Down the Rabbit Hole: epilepsy in Tanzania

Epilepsy.  The Swahili word is kifaafaa, origins possibly from the verb “kufaa” meaning “to die”.  Although overshadowed by diseases such as AIDS, tuberculosis, and malaria, most of the same diseases and conditions present in the United States are also present in East Africa.

My interest in epilepsy in Tanzania was sparked over a pot of chocolate fondue in Arusha town.  I had met with my election buddy, founder of “Mwangaza” (www.mwangaza.com) who is working on an epilepsy initiative that will tackle multiple facets of the epilepsy problem within Tanzania over a 2 year time span.

Although the exact prevalence of epilepsy is unknown in Tanzania, it is estimated to be higher than that of western countries, ranging from 5 to 75 cases per 1000 patients (Foresgren, Winkler).  There are many theories, including increased incidences of diseases such as neurocystocercosis, cerebral malaria, and meningitis, head trauma, or toxins.  While there is a growing body of evidence regarding prevalence of epilepsy in sub-Saharan Africa, we have not even begun to go down the rabbit hole.

Cerebral Malaria

Of the four species of plasmodium known to cause malaria, Plasmodium falciparum causes the most severe illness.  Although many cases will remain as simple malaria, complicated malaria can cause acute renal failure, acute respiratory distress syndrome, changes in blood homeostatis, and cerebral malaria.  Cerebral malaria carries a drastically increased risk of mortality and is often characterized by seizures.

As diseased erythrocytes flow through the vasculature of the brain, they begin to stick to the endothelium and disrupt blood flow.  Cytokines are released to fight the disease, but, also do harm to the brain tissue.  Despite treatment, neurological damage may persist.  It is hypothesized that CNS infections, such as cerebral malaria and meningitis, may play a role in epileptigenesis for some patients living with epilepsy in sub-Saharan Africa.

While many questions remain to be answered, undoubtably many patients would benefit from rapid malaria treatment to reduce the risk of progression to complicated malaria.

Neurocysticerosis

Pigs are filthy animals.  Cysticercosis results from infection by Taenia solium, a parasitic worm that is acquired from undercooked pig meat.  Infection with the adult worm causes taeniosis, tapeworm infection.  The worm grows and begins to shed eggs which are released into the host’s feces.

The eggs can then be potentially ingested by other pigs, other humans, or auto-infect the original host.  These hatched worms will never leave the larval stage, but are deposited into the host’s tissue where they develop into cysts capable of causing an immune response.  Inflammation from the host’s immune system attacking the parasite results in the clinical symptoms of cysticercosis.  Eventually the legion will calcify and the inflammation will disappear.

Neurocysticercosis results when the parasite has penetrated the blood brain barrier and forms lesions in the brain tissue.  It is possible that the lesions will be asymptomatic, but there is a growing body of evidence to support high incidences of epilepsy or recurrent seizures in patients with neurocysticercosis (NCC), especially during the phase of intense inflammation.

Without access to neuroimaging technology, it is important for physicians in areas of endemic NCC to be able to identify symptoms.  Cysticercosis can be treated with anti-parasitic medication, such as albendazole and praziquantel, and steroids.  Additionally, anti-epileptic medications are helpful in symptomatically managing the disease.

Neurocysticercosis is the leading cause of adult onset epilepsy in the world, and it is completely preventable.  Increased education on proper hand-washing techniques and the dangers of ingesting undercooked pig meat could significantly reduce the prevalence of seizures and epilepsy in sub-Saharan Africa.

The majority of patients living with epilepsy in sub-Saharan Africa are untreated.  WHO estimates that over 80% of patients with epilepsy in Africa do not receive any treatment.  Untreated epilepsy leads to progressive brain damage, and patients are at risk of physical harm when they seize.  Major obstacles to successfully manage patients with epilepsy include a lack of resources, lack of experience in treating epilepsy among health care professionals, a lack of understanding of the disease for patients living with epilepsy, and cultural barriers. 

Resources

A simple lack of resource is the most obvious reason for the treatment gap.  The only medications I was aware of that were being used to treat epilepsy in Tanzania are phenobarbital, phenytoin, and carbamazepine.  Valproic acid seems to also be a common treatment in third world countries.

