close to Daniel, and revealed that he had even been considering starting to send some monthly remmitances to help him out once he returned to Germany. We waited around the bus station for some time to make sure he wasn't going to come back. He did not. Cedric had his email address somewhere, although I wouldn't expect a reply.

The odd part was that it seems that if he had wanted to, Daniel could have taken us for so much more. He probably had ample opportunity to make off with everything we owned. It didn't quite make sense. We wondered whether it wasn't just a spur-off the moment, at the bus station, inability to resist temptation. Or maybe it was that he felt that, as helpful as he was been, he was entitled to some recompense.

And that gets a bit to my general feeling about the attitude towards foreigners in Ethiopia -- I couldn't shake the word Entitlement from my mind. When you get down to it, the hassles were the same--beggars, undersired guides, faux friends looking for a few free drinks--but the degree was far more than anywhere else I have traveled, and the manner in which these techniques were carried out also felt different.

More examples -- I would estimate that I was overcharged at 2/3 or more of all restaurants that I ate at -- which is to say that I paid more than the locals for the same dish; sometimes twice as much (the difference between 70 cents and a $1.40). Anytime there was an English menu, there was no question of being overcharged. A traveling friend of mine, a lovely australian world-traveler who had worked hard to learn some Amharic was in the unusual position (for a foreigner) of being able to read the non-english menu, and know exactly how much he was being overcharged. He felt a bit more compelled than I to take a stand, generally, and he had the experience that a restaurant owner actually refused to serve him food at the local price. He had read both menus, knew the prices, and refused to overpay -- he had to find another restaurant to serve him. He disagreed with my impression of Entitlement, and felt that the issue lay in the fact that Ethiopians saw foreigners as fundamentally different: we might all be human beings, but these foreigners are different at a basic level, and therefore should be treated differently. He had managed to make more Ethiopian friends than I, and noted that even his closer friends didn't understand why he would want to pay the same fee for the same service. I see where he was coming from, but I think there is a bit of that splitting present in many places I've traveled, and that in Ethiopia, is was again a difference of degree.

So, again, I couldn't shake this impression of entitlement -- in addition, perhaps, to a bit more tendency to view foreigners as fundamentally different. How did this entitlement manifest itself? My last example -- I was walking into the old walled city of Harar -- an ancient city of hundreds of labyrinthine alleys crammed into a circle about 1km in diameter. As I walked in I was approached by an Ethiopian boy, perhaps, 12 years old, who struck up a conversation in the traditional way which assured me traveler that he was looking to make a few Birr. I pre-empted him and polited told him that I was not interested in a guide and would wander the city on my own. He replies:

- So you want to get lost?

[not really an issue because the city is so small]

-If I do, it's okay, many thanks.

- [with undeniable spite in his voice] I hope you get lost.

-Many thanks. That's very kind of you.

I continued my walk. And was weary when I left Ethiopia.

Injera and The Match, then, How Much Does it Cost to Learn a Lesson Again, then, Matched!

This is a day late. I wrote it yesterday, but am still working on publishing it via Blogger. Ethiopian internet is not astounding in funcitonality. Anyway...

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Greetings from Addis Ababa, Ethiopia. I would say it in Amharic, but I have no idea how. Even the word for thank you is about 5 syllables long and rather difficult. I’m writing from an internet café atop a hillside, hidden behind a clothing vendor, in the Piazza district of Addis Ababa. I would never have found it myself, but some nice Rastafarians gentlemen whom I somehow picked up on the street were kind enough to show me.

So basically two big things have happened/will soon happen in my life. First, I’m in Ethiopia. Why – you may ask? Well – one can only eat eggs and French Fries for so many meals…

I kid, but the food was a strong draw. I love Ethiopian food. No one with a tongue loves Kenyan food. Also, I’ve heard nothing but great things about Addis. Also, the women are spectacularly beautiful. Also, did I mention the food? It’s amazing how much your quality of life improves when you enjoy what you’re eating. I’m staying with a nice gentleman named Solomon from Couchsurfing.com and thoroughly enjoying every injera based meal he whips up.

The second big thing is The Match. From when I began to write this entry, I have 4 hours until I find out where I’ve matched, which is to say where I will live, work, train--maybe even sleep--for the next 4 years. I found out on Monday, in Nairobi, that I matched somewhere, though they do not initially tell you where. I figured a change of scenery for the big news was appropriate.

