My Dad’s Last Week of Life

My father, John Vernon Twelker, Jr. was born in San Diego, California on March 6, 1937. He died five years ago today in Tucson, Arizona, July 7, 2014.

Four or five years earlier, we had noticed important signs of memory loss. Medical testing had confirmed the diagnosis of Alzheimer’s disease. Dave and Hazel, my brother and sister-in-law lived in a different house on same Hawaiian property. For a couple years he was able to manage on his own with substantial help from family. Over time, it was clear that he needed daily in-home assistance. That worked well for a year or so but it was becoming clear that he needed 24-hour care. That type of service in Hawaii was about $6,000 a month while in Tucson I found excellent care for $3,000 a month, and my dad could afford that. We knew it could be a difficult transition, but we also knew that most of the time my father was not entirely aware of where he was.

Recommended by a coworker whose father also had dementia, in the summer of 2013 we moved my dad to a place called Desert Serenity. It was owned by Giselle, an experienced nurse and caregiver and located several miles to the south of my downtown Tucson home. It was a small, five bedroom, family-run operation.

Mostly, the transition went well. His entire life my father had been very social, and here was no exception. He made friends with the staff and other residents. I received several panicked telephone calls during brief moments of clarity. He said that he had been kidnapped and taken to an unknown location. He needed me to try and find him, rescue him, and take him home. I learned to comfort him and reassure that all was okay. I would come as soon as I could. The staff knew how to distract him with a conversation or task to do. Mercifully, soon he would forget.

We established a routine. I would pick him up after work on Wednesdays and take him out to dinner, and on Sundays we went to church and then out for lunch. We tried all of the local restaurants in South Tucson and determined that our favorite was Los Portales. It was a family-run business located just blocks from Desert Serenity. The food was excellent, and the restaurant staff treated him like a rock star. He loved the attention as he slowly made his way across the restaurant floor to his chair or booth. His favorite was Filetes de Pescado a la Veracruzana, grilled fish with a tangy sauce.

In the spring of 2014 we began having some difficulty. We liked sitting in one of the booths, but more and more often he would not be able remember how to sit down. He would stand next to the seat, perplexed on how to fold his 6 foot, 4 inch frame onto the bench seat. After ordering and being served, sometimes he just looked at his food and fork and back again with a perplexed look on his face. He was highly motivated, however, to take a bite. Oh, how he loved food! Usually all it would take was for me to remind him of how to do it. He would finish half of his plate, and the staff would wrap up the rest to warm up for lunch the next day.

We ran into a similar problem when getting into the car. I’d have to coach him on how to bend his knees and bend over to get in. He was very concerned about getting injured which left him paralyzed with fear, unwilling to move. On one evening, for five or ten minutes anyway, I was concerned that I wouldn’t be able to get him back into the car.

Almost always compliant and good-natured, he began giving the staff a hard time, only during bathing. He accused the staff of molesting him during the bathing process. Of course, I considered the possibility that one of the staff could be molesting him. But that seemed highly unlikely given that I knew the staff well and they all were exceptional. Most likely, he was misinterpreting their attempts to bathe him as an assault. Giselle told me that this was common towards the end of life. The barriers were coming down. He was revisiting childhood traumas. In a way, I was happy he was fighting back. He was finally able, in his last days, to say, “No! I won’t take it anymore!”

Monday, June 30th I received a telephone call as I was seeing patients in the eye clinic. “Do you have a few minutes to talk about your dad?” Giselle said. “Sure, no problem. I have a few minutes between patients,” I replied. “I believe it is time to request hospice care for your dad. Hospice care is not only for those who might pass away in the next weeks or months,” she continued. “We have seen steady declines in all of John’s functions. If he meets the entry criteria for the program, Medicare would cover a hospital bed, additional supplies, and staffing when needed. Just in the last few weeks, he lost the ability to feed himself on a regular basis.”

Giselle continued, “If you agree, what I could do is call Casa de la Luz Hospice Care. They will send a nurse to do an assessment. If he qualifies, Medicare will pay for a hospice care nurse and other necessary medical equipment,” Giselle said. “Yes, Giselle. Let’s do it,” I said.