In Tanzania, phenobarbital is the most frequently used medication.  It is far from being first line treatment of epilepsy in the United States for the simple reason that many patients taking it turn into a sort of zombie.  It is very difficult, if not impossible, to be high functioning while taking large daily doses of phenobarb to control seizures.  However, it is very effective in controlling seizures and patients can safely take it without needing blood draws.

There is a shortage of neurologists in Tanzania, and with this, there is less understanding in how to effectively manage the disease and manage the medications.  Many health care facilities may not have labs with the capacity to monitor serum levels of carbamazepine or phenytoin, essential to avoid blood dyscrasias and seizures that can result from high phenytoin levels.  Additionally, many patients with epilepsy live in very rural areas, where seeking any kind of medical care is a challenge let alone getting to a larger facility with the capacity to determine serum drug levels.

Carbamazepine is available in Tanzania, but it is only available in larger urban areas.  A challenge for my friend, that is developing the epilepsy initiative, is not only to find patients and get them started on an antiepileptic medication, but also to keep them on that medication.  As she goes out into the villages, she not only has to provide medication on this visit, but ensure that systems are in place for the patient to continue their therapy.  The wider availability of phenobarbital again makes it a more desirable choice for this reason.

Culture

Epilepsy is known as “kifaafaa” in Swahili, which may be translated as “deathdeath”.  The disease is not understood well by the majority of the population and is surrounded by a number of superstitions.  Learning about these was one of the most interesting aspects of the disease; to treat the epileptics of East Africa, these beliefs must also be confronted.

Many people believe that epileptics have been cursed or that they are being possessed.  Under this belief, a person that is seizing is less likely to be helped, even if they fall into the cooking fire.  Many people that have been living with epilepsy for a long time have been badly burned.  Poorly controlled epilepsy also results in decreased brain function, as a result from a lack of oxygen delivered to the brain during seizures.  Epileptics are the victims of social stigma, increased physical risk, and risk of neurological damage. 

Another friend of mine was working to set up a homeless shelter for women in Usa River Village.  He wandered the streets with Ibra, a former student, as an interpreter and met women in the worst situations of life and listened to their stories.  One woman who was of great interest to me, was covered in burns.  She told him she had a “fainting problem”.  She also exhibited neurological damage; she was not really all there.  Her strangeness drew neighbors out of their homes, who in turn laughed at her.  She had virtually no support system, and neither she nor her neighbors understood that her condition could be treated with medication.

Given these stories, my heart goes out to Mwangaza.  I have only begun to go down the rabbit hole, but Mwangaza is already in action, setting out to tackle a disease state that is not only misunderstood by the general population, but also has little scientific research behind the prevalence, origins, and treatment in this geographical area.  If given the opportunity to go back and make myself useful to Mwangaza’s initiative, I would do so in heartbeat.  

References:

Winkler AS et al.  Prevalence, incidence, and clinical characteristics of epilepsy- a community based door-to-door study in northern Tanzania.  Epilepsia 2009; 50(10):2310-2313.

Mbuba CK et al.  The epilepsy treatment gap in developing countries: a systematic review of the magnitude, causes, and intervention strategies.  Epilepsia 2008; 49(9):1491-1503.

Ngoungou EB et al.  Cerebral malaria and epilepsy.  Epilepsia 2008; 49(Suppl. 6): 29-24.

Zafar MJ. Neurocysticercosis.  eMedicine Medscape 2009.  Taken from http://emedicine.medscape.com/article/1168656-overview  on 1 November 2010.

Winkler AS et al.  Epilepsy and neurocysticercosis in sub-Saharan Africa.  Wien Klin Wochenschr 2009; 121(Suppl. 3): 3-12.

Quet F et al.  Meta-analysis of the association between cysticercosis and epilepsy in Africa.  Epilepsia 2010; 51(5):830-837.

Mzungu / Mafrika

Jumapili 26 septemba

KiSwhili word of the day is wimbo. Song.

Back in Mombasa and I already have my ticket to Tanga. I didn’t really want to come back, but I don’t think Lamu to Tanga was possible, and I had a really great day anyway.

The bus ride was miserable but at least I prepared myself for it. I was in the VERY back and everytime we went over a pot hole I flew out of my seat almost over the chair in front of me. The guy next to me kept getting so angry at the bus driver and calling him lazy and all kinds of names. The reality was the road was in bad condition and we had shitty seats.