First impressions of Ethiopia -- they drive on the right side of the road, and not all crazy-like. The people are spectacularly friendly. I think that Ernie (my ex-roomie) could pass for an Ethiopian guy -- so long as he didn't speak.

Look out for a Match update in a few hours… Wish me luck…
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Addendum -- so what's happened between 4pm and 6pm?

I would title this entry, if it were separate:

How much does it cost to learn a lesson.
Or
How much does it cost to learn a lesson again.

This afternoon, the answer was 400birr, or roughly 36 dollars. As I was wandering around town, a nice gentleman suggested that, because today was a holiday, if I went to a certain place, I could see traditional dancing. I thought: okay. I went.

Along the way, I got directions from another gentleman -- more than directions, he was walking in the same direction, so he came with me as my guide. He led me to a door in a sheet metal wall which was a bit more sketchy than I would have imagined. I hedged. I slowed. I looked both ways.

When I went through the doors I was greeted by many young 20-something Ethiopians who begged me to come watch them perform traditional Ethiopian dance. Sounds sketchy, right?

Well. I got the back story. They were Ethiopian students, on break from college, and they came to the city on their break to perform traditional dance. Still sounds sketchy, right?

So I ask from outside the door -- How much does it cost? Free. I ask again. Free.

Okay, I come in.

My guide and I sit on couches, while the girls start to perform some wholly unimpressive traditional Ethiopian dancing. Picture fairly normal dancing, but with more shoulder movement. I'm sure the experts are excellent, but experts these were not.

One of the girls sits with me on the couch and I try to get the story, since it still doesn't make sense. So she says that they're brought in by the church (which is huge in Ethiopia) on their vacation, and they do these dances, and if you buy a drink or get a coffee ceremony or whatever, the proceeds go to the church for orphanages (or something). I think -- okay -- overpriced drinks. I can deal with that.

I order a coke. My guide orders something that is yellow and comes in a large unmarked bottle (Tej, traditional Honey Wine). We watch rather uninspired dancing, and different girls come and sit and introduce themselves. They each have fairly convincing back stories -- one studies Marketing. One is a med student. They each name a different home town around Ethiopia. Etc...

Then one says to me -- would you like to buy us some drinks? I think -- okay -- this is gonna be it. I ask -- how much are the sodas? She says, oh -- 10 or 15birr. The conversion is 11birr to the dollar. This means they're way overpriced sodas. Okay. For the church. I can live with it.

How many bottles will you get? Oh -- we will share. How many? We will share. I didn't get a number. There were about 10 girls. I figure, a dollar a girl. Okay, fine. After all, they've been performing mediocre dance for me for like 20 minutes now.

So I agree to buy them drinks. Hurrah's all around! Dancing continues! Moments later out comes a tray filled not with cokes, but with the same bottles of Tej that my guides was drinking, and they were immediately opened, rapidly distributed, imbibed, and enjoyed. I made sure to get myself some Tej along with my Coke, too.

Would I like to buy another round?

Well hold on -- how much was this one? I'll go check.

About 15 minutes later the waiter/proprieter/whoever guy comes back -- you want the bill? Yes.

The bill: 900birr. That's about 80 dollars. 1 coke: 10birr. 12 bottles Tej at 75birr a piece.

So crap.

So here's the question -- how much do I argue? How much do I believe the back story? How much is it my fault? How much money do I actually have on me? What will happen if I refuse to pay?

Here's the thing about all scams I've encountered in the developing world: it's not that you couldn't do anything about it. It's not that you couldn't call the police. It's not that you couldn't make a huge scene. But when you start to think about it, and if you're familiar with how level of functionality of local enforcement agencies, you realize that it's just not worth the hassle. You give in. You rationalize. You take the easier way out. Whether it's 10 dollars in Zanzibar at a traffic stop for not wearing your seatbelt (a friend of mine -- I had learned that lesson in Ghana -- check my very first blog entry), or money for overpriced booze and bad dancing.

I let out a sigh that must have been audible above the Ethiopian music and claps of mediocre dancing that continued around me. Capitulation. I made some small show of objecting -- I was told it was this 10 or 15 a bottle. I was not told how many bottles were coming -- I was told a few would be shared. Blah, blah, blah. This was really just to kill time while I decided how much of a fight to put up and how much to cough up.