By Tuesday afternoon the hospice care had been approved, he had an assessment done by a hospice nurse, and supplies had been delivered. I went over after work on Tuesday and made sure he had a comfortable chair to sit in and that his CD player, CDs, and headphones were working properly and accessible. One of his favorite activities was to listen to music. He loved relaxing music like Enya, Andreas Vollenweider, and probably his favorite, Phil Coulter.

I was out of town two days later when I received another call. Giselle said, “Your father has fallen into a coma. Is there any way you could make your way here?” “Of course,” I replied, “I’ll be there tomorrow.” I called my brother, sister, and nephew Sky. By Saturday we had all arrived, including my sister-in-law Hazel.

Once we were all there, my father woke up. It seemed like a miracle at the time, but anyone who knows my father knows he loved a get together, whether it be a meal with 15 or 20 people, or simply chatting in the late afternoon over a cappuccino or latte he had made. If we were there, he wasn’t going to miss the opportunity to enjoy the company and fellowship. By now, however, he had a very difficult time communicating. He struggled to speak. He would remain awake for an hour of or so before he needed to rest.

We took turns sitting with him as he slept, sometimes holding his hand. When he would awaken we would gather around. Saturday afternoon he asked to speak with his identical twin brother Paul. We dialed up Paul and put him on the speaker phone. I have experienced few things more touching and profound than witnessing the last conversation of two brothers so close, so similar in many ways, and yet of course quite different.

As Sunday progressed another dynamic developed. He would sleep for hours at a time and wake up and be able to communicate a little. But after a while his breathing would change and his body would begin to vibrate. I discussed this with the hospice nurse and she assured me that his was part of the dying process, at least with many Alzheimer’s patients. The amyloid plaques that caused the dementia were now attacking parts of the brain necessary for life. It was a small seizure. He was on pain management medication and we were doing all that could be done to keep him comfortable.

It felt like he could easily pass away during one of the seizures. It also felt like he was trying his very best to not pass away. After all, all of his children were there with him along with Hazel and Sky. It was a get together just like countless other get togethers we had enjoyed all of our lives. There was no way my dad would miss this, or at the very least, he was going to stay around for as long as he could.

This was the very intimate failing of the body, not asked for, not desired. And yet it was happening. It was the most open and exposed my father had ever been. All his life he was an intelligent and capable man that treasured his health and activity. He worked hard on his farm in Hawaii planting hundreds of native trees. He devoted a portion of his land to a 2.5 acre solar array to produce clean energy and provide an income. He was an avid windsurfer well into his 60’s which required a high degree of skill, agility, and physical fitness. He was a self-described health food nut. He was an author and speaker. He was father, and then loving grandfather, Papa Maui to his grandchildren.

For his body to be failing, involuntarily failing, in front of family and loved ones could have felt embarrassing. He was absolutely vulnerable, open, and unable to hide what was happening. This was his worst fear.

Thinking back on my youth, I remembered him as a strong and stern father, sometimes harsh and judgmental. I remembered how I worked so hard to seek his approval. I remembered how he cried when I announced to him that I was not a Christian. I did not believe the story was required for me to believe to be a Christian, I said. He cried, he said, because he wanted to be in heaven with me and other loved ones and with God for eternity. He did not want us to be separated. He did not want to see me suffer in hell.

In these last days, I would sit with him, just be with him. There was little else to do. Every now and then I would think, “There must be something more we can do.” But there was nothing. I was not in control of what was happening nor was he.

During the seizures, every few hours, Dave and Hazel who are also strong believers in the Christian way, would sometimes sing hymns. At any moment, it felt that he could breath his last breath. And yet over and over that weekend, we would gather and sing or sometimes someone would say a short prayer, and the tremors would subside. He would fall back into a peaceful sleep for several hours. Twice a day we would all leave the room and allow the hospice nurse and other health care workers to do an assessment, gently clean him up, give him his pain medications. We took turns sitting with him, holding his hand. We made sure to get rest ourselves.

It was on Monday afternoon that I realized that as long as we were constantly with him, my dad was going to stay as long as possible. In addition, even though he was on pain medication, he was suffering. His body was relatively strong and he could probably keep this up for quite a while, probably days, maybe weeks. I wasn’t sure he felt comfortable dying in front of any one of us, and certainly not a group of us. I recommended that we all take a break, let him rest. If he wanted to remain alive, he could rest and we could be together later. If he wanted to die, he could pass away in peace. We all agreed and left his room. We went over to an identical but uninhabited house next door. It was being prepared as another care home but wasn’t quite ready yet. We chatted. We got some food.