As soon as I arrived in Mombasa, I just wanted to walk around. I walked to Fort Jesus and was debating paying to go in when this guy started talking to me and he is a tour guide but wasn’t pushy and really knew the facts. He wanted to show me around... How much? He told me he would show me the city and I could decide after how much to pay him.

Sweet.

Fort Jesus is built on the highest part of Mombasa, 17 meters above sea level, on the coast. It is shaped like Jesus on the cross. The Portugese had a weird sense of humor. It was built in 1497 (?) and the walls are a meter thick. After Vasco de Gama was turned away from Mombasa the first time, the Portugese came back later and settled in here.

There is also an expensive club next to it. Only for people with big pockets. Like Brangelina. I asked if Brangelina had ever come. My guide, Harrison, said no, but they frequent Diani Beach (south of Mombasa) and are apparently very loud.

In the bedroom.

I would have been surprised if he had said otherwise.

Old town in Mombasa had similar architecture to Lamu, with large mahogany doors with shackles carved into them. I noted that it was weird the Arabs made such beautiful carvings to symbolize something so immoral and depressing, but Harrison responded that slavery to the Arabs WAS beautiful; it was a very lucrative business.

I also saw the old ferry port, a Mosque for Indian Muslims, and a Hindu temple. Mombasa is mostly Christian and Muslim with some Hindus and very few Rastafaris. Harrison is rastafari: one man, one woman, peace and love. They pray to Haile Sallassie because, one year, during a drought in Jamaica, Haile Sallassie came to Jamaica and as soon as the plane landed, it began to rain. When Harrison prays, he prays to "Ja". I asked him why he calls his god "Ja". It sounds cool when you're stoned.

When we were leaving the Hindu temple I saw this really cool looking night club so we went over to have a beer and just talked.

Of course he was very curious to know how many children I wanted.

Zero.

Little Chi Chi is enough for me. And I can only think about finishing school and starting my career.

School can wait! But you must have babies now to bring you blessings and happiness!

Which of course is the opposite of American/Western thinking. BABIES can wait. But Harrison already has 4 children by different baby-mamas. He says when he gets married he wants to have 14 children because his father had 10 and he must have more than his father. He asked me if I would like to make a little zebra with him. I politely declined.

We talked about birth control. He said a lot of women in Kenya used the shot (which does not protect against HIV) but said it is frowned upon if a woman does not have many children; it is like being selfish. Comments on condom use, "Why would you eat a banana with the peel still on? It can be done, but isn't better to remove the peel first?" Again I reminded him that eating it with the peel on is better than getting HIV, herpes, HPV, and other STIs but he replied that if you are sleeping with a boyfriend/girlfriend you do not have to worry.

I wanted to ask him how many times he'd been tested. My bets are on zero.

It was interesting. Also because of the amount of corruption in Kenya, the only thing that guarantees you a job is knowing someone at the top, so why bother with school? Family has much more significance in East African culture, so it is only natural that people would want to have large families and start earlier, even though it does not make sense from my cultural perspective.

Harrison also talked about he does not understand wazungu who come to East Africa and get stressed out. You are on vacation. Why are you stressed? He said that wazungu would not endure one day of what an African endures. From the moment a baby leaves its mother, everyday is a struggle to survive. But you know you can survive this day because look at how many days you have already survived this far.

I talked about how many people in the U.S. are depressed. I think part of it is we are told to work hard in school so we can get a good job and be able to afford the American lifestyle, but sooner or later many people just figure out its all just crap. Harrison said even the poorest person is able to laugh and enjoy himself no matter what because he knows what is important. He has life, family, friends. While I couldn't agree with Harrison that I should make a zebra with him immediately, I really value what he said about family.

We finished the Tuskers and parted. I gave him 500 KSH for the tour, but he told me the thing he appreciated most was just having the beer with me.

Beautiful.

Good Snorkeling

Jumamosi 25 septemba

KiSwahili word of the day is "baharini". The ocean.

I drank too much last night and am now preparing myself for a day in the sun on a boat with Captain Happy.

3 other girls from my hotel also paid Omar Shariff the deposit for snorkeling, but counted their losses and are going with someone else. So my American friend and I decided we would ask Omar Shariff if he could go in place of the girls.