Their responses were something like -- you should have asked the price before (I did), you should have asked ME (the proprieter), you should have specified the number of bottles. Whatever.

What it came down to, at least as I presented it, was: I don't have this money. That was somewhat true. I had about 470birr.

We also take dollars! Oh -- well that's very nice of you! I, in fact, travel with a 100$ bill hidden inside my wallet, but no one was getting that without a fight. And I'm scrappy.

I had not told them how much money I had. I was still sighing and staring blankly into a mass of mediocre dancing.

In a surprise move, my guide -- really just some random dude from the street, unless this was WAY better orchestrated than I suspect -- coughed up 200birr.

I pulled out my wallet, which contained 400birr (in 100birr notes, from the ATM this morning), making sure to leave the smaller bills loose in my pocket. I keep smaller bills outside the bill clip so that I don't have to constantly pull my wallet out in public. I made a show of giving him everything in my wallet (excepting the hidden 100$, of course).

Didn't I just have a 20$ bill? Nope.

So that was that! He took the 600birr and called it even. He even thanked me, performing the traditional formal handshake (with left hand to right elbow).

I stood to leave.

The girls, who had been paying no attention to these proceedings, continued to dance, and asked if I was leaving? So soon? Please stay! There was still some Tej left! I considered whether I shoudn't drink every available drop before leaving. Probably bad form.

I left with my guide. I looked over my shoulder. Only a sketchy corrugated metal wall. That was that.

So. The answer is: 30-some dollars. That's how much my lesson cost today.

Were the girls really students? I would still buy it. Was it a scam? Yes and no. Certainly it was designed to bilk visitors from more money than intended, but perhaps it could have been avoided with more scrupulous ordering skills. And I believe that I could actually have come and gone and seen mediocre traditional dancing for free if I had not bought anything. Was the money going to the church? Highly unclear.

I walked home. I could have taken a minibus, as I still had the 70 birr, but I had daylight to kill.

I stopped at the same ATM I went to this morning. Another 500birr withdrawal. For me, in reality, it's just a blip. For whomever has my 400birr, hopefully an orphanage, but even a scam artist and some possibly fake students, it's a lot of money.

Alright -- an hour and 15 min to match!
_________________________________________

The Match:

Yale!

Very Exciting!

Please Do Not Feed The Rock Hyrax

Let me start by cutting to the chase so that you (Mom and Dad) don't get too worried:

I probably don't have rabies.
And I'm probably taking sufficient treatment in the event that I do.

So. It's been a fun few weeks since I wrote last! I finished my last week of medical school type stuff and parted ways with the guys. Traveling on my own, I decided to stop at a few well known parks on my way towards Nairobi, the first of which was Lake Nakuru National Park. A rather small park, it's located just outside Nakuru, Kenya's 4th largest city, and is easily accessible as a half-day safari from town.

Unable to afford a solo excursion, I joined a middle-aged Venetian couple whom I met outside our lovely rooftop rooms at the Mt. Sinai Hotel (only the wazungu -- whiteys -- like to stay on the roof for the view; no one else likes the 6 story climb). We rented a small Jeep for a morning jaunt into the park. The park starts abotu 4km from the city center, and as such is one of the few national parks that has fenced boundaries. Some city dwellers can watch zebra from their windows! The lake boasts an impressive array of flamingos, storks, cranes and other large birds, and the park is packed with a selection of your standard African game. It doesn't have many big cats, and no elephants, but it has quite a large population of rare White Rhino, which had been reintroduced from South Africa. It also has Rock Hyraxes.

Rock Hyraxes are adorable little guys, which look kind of like big gerbils. And, as my tour guide put it: they have the same skeleton as elephants! Right. It turns out he meant that they are rather more closely related to elephants than to gerbils or other rodents with whom they share certain gross similarities.

Rock Hyrax are also known to become rather quickly accustomed to humans -- tame even. I discovered this during our mid-morning break at a picnic area on Baboon Point. How cute! They'll walk right up to me and eat cookies out of my hand! How cute! He's licking the crumbs of my hand! Okay -- one more piece of cookie... Damnit!

Turns out they have really sharp teeth.

He only got a little piece of my fingertip, but it was more than a scratch. My guide advised me not to worry about it. It's not dangerous. And, specifically: No -- there is no rabies here.