My sister wanted to sit with him alone Monday evening and she did that. Then we left him alone again. Perhaps a half hour later, Sky went to check on him. Sky came back with an astonished look on his face. He said, “He’s gone. I just went to check on him and he’s gone.” Immediately, I felt relieved. I felt we all, everyone involved, had done a good job, especially my brave father. He faced death courageously, with dignity.

I went over to his room to see my dad for the last time. In life, even in the last hours of life, there was a vibrancy, an essential presence. Now, only the form remained. I saw the form, the shell, for what it was. The essence that was my dad was no longer present, at least, not expressed through this body.

In the days that followed his death we arranged for cremation, and then transport back to Hawaii for a memorial service. We had a beautiful memorial service with friends, his church friends, and family. We scattered his ashes in the Pacific Ocean off of Oahu.

–  Dan Twelker

 

“When conditions are sufficient we manifest. When conditions are no longer sufficient we no longer manifest. It does not mean we do not exist. Like radio waves without a radio, we do not manifest.” – Thick Nhat Hanh, Buddhist Monk and Author, from No Death, No Fear

“If today were your last, would you do what you’re doing? Or would you love more, give more, forgive more? Then do so! Forgive and give as it if were your last opportunity. Love like there’s no tomorrow, and if tomorrow comes, love again. – Max Lucado, Christian Pastor and Author

The Hondurans Are Coming

I have worked doing vision and eye care in many developing countries. One of those places was Honduras with a non-governmental organization called Salud Juntos, Health Together. Perhaps more than any other place I have been, Honduras was uncomfortable for me. It wasn’t only that we were there in June, one of the hottest and most humid months. It was the overall feeling I got there. The people were hard working, generous, and warm-hearted. The tropical jungle was beautiful to experience. But we flew into San Pedro Sula, which was considered to be the most dangerous and violent city in the world. We traveled as a convoy. We were asked to stay in the hotel compound when not doing eye exams. When we went out we went as a group.

Honduras was the classic Banana Republic with businesses directed toward sales and export to the United States, mostly bananas, coffee, and clothing. The only presence I could see from the Honduran government was in the form of a police state, men in fatigues with M-16s. Even the cultural environment seemed impoverished. The way it was explained to me was that Honduras did not have a culture of its own so it borrowed its culture from its more developed neighbor to the north, Mexico. Mariachi bands frequented the local restaurants.

As you may have read, there is a group of about 4000 migrants moving north through Mexico toward the United States. This is one of those stories that could easily fade away in the constant barrage of new headlines. What are the odds they will make it 2000 miles through Mexico? The group has already faced Mexico’s military at its southern border but apparently they continue to regroup and progress.

Trump is portraying the migrants as thugs and criminals. He has already threatened to close the US – Mexico border and call in the military. He says he will cut aid to Honduras, El Salvador, and Guatemala. From the Republican perspective this would make sense. The moderate Democrat’s response would be strikingly similar. We must respect the border, they will say.

Think about it for a minute. Four thousand people with little to no money and very little food are walking across Mexico headed to our doorstep. They are scavenging plastic to protect themselves from the rain. They have suffered sprained ankles, foot injuries, and falls. What in the world could possible motivate them to do this? It’s crazy, right? If you ask the migrants they will say poverty, corruption, and violence have given them no choice. They must leave. And where will they go? They will head toward the economic promised land, toward freedom and security, to the United States of America.

It’s not clear to me if they really know what they are headed into. Do they know that the US is more isolationist now than ever? Do they know they are feeding into the paranoid rhetoric that fuels the right with images of hordes of brown people threatening to invade? Do they know that they would almost certainly be met with Trump’s military at the border with tear gas first then rifles and cannons?

What I do know is that this is an important occurrence. I know that the United States bears some responsibility in the social and economic injustice created in these countries. Americans from the Central Region work for a dollar or two a day with no benefits to provide food and clothing for Americans from the United States. US policies have fueled civil wars in Nicaragua and El Salvador. These policies have created the violence, corruption, and poverty they are fleeing. And yet most Americans from the United States remain largely ignorant of the policies and the effects of those policies promoted by both Republican and Democratic administrations for decades.