As soon as I get to the ferry port and ask Omar Shariff, he flips out. FLIPS OUT. He's yelling about all kinds of things. I said the girls said it was ok for the other American to go in their place so he drags me across the port looking for the girls and we find them as they are getting onto their boat.

I felt awful for them! Seeing this horrible angry stinking Omar Shariff coming at them yelling about how it was rude to promice this and asks if they said what I had told him.

One of the girls nervously looks at me and says, "yes"

"OK THEN IT IS FINE!" Omar Shariff yells and turns around and we walk back to the boat. Whew!

So there are 5 wazungu on the boat: Myself, my American friend, 2 German girls, and a photographer. And 2 sailors. The photographer was great. He is originally from Australia but has lived in Fiji and California (holla) and for the past 14 months has been driving around the continent of Africa taking pictures of tribes in their traditional clothing. He is is Lamu because he is waiting for his Ethiopian visa (which is really easy to get IF you fly into Addis on Ethiopian airline which is owned by the sultan... if not, it is damn near impossible to get).

So we pull up to this spot near another island that is brown with silt from mangrove trees and the captain says "I think here we make good snorkeling". I can't even see my hand under the water. So we are given "fishing poles" which are blocks of wood with fishing line tied around and a hook and weight on the end and sit for some minutes trying to catch fish. The water is so murky the fish probably can't even see the bait.

So we move to another location. Slightly better, but still the water is really murky. "Ok I think here we make for snorkeling".

The photographer inquires about a house boat in the distance. It is a hotel. Bar? Yes.

He immediately jumps ship and starts swimming.

Is he going to the bar?

Just a few meters before he reaches it, I jump in after him, swim to the house boat and he helps pull me up onto it.

Did you bring any money? He asks.

No, did you?

No.

Well, we tried. We hung out for a while and talked then swam back to the boat. The water was warm but part of me was completely panicked about sharks and crocodiles the whole time, especially because I couldn't see under the water.

We finally ended up at the beach across from Shela and played in the waves. I watched Omar, the captain's helper, prepare the food. Then we all got back onto the boat and the captain put up a sun shade for us.

"For you, not for me" he says.

"Well, you certainly have a lot of pigment. But supposedly we are all from Africa... I guess if you don't use it you lose it..." the photographer replies.

After eating we went back to Amu port. Even though I didn't snorkel, I really enjoyed the boat ride. We passed a house or shop near the water with all these 8x10 inch windows but every single one was broken. We asked about it, and the captain said these French people lived there who hated locals walking by their house (even though the house is on the main walkway) and are always giving the locals trouble about whatever issues so one night, a bunch of people came and broke all the windows a few weeks ago. So funny!

L'amour in Lamu

Alhamisi 23 septemba

KiSwahili word of the day is salama. Peace.

I also made a YouTube video of my time in Lamu:
http://www.youtube.com/watch?v=2G90z3zLBbg

So today was a trip and a half. It begins with waking up and taking the bus to Mokowe to get the ferry. So far I have been spoiled with the Kenyan roads (so far so paved!) so I didn't mentally prepare myself for this journey and had a seat in the second to last row so was bumping all over the place on dirt roads and my bottom hurt so much every time the bus slowed down, I prayed that we were in Mokowe and it was time to stop.

ALSO there were checkpoints somewhat reminiscent of Hotel Rwanda; with armed guards and spikes in the road that had to be manually moved out of the way for buses to pass. I found out later this evening that these points were instated 3 years ago, but prior to this there were lots of bus robberies and everyone on the bus would be killed... so I am very thankful for the extra precaution.

The scenery was gorgeous though. So many ponds with lilies and monkeys! and my favorite scene was this baboon standing on top of a grass hut, with only banana trees and grasses around and a circle of baboons surrounding the hut and looking up at the first baboon... it was like nature was reclaiming civilization. or just a scene from the Lion King.

Finally at Mokowe I get onto the ferry with maybe 75 other people, all their luggage, chickens, and vegetables and the boat itself I cannot believe that it actually floats even without all the luggage and people. So the whole time I am gripping the side of the boat and trying to stay calm, but somehow we made it safely to Lamu.

I was taken to Yumbe House (GORGEOUS! even though a little more that I wanted to pay) and arranged a Dhow Tour with "Captain Happy" or Omar Shariff who would later become the bane of my existence. The whole time I was in Watamu, I felt badly for being so suspicious of everyone so placed my trusts fully in Captain Happy.