That was enough to make me feel better. For a few hours. Because it was what I wanted to hear. Then I came to terms with what I knew to be the truth -- in casual speak here "No! You have nothing to worry about! There is no rabies here!" Means something like: I wouldn't do anything about it. I've never heard of there being any rabies here.... Though I've never thought to ask about it or look into it..... And there was that ranger who went crazy then died....

I double checked the WHO and CDC recommendations on rabies post-exposure prophylaxis. Given that I didn't catch and/or kill the animal, and could therefore not observe it for symptoms, I was supposed to take the full treatment course -- 5 shots of vaccine spread over a month, and an injection of Anti-Rabies Immunoglobulin as soon as possible.

I wasn't wholly convinced. I mean, what were the chances that THAT random hyrax had JUST gotten rabies, and was infectious, even though it was still acting normally and showing no other overt signs of infection? Very small. Definitely very small.

But were they risk-uniformly-fatal-central-nervous-system-infection small? Geh.

I decided to do some research. I found, amongst other things, that I was not the first person with this problem. But unfortunately that Rock Hyraxes can carry rabies. Still, there are only 11 known cases of Hyrax rabies (out of over 15000 total cases) in South Africa from 1928 to 2002. Furthermore Virus is rarely present in the saliva before overt behavioral changes (http://www.nda.agric.za/docs/rabiesB5.pdf).

Plus I was pretty sure it was going to be a pain in the ass to get the treatment. Let's be honest. This is Africa.

I turned out to be half wrong! I went to a clinic the next morning and found that I could get a rabies vaccination (essentially no questions asked and no consult needed) for about 23$. That's great! In the US it's 100$ a shot, and there is a shortage right now, so that you can only get post-exposure, not pre-exposure vaccinations. Believe it or not, knowing that I have a thing for strange wild animals, I tried to get the vaccinations before I came, and was told I could not get them because of the shortage.

The immunoglobulin was a different story. I was told that there was no Rabies Immunoglobulin present in Nakuru. So. Where did that leave me. I had gotten my Day 0 vaccination (now I only needed days 3,7,14 and 28), which would begin to prompt my immune system to create a response to clear any rabies virus present. But that response is not immediate... what if the virus is already creeping towards my peripheral nerves, from whence it will gain entry into my central nervous system, no longer susceptible to the humoral immunity which is induced by the vaccine? Shouldn't I rush immediately to Nairobi?

Probably a good idea. But nah. It's probably okay.

Instead I went to Lake Naivasha and Hell's Gate National Park (which was towards Nairobi, Mom). Hell's Gate is great because you're allowed to walk or bicycle through it. And I was alone. So just my bike, the animals and me. Sometimes just my bike, the buffalo and me. Sometimes me way too close to the buffalo... But that's another story.

So yeah. Rabies. I decided not to rush to Nairobi, but I was a little conflicted about it. I had gotten the initial vaccination, so I planned on getting to Nairobi by Day 3 for my next shot, but what about the immunoglobulin?

Despite these misgivings, it was pretty easy to relax on the shores of Lake Naivasha, renting a tent for two nights in a campsite notable for the electric fences which were turned on at 630pm nightly to keep the grazing hippopotamus from mauling tourists.

Eventually, yesterday afternoon, I arrived in Nairobi. I called around and found a private hospital which stocked the Immunoglobulin, and went into casualty (what they call their ER) for a consult. As I waited in the waiting room I read a plaque noting that the hospital building had been built with the kind funding and support of a number of large corporations, such as Barclays Bank Kenya and Kenya Airways. A good sign -- in poor countries the rich people will pay to build a hospital that they are willing to visit. I had found the right place.

The consult fee was equivalent to 15$. And the doctor basically looked at the little (tiny) wound on my finger and said I didn't need the immunoglobulin. Despite the WHO rec's, they only give the immunoglobulin in cases with high risk animals and severe wounds. My case had neither. The last time he had given the immunoglobulin was to a tourist who had been mauled by a baboon, and who had 4 finger-sized puncture wounds into her thigh to the bone.

Subtitle: Don't feed the rabid baboons.

He said that we COULD give me the immunoglobulins, but that it would really just be to make me feel better. I told him I felt alright.