We eventually had to stop our vision development work in Honduras. We had teams of health workers there, undergraduate students from US colleges and universities, and stray bullets hit their small home in the community. Reports were that the national security situation was declining. So we made the reluctant decision to work elsewhere until there was a more stable security situation. It turns out, we might not need to go back, because the poor people of Honduras are coming to us.

My Ever Spinning Mind

I have realized something about myself. I have obsessive compulsive tendencies. I’d prefer to avoid the label of having obsessive compulsive disorder and I’m not going to visit a psychologist to get the diagnosis, but, oh, my mind can spin and spin. I have learned three techniques that help, and have saved me more than once.

Meditation. My meditation technique is very simple. I sit, back straight, feet on the floor, hands on my legs. I close my eyes and follow my breath. Breathing in, breathing out. Sometimes it goes like this, “Breathing in one, breathing out one, breathing in two, breathing out two…” I see how far I can go before my mind drifts off on another tangent. I rarely get to ten. And when I realize that I have lost the thread, I just start over.

This saved me once while sitting in a window seat on a hot plane. I was pinned against an airplane wall by an obese man in the middle seat. His flesh was heavy and sweaty and it flowed over my left side, pressing me into the warm wall and window. This was bad enough but suddenly the power went out. The air conditioning stopped working and I went into a claustrophobic panic attack. My heart was racing, breathing quickened, and I had the strong urge to flee. I wanted to jump out of my seat, claw my way across two people to the relative freedom of the aisle. I was able to follow my breathing and calm myself. Fortunately, after a few minutes the air conditioning started working again and I relaxed.

Letting go. I’d like to think I have control in my life. Sometimes I will intend to do something and then I do it, and I think to myself, “Wow, I am really in control of my life.” But just a little bit of reflection will show that that’s just not true. There are times when we have quite limited control, or no control. My dad’s death from Alzheimer’s showed me this. There was absolutely nothing I could do to prevent the situation. My only recourse was to take care of him, and love him, and let go of any sense of control.

Personal relationships, especially romantic relationships, have taught this to me. Sometimes, for whatever reason, the relationship just isn’t working out. I have been on both sides of a break up, more than once. While the dynamics can be different, there are times when it is best to just let go. The situation had become too messed up, too complicated, and the best thing to do was to separate, to walk away. I have had to accept that for the time being the unresolved issues, or hurt feelings on both sides, would just have to work themselves out in time, or not. I had to let go.

Love Everyone. Tell the Truth. If my mind is going to spin and spin, at least I can choose the topic, perhaps something worthwhile. I have found this teaching to be helpful. Rather than obsess about a situation at work or a personal relationship, I will contemplate this teaching by Ram Dass through his teacher Neem Karoli Baba.

There are many aspects to this teaching, starting with the definition of love. What does love mean? How does it apply in this context?

Many will say that this teaching is not correct. Why should we love everyone? Perhaps we should not. Perhaps we should love some people and hate others, choose sides. Where does that lead us?

Even if you accept this teaching as helpful, you will find it is impossible. I have been asked to love everyone, but the truth is I don’t. What do we do with that? This teaching always gets my mind spinning but I almost always come away from the contemplation feeling better, more calm.

I meditate. I let go. I try to love everyone and tell the truth. That is how I deal with my ever spinning mind.

Chicago

This Tuesday I woke up at three in the morning, cleaned up, had breakfast and coffee, and got to the Tucson International Airport by 4:30. At 5:40 the plane left nonstop for Chicago. It was quite a shock to go from warm, quiet, dark Tucson and in a matter of a few hours arrive in cool, loud, daytime Chicago. Even the train from the airport was clunky, jolting, and noisy. I exited at the Jackson station downtown to be greeted by slightly overcast skies with a pleasant crispness to the air. My idea was to walk a couple miles east to my hotel in Chinatown. I chose the hotel because it was affordable, got good reviews, and was a mile away from the optometry conference I was attending.

I prefer to walk whenever possible. I like to get the feel of a place. The best way to do that is to be on foot or in certain situations, on a bike.