Omar Shariff took me all around Amu (the main town on Lamu), really fun, then through Kashmir (everyone is obsessed with India so many towns on the island are named after places in India) then finally we went to get tea with his friend.

His friend was building this very nice apartment complex. If you have ever seen a movie depicting a Columbian drug lord, this is kind of what the scene looked like. We met with the owner, 2 other Kenyans, and this other American was there who was just traveling after spending a year volunteering in Rwanda. We were both equally confused over what was going on, and my new friend refused to drink any of the tea or food offered.

Omar Shariff and I returned to Amu and he bought me dinner then was very eager to show me the stars from his apartment. HELLS to the NO. I appreciated his generocity in showing me around town and promising me a ride to Shela Beach on his donkey, Shakira, but the man was super sketch and had really bad body odor.

When I got to the hotel I was asking one of the guys who worked there about Omar Shariff, and a lot of what Omar Shariff had told me didn't check out, which I had already suspected. O well. Today was good anyway. Omar Shariff is a character. He is the sketchie Kenyan version of Danny Brooklyn. Maybe this is why I was so eager to trust him. He reminds me of my friend.


Ijumaa 24 septemba

KiSwahili word of the day is : rafiki. friend.

I met the American from the night before with a new guy, a Brazilian living in Italy and who had just finished working for some time in Zambia. So great. We walked to Shela Beach which was absolutely unreal. Kilometers of clear waters and white sands and no hotels in sight. We played in the waves then I turned around and the tide was already past our bags. The ground was so flat that the tide came in rapidly, I could literally see it moving across the sands. Really cool.

Then we were all desperate for a beer. Lamu is mostly Islamic, so the only beers were either really over priced at the resort or at the bar at the police station. So in Lamu, essentially, the only place you can drink or buy alcohol is at the police station.

As we were leaving the police station and going back to one of the guest houses, we were approached by Ali Hippie offering us this food and cultural experience. The Brazilian immediately starts gushing "I don't believe it! I don't believe it! THE Ali Hippie? I must get your photograph for my blog!" I am frantically flipping through Lonely Planet... "who the hell is Ali Hippie?" then finally fall back and ask the American what is going on. He explains that Ali Hippie was in some guide book in the 1970s, but recently there have been a lot of Ali Hippie imposters. My Brazilian was super excited to meet an Ali Hippie imposter finally after 6 days on Lamu and was just messing with him.

Anyway this guy was waiting outside Causarina Guest House for us for 2 hours while we hung out and learned how to chew qat. I have the final rejection on tape.

What a great day.

The three of us stayed up late talking and drinking by the main ferry port then were hanging out on top of Causarina. They have a nice porch area but too many trees to get a good view. The view from Yumbe is a lot better, but I'm paying 1000 KSH more for it.

Boat ride with Captain Happy tomorrow. Duh na na!

Sweet People

Jumatatu 20 septemba

KiSwahili word of the day is : "Tamu" for Sweet. Also can be used for "delicious!"

I have arrived in Watamu, named for "watu tamu", sweet people. I am staying at Tiki House which seems too good to be true. Its hidden off the main road, has a beautiful garden, a kitchen, hammock, and couches. The beds are Arab style and the people who work here are so helpful and friendly. I booked a snorkeling tour for tomorrow.

I have already gone to the Gede ruins and butterfly park. The Gede ruins are much larger than the ones in Mnarani and my guide, Kendi, was really cool. She was doing an unpaid internship, so we bonded over being students.

There are SO many italians here. Children in the street run up to me saying "ciao!" and speaking Italian.

I met an older American couple at an Italian restaurant; they had lived all over the U.S. so gave me great tips on American national parks.


Jumanne 21 septemba

KiSwahili word of the day is "Mikoko", Mangrove trees.

Thankfully my guy showed up to take me on the snorkeling tour, so he dropped me off at the ocean and I got on a glass bottom boat full of Kenyans and Italians. Everyone was really tan. And everything was said in either Italian or KiSwahili for the rest of the day.

We went so far out away from shore but still the water was very shallow. The reef is very large and the water was clear. There were a lot of fish, but compared to snorkeling in Maui, it was nothing spectacular. But still fun.