So! I was vindicated! I'm glad I didn't rush to Nairobi to be told that I didn't need the treatment. And I'll be sure to finish the vaccine series, which shouldn't be too hard...

Today was Day 3. I needed my second shot. And I guess it wasn't TOO hard.

I did have to pay some sketchy doctor 500shillings (6$) to write me a prescription for the additional shots. It turns out that the pharmacies in Nairobi, at least the ones that carry vaccines I would take, are more uptight than those in Nakuru and require prescriptions. After a bit of the run around, and after borrowing a piece of gauze soaked in rubbing alcohol from said sketchy doctor, I gave myself my second vaccination in men's bathroom outside the clinic. It kind of gave me a new respect for IV drug users.....

Anyway.

Only three more to go!

And here's hoping that I won't get some semi-vaccinated paralytic form of rabies!

Work and Play

As usual, play is more interesting than work, but here is the update.

About a week and a half ago the other students and I moved from Eldoret - a modestly sized city with a large referral hospital - to Webuye - a rather unimpressive town with a district hospital. The referral hospital in Eldoret is used to having students. The district hospital in Webuye, on the other hand, is not. The hospital does have a Family Medicine Residency program, which is affiliated with Moi Referral Hospital, and run by some American family docs, but that didn't end up meaning that they had any idea what to do with 5 visiting medical students. We decided to focus our time on work for the research projects that we are required to do as part of the rotation. Two of the guys are doing a survey on pain prevalence and pain control, while the two other guys and I decided to do a survey on GI disease (diarrhea, vomiting, abdominal pain) and health, sanitation and hygiene education and practices (like latrine use, hand washing, ORS use, water treatment). So essentially we've spent all our time here filling out surveys. It hasn't been very interesting. I won't tell you any more about it.

What HAVE been interesting are our weekend adventures!

The weekend before last we decided to go on a little PikiPiki adventure. PikiPiki is the swahili word for motorcycle. Given the size of motorcycle engines here, it turns out to be a quite pleasing and appropriately onomatopoeic term. Trey - one of the other med students and our local motorcycle enthusiast - fomented enough excitement to get quite a little posse together. The plan was to head to the Kerio Valley -- about 60km away -- and head down into it (another 60km) to a secluded national park (down a 25km sometimes passable dirt track) reknown for birding and crocodiles. We rented four motorcycles at a cost of about 9 dollars per bike per day. Trey and I were both riding. I also had one of my new Kenyan intern friends as a passenger. Naomi, our Moi University med student liaison, jumped at the opportunity to learn to ride, and after only 2 short lessons from Trey and I during the week, was adamant about joining us. Phil, another visiting med student and novice cyclist was going to join us, but thought better of such an adventure given his experience, and opted to hop in a car with the other guys and meet us there. This, it turns out, was a fairly wise decision.

It's not that there were any MAJOR injuries. It's just that, as spectacularly curvaceous and entertaining as the descent into the valley was for we rather more experienced riders, it turned out to be a little too much for Naomi, who at some point got a bit nervous, hit a turn too fast, mistook the clutch for the break and drove off the road into some rocks. And some thorn bushes. She escaped with some scrapes and bruises and only one huge thorn in her side. Her bike wasn't completely nonfunctional afterwards, but it wasn't exactly in peak condition, having lost a mirror, the front brakes, the headlamp, any semblance of alignment and the rightwards range of motion of the front wheel. I tried calling AAA, but it turns out we were in rural East Africa. We bent the bike into shape sufficiently to drive it to the nearest town, where a mechanic charged about 8 dollars to fix everything. The alignment was still a bit busted, but it was far more ridable. With daylight remaining, we still made an attempt to make it to the park, down what turned out to be an alternatingly insanely rocky and uselessly silty road. Naomi opted for the car for this portion.

Despite our valiant efforts, we never made it. Daylight was failing and we didn't want to brave Kenyan roads at night, so we turned around. Impressively, Naomi got bored in the car, and decided to ride again. While this seemed reasonable at the time, it turned out poorly, as she became increasingly frustrated and despondent as her motorcycle troubles continued, and the stress of heading back up the valley wall turned out to be too much. We ended up having to stop in a town called Iten on the valley edge and hire someone to drive her bike back to Eldoret, while she got a ride in a car. This took an unfortunate amount of time to arrange, and by the time Trey and I eventually arrived back in Eldoret we were sufficiently tired, dusty, and freezing from the night ride home to know that it was a good day.

