ROTW (2): Chapatis, made right

Everyone has that one dish that they make so expertly themselves, they have no interest in ever trying it away from home. It could be a fresh-ground morning cup of coffee, your Kraft mac-n-cheese, or that family recipe for matzo ball soup. You know what I'm talking about.

Enticing chapati, to which I did succumb
(Ggaba, outskirts of Kampala, on Lake Victoria)

Anyway, my "twin" has this thing about chapatis. Fresh and incredibly delicious chapatis are sizzling on almost every street corner in Uganda (see exhibit A above), and she doesn't even sniff in their general direction. Meanwhile, I am drawn to them like a mosquito to my ankles! That's how I came to realize that I had to find out her recipe.

So, I here present you with the secrets to making a most superior chapati:

Ingredients
1 cup warm water, 1/2 packed cup grated carrots (or grated coconut, onions, or some other flavor of your choosing), 1/2 tsp salt, 3 tbsp oil (or ghee...mmmm), 2-3 cups wheat flour, lots more cooking oil

Special equipment
rolling pin, hot skillet (preferably cast iron)

Instructions
1. Soak carrots in warm water
2. Add salt to taste  - it should taste just a little too salty at this point, since this is going to flavor the whole dough
3. Add oil to look

Oil - this is what makes the chapatis soft, but not too soft! I know it's not the most gorgeous photo, but I wanted you to see what I saw - the precise science of adding just enough oil for the oil droplets to barely cover the surface of a shallow mixing container

4. Gradually add the flour - first turn with a spoon, then with your hands. It is ready when the dough is soft, springy, and no longer sticky
5. Roll the dough into a rough "baguette", cut into 8 chunks, press into small discs, then roll out each disc into a chapati about 8'' in diameter - keep them about 1/4'' thick, since you want nice, chewy chapatis that you can maneuver through the cooking process
6. Heat your skillet over medium flame, then roast each chapati til bubbles form on both sides. Set aside

Roasting - I am told that this is they key step in making a great chapati, for it brings out the carrot/coconut/onion flavor. Just like some greedy person in the shadows of this photo (who IS that?), you're going to want to eat them right now, but hold on for one final step

Seems pretty healthy so far, right?
Well.
That is about to change.

7. Heat about 1/4 cup oil on the skillet til smokin'. Lay down roasted chapatis 2 at a time so the lower side sizzles while you smooth over the top side, adding oil between turns and flipping every minute or so til you have nice big brown bubbles on both sides of all chapatis

 Frying - apparently the top chapati is very important to the chapati below. First, it keeps in the moisture; second, it applies even pressure. You can also use a spoon or your hands to press down 

Chapatis - (left) fried, finished, ready for feasting; (right) roasted, waiting for a hot oil bath

8. Keep chapatis covered until ready to eat. Then, DEVOUR THEM ALL! These are particularly yummy with just about anything, but beans and eggs are the most common pairings here. Avocado good, too.

Our dinner of chapati and white beans

Without power, but not powerless

What do you do when you walk into work and find a large mass slumped over your desk - rising, falling, shuddering - - - a body?

You wipe the sleep from your eyes, for the 2-hour journey from Kampala is over, and you think to yourself, Welcome to Kiboga.

I remembered seeing this teenage boy (one of the participants in our study) the week prior. At that point he had come in for extreme fatigue, with blood counts so low that his tongue and palms were white as chalk. We diagnosed him with AZT-induced anemia, which is a rare side effect of AZT (stands for zidovudine, one of our first-line anti-retrovirals). In unlucky cases like this one, AZT stops the body's production of red blood cells. The resulting anemia is often severe and sometimes fatal, but it can be reversed by stopping the medication. Unfortunately, despite changing this boy’s regimen 7 days ago, the AZT had lingered in his body and continued to bring down his blood counts. Now he could hardly stand up. To make matters worse, when we placed a needle in his vein to draw a blood level, he started vomiting. Projectile yellow muck - all over himself, the chair, and the clinic floor.

What do you do when you have a super sick anemic patient?

You make an urgent order for 3 units of blood. (His hemoglobin came back at 3.5 - for reference, normal is above 12.5, and many clinicians would consider this value "incompatible with life".) Sadly, you are told that blood is in short supply (3 units total in the hospital) and only 2 units can be spared; the other must be saved in case any one of the 200-300 patients in the waiting area and wards needed it. So you find a volunteer to carry your young patient to the ward, and you hope for the best. Welcome to Kiboga.