We stopped at a beach for lunch and were fed so much! Rice, prawns, lobster, fish, and shrimp. By the time the lobster came around I couldn't eat anymore, so I still have never eatten lobster. So good...

I paid another 500 KSH to go out in a dhow tour around the mangroves. I saw barracuda eggs and crabs. Awesome.


Jumatano 22 septemba

KiSwahili word of the day is "Msafiri". Traveler.

I'm in Malindi! (I later found out in Mombasa that Vasco de Gama was chased out of Mombasa so relanded in Malindi, where he received a warm welcome and received a wife, named Malindi, from the sultan of Malindi. The city is now named after his prize wife.)

I was sad to leave Watamu because I really liked the people that I had met. I am feeling slightly uprooted. I'm staying in Premier Guest House. I arrived an asked my took took driver to take me to one of the lonely planet recommendations and we got so horribly lost and were driving around forever on dirt roads (dying) bumping around and his gas was on empty, so any minute I was expecting it to break down and I would be stuck in the middle of no-where. Finally I was begging "Please! Just take me to any guest house! I really don't care!"

I saw the Vasco de Gama pillar and made a new friend, Muhammad. He comes from Somalia. He was really intelligent and friendly, but I think was mostly just interested in me helping him get refugee status in the U.S., which I have no idea how to help with, so eventually we parted ways. He left in 1993 and was living on Lamu for a long time. Good luck to him.

So excited to leave for Lamu tomorrow!

Pekeangu

Jumamosi 18 septemba

KiSwahili word of the day is: pekeangu. alone. As in "unasafiri pekeako?" "ndiyo, ninasafiri pekeangu." I travel alone.

Safe and sound in Berachah Guest House in Mombasa. I have a really nice room with a window and a television. When I spoke in KiSwahili to the man showing me the room, he moved me up to a better room in the front of the hotel with the TV, which I didn't watch but really appreciated his consideration.

I am listening to the call to prayer coming from the mosque accross the street. I also met another woman traveling by herself. She is from the UK and older than I am. She was telling me about hiking Mt. Kenya with her brother and we talked about porters. She specifically wanted to climb Kenya and not Kili, because Mt Kenya can be climbed without a guide and porters. BUT going up, she saw this other group with the porters carrying wheel-suit cases on their heads going up- disgusting. I can't beleive that people would make the porters do that.

I sat next to a woman with a very animated baby the whole bus ride. The baby didn't cry once. Maybe almost half of the 8 hour bus ride was spent with the woman feeding her baby. Sweet but awkward.

Really no problems with the bus ride though. All of it was paved and minimal traffic.

Jumapili 19 septemba

KiSwahili word of the day is "mnara" for minnarette (unfortuanately I cannot spell in my native language...)

Made it out of Mombasa on a matatu to Kilifi, only about an hour and a half. I finished seeing the ruins and snake park and my hotel, "Dhow's Inn" is so nice!

The snake park in itself wasn't that great, but my guide was very animated and dedicated to the care of snakes and stopping snake trafficking. He was an undercover agent essentially. 007 Kenya. His role is to catch snakes that have come into people's homes to hunt and release them again into the wild far away from homes. He also has been very involved in catching people who illegally export snakes to other countries. He goes undercover to find the people involved then notifies the government. Unfortunately, it is hard to get the government to actually take action so he has been frustrated. Most often snakes are exported to Germany, now there is also a growing demand from Japan.

I also learned that all snake antivenom in East Africa is produced in South Africa. And considering that black mambas, green mambas, and other fun poisonous snakes are endemic to this area, creating a factory in Kenya that would manufacture antivenom could be very lucrative. For a green mamba bite, you have 40 minutes to get the antivenom but for a black mamba, 15 minutes only. Crazy! My guide's dream is to open an antivenom factory with a snake-park and a clinic that specializes in treating snake bites. Hope the best for him.

I also saw the Arab ruins. My hotel was actually in Mnarani, on the other side of the river from Kilifi, and was named for the minaret at the ruins.

The Arabs caused the birth of KiSwahili and traded clothing and other goods for hides, iron ores, and slaves. They converted many Africans to Islam, so the ruins at Mnarani are of ancient mosques.