This past weekend was arguably more exciting, and it was even motorcycle accident free! This past weekend we went to Uganda. Webuye is only about 70km from the Ugandan border, and it's only about a half day's trip to Jinja -- the burgeoning Adrenaline-Sport capital of east Africa (per lonely planet). Jinja is a nice little southern Ugandan city on Lake Victoria at the mouth of the Nile. At this point it's the Victoria Nile (it becomes the White Nile somewhere in Northern Uganda, and the Blue Nile comes from Ethiopia, I believe), and it boasts some of the worlds best class 5 rapids.

Rafting Ensued.

What can I say? It was awesome! And we only seriously thought we were going to die once. Luckily there is DVD video of it. Our boat's colossal crash made the highlights real in slow motion, though the clip doesn't continue to the point where I resurface somewhere downstream, having gotten trapped under water between our river-guide's legs somehow and having failed miserably at my attempt to breathe Nile water.

My advice to future rafters -- take a deep breathe BEFORE the raft flips over. Then just enjoy the ride. Also -- apply copious sunblock to the legs. While I have learned that I am incapable of achieving other than a Lobster Tan, and apply lotion as such, one of my compatriots neglected to protect his legs, and ended up essentially bed-bound for 2 days, with a burn so painful he could not bend his knees.

There was also Bungee jumping. Despite my father's email pleas to reconsider, I bungeed. Sorry Dad. I can't think of a lot of spots more ideal than this alcove of the Nile, with monkeys playing along the steep banks, and the sun setting over the western bluff, to stupidly thrown myself off a cliff with rubber bands tied to my ankles. When you get up to the edge they say don't look down. For me, the looking down wasn't a problem -- I've never had much of an issue with heights. I think they should have said -- Don't Think. Becuase if you think, you'll realize that you're about to do something incredibly foolish, and if you let rationality take over, you're just not going to have any fun!

I bungeed 3 times. The second time is half price and the third time is free. How can you resist! The first time I went for the straight down, full submersion dive, hitting the water up to about my thighs. The second time I went for distance -- if you jump out you don't get as much water, but the rebound is real real fun. The third time I went for something they called a Harness Jump, but I think should have been called the Leap of Faith. Basically rather than being tethered at the ankles, you wear a harness with an attachment at the chest. Then, instead of a dive, you just run off the edge as fast as you can. Basically, all techniques are awesome. The only style I didn't try was backwards. They say it's the scariest way to bungee. It was tempting, but you gotta save something for your second time, right...?

Old and New.

Returning to East Africa has been both a new and a familiar experience. Kenya and Tanzania are quite similar, so there is a more than vague familiarity. The most notable differences are that the Kenyan infrastructure is much more developed, especially the roads, and that English is widely spoken. I’ve been using Swahili a bit, though you can get by without knowing any.

Working in the hospital, with direct patient care responsibilities, is a new experience, but the frustrations are familiar. I was actually rather impressed with the resources available at the Moi University Teaching and Referral Hospital (MTRH) here in Eldoret. Unlike the clinics, health centers and even the regional hospitals to which I was exposed in Ghana and Tanzania, MTRH has a functioning CT machine, a relatively respectable repertoire of laboratory resources, and even a highly functional HIV/AIDS treatment program sponsored by Indiana University and USAID that provides Anti-RetroVirals (ARVs) and even has an Electronic Medical Record (EMR) system. This doesn’t mean that patients in the medical ward don’t sleep two to a bed, that life-saving non-ARV drugs are available swiftly or consistently, or that more than 1 intern is present to cover up to 200 patients when on overnight or weekend call.

Although there is an undeniable lack of resources relative to, say, Columbia University Medical Center, the familiar frustration is not necessarily due to a lack of resources, but due to systems level issues by which it seems that even the available resources not used to their highest potential. The physicians and medical students are generally extremely knowledgable, but this doesn’t seem to translate in to efficient, high-quality patient care. It’s difficult to describe the issue precisely. An example: as you might expect, the in-hospital mortality rate is quite a bit higher here than in the US (though I can’t provide a number). Saying that medical the staff here is more accustomed to death than their western counterparts is a gross understatement. Unfortunately, it sometimes seems that this familiarity saps the sense of urgency from the treatment of acutely ill patients, patients in whom treatments like oxygen, diuresis, or atropine (which are available) may be potentially life-saving. Does this apparent lack of urgency have something to do with a different approach to resource management, by which physicians here have come to terms with the fact that temporizing treatments may be wasted if more chronic care resources are available? Maybe. Maybe not.