And, what do you do when you have vomit all over the clinic?

You ask for a janitor. Sadly, the janitors are missing. Someone tells you that it was hard enough to get them to sweep a clean floor this morning - let alone help with a dirty one now. Your intrepid study nurse and community health worker take matters into their own hands and go on a search for cleaning supplies (almost as hard as finding a janitor), then clean up the mess themselves. All this, before clinic even starts. Welcome to Kiboga.

Kiboga is a town of 16,000 people, about 120 km northwest of Kampala. For this research project, I will be spending half of each week here with my Fogarty twin. We come up on Tuesday morning, work for 3 days, and return Thursday night. Eventually I'm going to get used to the aspects of work and life here that make it so interesting, frustrating, and exciting. But before that happens, let me record a few early observations:

Kiboga District Hospital

1. The Kiboga public hospital takes all comers:  healthy (rare), sick (many), rich (none), poor (all), and even animals (as residents, not patients). I would say that there are more chickens than doctors in the hospital. Infinitely more, I should say, because isn't it true that any number divided by zero equals infinity? Yeah, that's right, ZERO. I have yet to meet a doctor here (except for those in our research team), even though the government employs 4 of them to work in the hospital full-time.

Chicken at the back door

2. Health privacy exists at a minimum. The study clinic is set up for interviews to be conducted 2-at-a-time in a shared room, with physical exams behind a screen - however, we often have so many patients that exams have to be done out in the open. For a generally modest society, it’s remarkable that patients are comfortable baring their breasts, exposing their rashes, and revealing their pain in front of anyone who happens to be in the room. The upside is that there is a tremendous amount of camaraderie among the patients. I hear constant pep talks taking place in the waiting area, and patients share rides to and from clinic. It's a case of confidentiality down, community up.

My research "twin" and the study nurse, hard at work in our office/clinic
(Obama's got our backs)

3. The shared space does allow for some amazing clinical experiences on my part. I was the first to feel a patient’s swollen axillary lymph nodes, signs of likely lung infection or breast cancer. I inspected an invasive mouth cancer, a thick fungating mass on one side of a woman’s tongue. The smell was so bad that the whole room smelled like rot whenever she opened her mouth – I had never smelt a cancer before. I held the hand of an AIDS orphan, who came by (alone) after school to get treatment for her infected salivary glands. She didn't flinch when we stuck a syringe into her cheek and sucked out 10 mL of fluid, and she just bowed her head in acceptance when we asked her to come back for another poke next week. I talked with a woman dying of AIDS. Young, emaciated, beautiful, in a wheelchair pushed by her robust but wrinkled mother, she embodied more paradoxes than that Alanis Morisette song, “Hand in My Pocket”.

I didn't photograph our patient, but here's another chicken
(I'm beginning to think we should have a poultry immunization program)

4a. It is inspiring to see how much a doctor at a desk, with a stethoscope in one hand and a pen in the other, can do for a sick patient. Medication prescriptions, counseling, and continuity of care keep a lot of these patients alive – even well. At the end of a clinic day, small bags of groundnuts, tomatoes, and sugar cane left behind by our patients show their gratitude for these free services.

4b. On the other hand, it is upsetting to admit that good intentions and years of medical training sometimes cannot overcome the systems issues. Yesterday our doctor performed minor surgery in the clinic - cut and drained spoonfuls of pus from an abscess in a young lady’s leg - only to stop at the point of closing the wound. We didn’t have sterile gauze. How do you keep an opening from getting re-infected, if you can’t pack it with clean material? We searched high and low and thought of many possible replacements, but there is no substitute for a little 4x4 inch square of cotton that comes in a sterile wrapping. Probably costs pennies; I know we throw out handfuls of them in a single procedure in the States. But that didn’t help the lady with the hole in her leg. Eventually the doctor just leaned back on the paint-chipped wall, her bloody gloved hands held high, idle, unable to properly finish the job. It was the look of defeat. We ended up putting on a loose bandage and sending the patient home with antibiotics, to fight the infection that almost surely would come back.

...This reminds me. I haven’t even mentioned that the hospital operates with no running water, power about 50% of the time, and intermittent network access for internet and faxing capabilities. Thank goodness for bottled water, fire, batteries, cell phones, and wireless USB sticks! Some combination of Stone Age and Digital Age inventions keeps this place functional.