I also learned about mkilifi, the tree for which Kilifi is named. Drinking a tea made from its leaves is said to cure 40 illnesses, including malaria. The leaves taste bitter like quinine.

I learned also that before the Arabs, Africans worshiped the Baobab tree. Even today some people come to slaughter animals at the trees and place coins inside it. I got to taste the baobab fruit, which was really dry and sour. It was disgusting. He said it is good for pregnant women and tastes good on fish; its probably high in vitamin C. The shells of the fruit can be used to make drums or mouse traps. It can also be used to make soap and shampoos.

My guide was really great. He also told me a lot about the history of the area and issues today. There is a lot of malaria in Kilifi, because of the creek. The hospital there gets additional funding for this reason so my guide says the Kilifi hospital is better than the one in Malindi.

At dinner I fed feral cats and made a new friend who was very eager to show me the beach at night. Thanks, but no thanks.

Nairobi

Alhamisi 16 septemba

KiSwahili word of the day is: Karibu. Meaning is "you're welcome", but in East Africa, it really is much more generous and people saying it whole-heartedly welcome others to share in what they have.

Today I saw the elephants again! So great, and they had a new rhino named "Shida" that was adopted here when she was 2 days old, she was premature and only 25 pounds, so crazy.

We got a free ride on our way out when leaving in the back of a pick up truck. Beats getting eaten by lions. I went with 2 Americans and an older woman from Australia who came to find a long term volunteer position in hospice care here. She's really sweet and I really respect her opinion on things, especially because she has much more experience than I do. She was criticizing me for always telling the shop keepers that I would come back, which I honestly do intend to do when I say this, but she says so many people come here and make promices that they never fulfill. She said it is therefore more honerable to not make any promices at all, no matter how small.

She also criticised me again on the bus because I was asking the matatu driver if we were getting the "mzungu price". She was saying a few extra cents does not make a difference to us, to which I retorted that everybody should get the same price, its only fair. She said she believed that everyone should have the same standard of living, but clearly, do not... is that fair? She got me there... and even though for this it was only a few cents, it really is the Robin-Hood connumdrum: Is it fair for the poor to cheat or steal from the rich? Ultimately, I don't think that anyone should be able to rise above because they were cheating, but in this case, I was fine with handing over the collector the stated price.

Conversely, earlier in the market I was trying on these GORGEOUS necklaces, great craftmanship and really high quality beads. But simply could not afford them at all. The same woman was telling me essentially that this price was too high and he was somewhat cheating me, but I really felt that the necklace was worth the stated amount and in good conscience, I did not want to rob an artist of money that he really did deserve.

Ijumaa 17 septemba

KiSwahili word of the day is "Amani", meaning peace. Usually written on the back of matatus or dalla dallas.

Today was really eventful. I stayed an extra day in Nairobi to go to Hell's Gate national park and bike with the other American girls I met the day before. They are leaving for safari tomorrow, so first we went to the safari office, then Jim from the safari co. escorted us to the bus stand below Moi Ave to get the right matatu to Naivasha.

The bus area was so hectic in a really exciting way. I was just remarking how wonderful everything was, all the different people and the brightly colored shops and matatus driving everywhere. Just in front of us was a matatu that was having difficulty starting, and of course there were people absolutely everywhere.

The matatu suddenly lurched to a start. A man had been passing in front of it and we saw his arms flail upward and he went down like a rag doll. It happened so quickly then time stopped. Everything was quiet and people came out of the shops and from the sidewalks and gathered around the fallen man. I grabbed hold of one of my new friends' hand and firmly looked away as we passed.

"It happens, ya?" was pretty much the response from Jim. It just made all the dangers of bad driving suddenly real. Being in the bus area no longer was exciting because I felt like death was everywhere.

And with that, I was ready to get out of Nairobi.

We waited in the matatu for an hour and a half, waiting for it to fill up so we could leave. The three of us just wanted to get the hell out of there. The drive was gorgeous. We passed along the rim of the rift valley and during our waiting time, made friends with a guy on the matatu who was really mellow and welcoming. He enjoyed quality American shows like "Ellen", "Oprah", and "The Kardashians", so funny. Also it was nice to talk to the other girls and hear about their travel experiences.

We unfortunately didn't get to bike that long because we spent so much time waiting to leave, but we biked to the gorge and saw zebra, pumba, and a lot of different kinds of birds.