Another odd quirk of the system here is the staffing situation. During my two weeks in the medicine ward, daily rounds on the service are attended by between 20 and 35 people. My team had 8 4th year medical students, 4 6th year medical students (they’re on the British system where they do 6 years after high school, then internship), and a mass of other people who appeared on rounds but didn’t seem to be present on the wards otherwise, such as clinical and nursing officers in training. There were also about 2 foreign students present (myself and a Pharm D. student, for instance). Despite this mass of humanity, which makes it all but impossible to hear what is being said about the patients at the front of the pack, there is generally only 1 or 2 interns and 1 or 2 residents per team (of 25-50 patients). Attendings or consulting physicians are present only on some days of the week. The intern is responsible for all the patients, and the resident is rarely present on the ward after rounds. It would be near-impossible for an efficient intern to effectively carry this patient load even if ancillary services (nursing, pharmacy, laboratory, radiology, etc.) were highly coordinated (they’re not), and even if the intern was not sometimes stuck at the back of the crowd and therefore unable to hear the plan of care. As such, because it is essentially impossible for the largely unsupervised intern (assisted by medical students who come and go from classes) to perform all the patient care tasks required, things just don’t get done. Laboratory tests are not sent. X-Rays are not ordered, or if ordered, not performed or not followed-up. Medications are not administered as ordered. Oxygen for a patient in severe respiratory distress may take 30 minutes to arrive. Patients die, and there seems to be little direct accountability or structured quality improvement monitoring. There is a lack of both positive and negative incentives for appropriate patient care. And everyone seems to be used to it.

So that’s what it’s like working in the hospital.

Want to hear about more fun stuff?

Well. My first weekend here in Eldoret, I was lucky enough to be invited by my team intern to head with her and her friends to the Safari Rally being held in nearby Iten. Picture long-distance, 4wd NASCAR, on tiny rural African roads. And Indian barbeque.

My intern is half Yemeni, half Indian, and raised in Kenya. Since she moved to Eldoret for her internship, she has fallen in with a crowd of Indian kids who grew up in town, and represent the demographically small, but economically important Indian presence in East Africa. Their families tend to own factories and large local businesses and most of them attended university in the UK. While it was a quintessentially Kenyan weekend (inasmuch as I was hanging out with Kenyans), one might not have expected camping out on the edge of the Great Rift Valley to involve a caravan of SUVs of pick-ups, Indian food cooked over a gas stove, trance music, and lots of beer. Following an evening of such incongruous culture, we drove out to the race course--120km of apparently randomly selected back-country road--parked on the roadside, and watched cars fly down the tiny dirt tracks at sufficiently breakneck speeds to entertain even American medical students highly skeptic of racing sports.

I dug it.

This weekend I ventured out with a few of the other visiting medical students to Mt. Elgon National Park on the Kenyan/Ugandan border. Perhaps I’ll provide further details in another post, as this one is becoming excessive, but lessons learned include: Don’t trust the trail markers in Mt. Elgon Park. Never get separated from the guy in your group with a map. Always carry a flashlight, no matter when you think you’ll be done hiking for the day. Iodine tablets are good to hike with, but a water filter is better. When all else fails, just turn around and go back the way you came, even if it is 15km back to camp. Don’t startle Giant Forest Hogs in the dark. And finally, stalking giraffe on foot through the forest is awesome.

Karibu Africa Tena!

I'm back! (In Africa)

Hello!

For those who weren't aware, I'm back in Africa. I'm finishing my last few months of medical school in style by working at Moi University Hospital in Eldoret, Kenya. I'll be working here through mid-march, after which I'll be gallivanting until my mid-May graduation to Doctorhood.

I'm also accepting suggestions onwhat to do with 6 free weeks in East Africa. I just have to make it to Nairobi by May 1st. Leading possibilities include Ethiopia, Madagascar, or perhaps heading to the coast and bartering my labor to get on a boat and learn to sail. Anyone want in?

More soon!