5. Outside of our clinic space, a few formidable personalities run the entire hospital. There is one extremely maternal nurse – big-bosomed and big-boned, with a white cap perched on top of her head, just like you would like to imagine her! – giving those motivational speeches in the waiting area. Her most recent topic was couples treatment, with a message directed at women to bring their husbands in for care. (Women outnumber men in ART clinics because they are more willing to seek treatment, but they often have to come in secret. I am told that a husband may blame his wife for his HIV infection if she suggests that they need treatment. Furthermore, if she or her husband has multiple partners, she may be constantly exposed to different HIV strains and at risk of developing medication-resistant infection. If she asks her husband to use condoms, he may accuse her of infidelity - even though the man is MUCH more likely to have multiple partners. And remember that most of the women are completely dependent on their husbands for financial and social stability, so it's not so easy to go against his will. The result is that many of the women - even those who are married, sexually monogamous, and on ART - remain in very risky sexual relationships.) There is one palliative care worker, an old man who recently realized his passion for this work and got certified, who can be found carrying meals and smiles to the bedridden. When he has free time, he sifts through the waiting patients to bring the sickest ones to our attention:  starving babies, a schoolgirl failing ART, a possible malignancy. And, of course, I have to get back to the research group. Our team of 6 manages hundreds of patient files, knows each subject individually, and bravely cleans up vomit when no one else will do the job. I am ever impressed with their sense of purpose (and sense of humor), hard work, and both practical and people skills.

Outside the hospital, Kiboga town awaits. See, it has the look and charm of an extended rest stop:

Very average roadside view

Into the jungle

There are about 100 tiny shops (well, mostly bars) situated along the paved road (that connects Kampala to Hoima, an oil town 70 km farther northwest), plus a few guesthouses and a hospital. Rough dirt roads snake down the main road to a row behind the shops, past a few residences, and into the jungle-ish forest, where most of the people live in villages. Green rocky hills circle the horizon, and a huge sky spreads overhead. I don’t know why – maybe it’s the low man-made structures, or could it be my enhanced sense of isolation? – but the sky just feels SO BIG here. Looking up, I think I can see different cloud formations at every layer of atmosphere, from thick whipped cream peaks blanketing the hills to wispy strands reaching for the sun. 

View from the balcony of my bare-bones guesthouse in Kiboga

When I snap out of my celestial wonder, the main road offers a parade of sights. There’s a man single-handedly rolling his truck to the nearest fuel station, since he ran out of gasoline 1 km back. Then, look, a motorbike with 2 live sheep (large! the size of small cows!) strapped on back. And finally, always, a gaggle of kids who find me much more interesting than the hills, sky, and traffic that so fascinate me. My soundtrack through Kiboga is a chorus of “Mzungu, hi! Mzungu, bye!” as they chase and follow me down the street. I feel a little ridiculous, a little celebrity, a little Pied Piper.

Even though “Mzungu” can be/feel pejorative (especially when barked by grown men sitting in in the shadows of Kampala), the Kiboga kids’ song is not unfriendly. Full of smiles, it is a joyous and innocent tune. Like everything else – at first strange, now it is growing on me. Though I'll never quite blend in, I believe that I can start to feel at home here. Yes, really. Welcome to Kiboga!

Now that I’ve written too much, let me wrap up the night in my favorite Kiboga fashion. I am off to devour a passionfruit (or four) for dessert, then retire to my dark (generator off) quarters, hours before a normal bedtime. Oh, this complicated and simple life!

Sulabulungi.

Magical mangoes

I've been working on my magic tricks. Well, just one. Here it is:

The Amazing,
                  The Incredible,
                                   The Unforgettable,

THE VANISHING MANGO!!!

No, but really, mangoes are vanishing - as the rains come in, mangoes go out. Sad. No offense, mud, but you're not a great replacement.

Anyway, I am consoled by the fact that there are two cycles of dry-rainy seasons per year, so we'll be seeing mangoes again soon, sometime around November. Countdown starts now!

In the deep end, and learning to swim

Time to talk about work.

But first, imagine that work is a giant body of water. Now, can you learn to swim by reading a manual? No. You cannot. Likewise, I could not understand the work until I dove into it - head-first, deep end. No arm floaties. I made the plunge last week, and now here I am (glug, glug, gasp!) with my head above water and ready to tell you about it.