I am excited to leave for the coast tomorrow.

About the Journey...

Armed with mefloquine, ciprofloxacin and a camcorder, I travel around in circles in East Africa.

Jumatatu 13 septemba

KiSwahili word of the day is "ndege" which can mean bird or airplane.

Newark take 2. Still stuck here for another 4 hours and some guy at the bookshop just called me "sir"...

I'm a lady!


Jumanne 14 septemba

KiSwahili word of the day is "kuzunguka" meaning to go around in circles, which is where the word, "mzungu" comes from, which is a person who goes about in circle, AKA a European in East Africa.

My flight from Newark was delayed for over 2 hours for a few drops of rain. I was positive throughout the flight that I would be spending the night in Zurich, getting to Kenya just seemed unattainable at this point. Luckily, a petite Swiss woman named Sylvia met a Southern gentleman and myself at the plane and we were sprinting through the airport and going through all these shortcuts and somehow made it onto the flight.

I later found out the other passenger running with me was an ER physician from Mississippi, named Phil, who was going to do medical work in Northern Kenya... so great!


Jumatano 15 septemba

KiSwahili word of the day is "asante", or thank you. Asante sana is thank you very much.

All day quest to find phone. Staying at Wildebeest hostel in Nairobi, where I stayed 2 years ago, really beautiful and I've met some interesting characters.

I met a middle aged man at breakfast who is a lover of travel and ! biking <3 He has taught English as a second language at Harvard and got really into taking long distance bike trips. He has biked from Montana to Alaska then also cross country then fluew to Amsterdam and biked to Bulgaria. Awesome. His crazy story of the day was in Syria, some man in an American military outfit was asking to see everyone at his table in a restaurant's passports. While everyone else was handing theirs over, this man said, "No! I refuse! You will have to kill me and everyone else in this restaurant to see it! You have no authority in this place!" Fortunately, no one was killed.

My favorite person of the day was a female UN employee. She is here to get married in Kenya to her Kenyan fiance in 4 days. She has done a lot of work in Africa, so was telling me about her experiences in Somalia.

She said she went on missions into Somaliland and also into the horn of Africa. The horn of Africa is where all the Somali pirates are based, so the risk of kidnap is so high she said the security had them changing locations every 20 minutes. Also about Somalia surrounding Mogadishu, she said despite that it is a religious fight, the religious leaders all employ the different war lords to do the fighting, and these people take sides with the highest bidder.

She said that aid coming into Somaliland, she can see the benefits because at least some of it is reaching the people but putting money into trying to help people in the Mogadishu area is essentially just throwing money away because all of it is taken by the people perpetrating the crimes. She said she hopes never to work in Somalia again, which was pretty depressing. The US military is also still involved in Somalia, no surprise when are we not involved, but just to gain intelligence on Al Quaeda, then we come in and bomb the shit out of their location and leave. It would be a mistake to have a permanent presence there, which we have not had since 1994. I asked about by-standers.

"Well there's always collateral damage".

We also talked about Uganda and IDP (Internally Displaced Persons) and now there is also more investigation of IDP in Columbia. The problem is, if people leave their country due to circumstances in the parent country, they can gain aid under a refugee status. However, with the LRA in Uganda, people moved from the north into camps in the south for 25 years, but were still within Uganda. Recently, the people have been able to return to their homes in the north but while in camps, the aid was given directly to women to manage as leaders of micro-finance (which has been shown to be more effective than giving it to men). However, during the time of internment the men lost their status as leader of the household and there was a rise in domestic violence and drinking.

Also, 25 years later, there are now land disputes because people cannot remember what land was theirs in addition to third party persons coming onto the land in their absence and making use of it. Essentially an entire generation of people has been raised in refugee camps and now that they return home, of course there are going to be issues in resettling.

The issue with IDP in Columbia is, of course, drug related but has been happening slowly and steadily so that the Columbian gov has refused to acknowledge a problem. Drug lords come onto the land and either require the land owner to grow coca, or displace the land owner from their land. Right now their is a discrepancy between the Columbian gov and an NGO on the number of IDPs (3.1 million versus 4.3 million), so this has been currently under investigation.

So interesting! I would have wanted to talk more, but I felt terrible for making her talk about work while on vacation. Its amazing the people one meets while traveling.