My job in Uganda is to help coordinate a clinical research trial. Our study hopes to show that you can reduce mortality during early HIV treatment, through the detection and control of certain other infections first.

Let's start at the very beginning. A very good place to start...
As you probably already know, HIV kills CD4 cells, which are important cells in the human immune system. When the CD4 count is very low, people become susceptible to opportunistic infections (OIs), which are diseases that only strike when the body's natural defenses are weakened. Tuberculosis (TB) and cryptococcal meningitis (CM) are classic examples of OIs. These infections alone can cause severe illness and death in people with HIV. Unfortunately, treating HIV with anti-retroviral therapy (ART) is not a simple solution. You see, ART causes the immune system to go rapidly from a suppressed to a boosted state, and infections that used to be relatively silent may suddenly stimulate a massive immune response. This can cause high fevers, painful and swollen lymph nodes, severe inflammation, organ dysfunction or failure, and even death. When this reaction is really bad, it is called immune reconstitution inflammatory syndrome (IRIS). The chance of developing IRIS increases if the patient starting therapy has a very low CD4 count, a high number of HIV particles, and no prior ARV treatment.

A recent study in Kampala showed that as many as 14% of patients may die within 1 year of starting ART, with most of the deaths due to TB and CM and occurring in the first 3 months. Newer studies at urban hospitals have shown that you can improve survival during early ART if you catch and control TB and cryptococcal infections first. Our study hopes to show that this can work in a rural Ugandan setting, too, where resources and follow-up can be a big challenge. We roll like this:
1. Enroll subjects who are at high risk of early mortality (HIV-positive, low CD4 counts, never taken ARVs) at a hospital in rural Uganda
2. Screen them for TB and cryptococcal infection before starting ART
3. If someone screens positive for either infection, give medications to control that infection over 2 weeks, then start ART; if someone screens negative, start ART right away
4. Check in with every subject monthly for 6 months to record any illnesses or deaths that may occur
5. Analyze the data
After about 600 subjects have been followed for 6 months, we hope to be able to show that our approach improved survival by preventing deaths from TB, CM, and IRIS.

In preparation for the job of study coordinator, I went ahead and studied the manual. It said that my responsibilities include supply procurement, employee contracts, grant writing, and data collection and analysis. As I learned last week, this means:  4 hours in Kampala looking for Ziploc bags, 3 hours between research offices getting signatures, 2 hours making photocopies, 3 days seeing and treating patients with severe HIV, 1 meeting with hospital administrators to advocate for our study, 2 trips to the ward to see patients who had been admitted for severe ART side effects, and 1 late evening figuring out how to process the samples we need for our study when the lab machines are broken AND we lack both running water and electricity. Whew!

Luckily, I am not alone. The Fogarty program has a very cool approach, in which every US scholar is paired with a local scholar. My "twin" is a Ugandan doctor, just out of her internal medicine residency at Mulago Hospital, with boatloads of experience in HIV medical management and research in Uganda. She and I will be sharing all of the challenges and joys of study coordination. We also have a small but awesome research team that includes another doctor (who works full-time at the rural site), a nurse/phlebotomist, a community health outreach person (who amazingly seems able to keep in touch with every patient), and a lab technician. And of course, there is our research boss at IDI, who will meet with us on a weekly basis and can pull strings at higher levels if/when we need the help. Our first meeting with her is tomorrow. Eek, I'm a little nervous!

Anyway, forget the floaties - I'm happy to be swimming! My job as study coordinator is busy, intense, difficult, and sometimes frustrating, but it's extremely interesting - and I'll get to know what it takes to run a clinical trial, which is a pretty cool opportunity for a medical student interested in a career with research. I love that I get to see patients almost every day, and that I will work alongside a great group of clinicians, community health workers, and researchers. And finally, I believe that we are asking an important question about how to reduce the risks of ART initiation. It's exciting that we may have an answer within the year. 

Home

Not that anyone should care that much what my apartment looks like, but I want people to note these 2 things:

1. I have finally been given the princess bed I dreamed of, when I was 8!

2. There is an extra bed taking up 40% of the floor space in my room. So if anyone wants to travel to Kampala, you know you have a place to stay.

Recipe of the Week (1): Avocado-is-a-fruit! salad

The competition was a perfect draw - Recipe of the Week vs. Snapshot of the Week - until 1 hour ago, when I made this recipe that just HAD to be shared. Credit goes out to a street vendor in the highlands of Kenya, who first introduced me to avocado in fruit salad. 'Tis absolutely divine. And I didn't even get sick!

Ingredients

1 mango, 1/4 small watermelon, 4 small passionfruit, 1/2 huge avocado

Instructions

1. Wash - twice, once with sink water and once with bottled water

2. Cut - don't take your GMO seedless watermelons for granted, because let me tell you, de-seeding this Ugandan melon was a doozie

3. Mix

4. Eat

5. Go back for seconds

Perhaps I will eventually take some photos that are good enough for SOTW status, but ROTW definitely won the first week's fight.

Bukoto from the street

First impressions from Kampala

My apartment (shared with a Norwegian embassy trainee) is part of the Bukoto White Flats, a series of buildings built on a quiet, green plot of land near a busy road that roughly divides a valley of slums and a fast-developing hill with big views, country clubs, and ostentatious estates. This juxtaposition is strange, but it is not unusual. Almost any spot in the city, regardless of the SES of its residents, seems to share a border with both slums and mansions. (Add this further challenge: it must touch at least 1 but no more than 3 major roads.) I can picture it now - a build-your-own-Kampala brain-teaser, like "Sim City" meets "Settlers of Catan". You could spend all day rearranging the pieces to achieve such a complex configuration. It is no wonder that the street map is full of kinks and dead-ends. The main roads seem to change names every kilometer, which I suspect comes from many shorter segments that connected over time, as the city grows from both center-out and suburbs-in.

I have bought the Kampala A-Z Atlas, in the hopes of not getting lost at each intersection, as well as several books on the Lugandan language. Although my Luganda stinks, already it has been a rewarding endeavor. Everyone is so encouraging! And I challenge you to think of any words that tickle the tongue more than "Nze njagala" (I like) and "Yeetooloola" (You go round)!

Two days ago, I found a copy of "How to be a Ugandan" in our apartment. Cool!! This book, written by a local journalist, gives a brief history and analysis of 12 major professions in Ugandan society. I have so far read "Doctor", "Sex worker", and "President" - all fascinating. The author explains how doctors were driven into private practice to make ends meet in the hard times of the 1970s and 1980s, then started to charge more as demand for services became too great in the 1990s, and that obscene pricing scale been escalated by the fact that wealthy Ugandans may regard high consultation fees and medical bills as a sign of status. In another chapter, he defends the sex trade as an integral and well-respected part of the Ugandan economy, which has long enabled young women to pass their exams and earn items of luxury, and has only recently been sullied by professional sex workers who force men to haggle over prices and pay in cash. Hm. I'm not sure I agree with his points of view, but it's an interesting read nonetheless.

Ntuuse Entebbe!

Hello there!

After a busy move from San Francisco and a brief layover in Amsterdam's wonderland of an airport (can you picture the fantastically huge teacup sitting booths?), I was finally on my way to Kampala. The first surprise was that about 3/4 of the plane passengers were white. I know that most Africans can't afford this kind of travel, but it also occurred to me that maybe Uganda is more of a tourist destination than I had realized.

We made a soft landing into Entebbe airport, built next to the sleepy former capital and 40 km from the bustling current capital city of Kampala, on Tuesday night. The visa line was short, my bags came quickly, customs was painless, and I found a baggage cart with all 4 wheels working. Outside at the parking lot, I was impressed to find shiny ticket machines where drivers were paying their fees. So far, so smooth...

All of a sudden, an arm shot out from the darkness behind one of the ticket machines, grabbed a driver's bill, and dropped coins into his palm. Down the row of paying customers, more arms shot out and more money was exchanged. Of course, change men! How else would the drivers have exact change for the machines? Those men on wooden benches made the whole computer system functional. I have to give mad props to Entebbe airport, because it took me this long to feel that I had arrived in a developing country.

A driver from IDI was there to greet me with a warm "WELLCOME!" sign, and he drove me through the night into my new neighborhood of Bukoto.

Hurrah! You found the blog!

Oh...you wanted more than that? Well come back soon, and your efforts will be rewarded with a real blog post from Uganda. In the meantime, here are some links related to the work I'll be doing:

Fogarty International Clinical Research Scholars program and FICRS Uganda IDI site description

Infectious Diseases Institute in Kampala, Uganda

Independent study in nutrition: observation and implementation

Looking forward to keeping in touch!

Mara