As I walked east, dense downtown high rises with fancy restaurants, cafes, and bars gave way to light industrial businesses, large residential buildings, and a train relay and transfer station to the south. As I walked, the multi-ethnic diversity of faces and colors slowly changed to mostly Black residents. I was hungry and was looking for a place to eat lunch when I passed the Studio 19 Hair Salon with a sign showing a woman facing left, a man facing right, with the classic red and blue spiral on a white cylinder. I popped my head into the open door and asked if I could get a haircut. A young and friendly African American woman smiled and said, “Sure, I’ll let the stylist know.“

I took a seat near the window. The woman in front of me was getting some kind of treatment. It looked like her naturally black hair had been bleached blonde and now was being dyed red. Two televisions were going, each loud and on different stations. A few minutes later a man walked in, friendly, smiling, wearing an African Dashiki with a black goatee extending a couple inches from his chin. He greeted me warmly and invited me to sit in the barber’s chair. “How much is it? I asked. “Uh, thirty bucks. Hi, I’m Nathan.” “I’m Dan. Good to meet you. Yeah, that’s fine,” I said, and sat down. “How do you want it?” he asked. “I don’t know, just shorter,” I said. “I don’t like it when they cut it straight across in the back. Just follow the natural hair line, but shorter,” I added. “You mean, you want it rounded?” he said. “No, I don’t want it straight or rounded, just shorter and along the natural hair line,” I said. “Okay, got it,” he said. “You want me to trim your beard too?” he asked. “Sure,” I said.

He started in the top and back with an electric razor. I’ve had my hair cut countless times and by far the most common way to go is a scissor cut, with perhaps an electric razor along the edges. But he was passing the razor in wide swaths. It felt odd. At one point the razor grabbed a chunk of hair and came to a stop. He pulled back, regrouped, and then kept going. I could tell he was struggling but I sensed he was sincerely trying to do a good job. I wasn’t worried. I felt that what would be, would be. Whatever happened, if I didn’t like it, it would grow back.

Slowly, he seemed to find his groove. He moved with more confidence. I wondered if I smelled cannabis on his shirt. “Ha,” he said, “We’re gonna do something different here, something you probably have never seen before.” “Okay,” I said, “I trust you.”

Nathan’s phone rang. He put down the razor, “Hey baby,” he said in a deep seductive voice. “Uh huh. Uh huh. Well, come on by baby. I’m just here doing a hair cut,” he said as he put down the phone and picked up the razor again.

“That sounded like your girlfriend. Is that right?,” I asked. “Yeah, that’s right. She’ll be here soon. “You married or got a girlfriend?” he asked “I’ve been seeing someone but it’s not working out. I’m pretty sure we just broke up,” I replied. “She probably wants to get married, right? They always want to get married. I’ve been dating Rita for five years. She’s always be like why you gotta talk with those other girls when you got me? And then there are some trust issues, but that’s my fault,” he said. “No,” I said, “The woman I was dating does not want to get married. I am sure of that. She wants to be independent.” “Are you sure she doesn’t want to get married?” He said. “Yes, I am absolutely sure,” I replied. Nathan kept moving the razor over my head.

“How long are you in Chicago?” he asked. “Five days,” I replied. “Doing anything for fun?” he said. “I’m not sure. I will be pretty busy. Anything going on?” I said. Nathan got excited and put down the razor. “This is what you do. You got an iPhone? He asked. “I have a phone but it’s an Android,” I said. “You got Facebook on it?” “Yes,” I said. He grabbed his iPhone and showed me his Facebook page. “You press here, then here, see here it says events?” he said. “Yes, I see” “Now look,” he said, “Here’s a list of things to do this week.”

I looked at the events and I saw a list of three or four. Every event showed a photo of an attractive Black woman or group of people having fun. The first was a woman in a skimpy dress with a champagne glass. “Look right here. This bar is just around the corner. Ladies night tonight. That’s a good one. Ah, and here’s another,” he said. He scrolled down and it read, “All Black Yacht Party.” I looked in his eyes to see if he was joking or saw the humor in what was happening. Nathan was very excited about showing me how to have a good time. He thought it would be a good idea for me go to an all Black party on a boat where I knew absolutely no one. I admired his enthusiasm.

Nathan picked up the razor again and went back at it. He was doing very detailed edging along the sideburns and then the beard. He was an artist at work, paying great attention. He must have spent, I don’t know, twenty or thirty minutes on it.

At this point an attractive woman walked in and sauntered by in blonde suede high heel boots, the short ones, wearing tight capris and a business-style blouse buttoned all the way up. “Hey baby,” Nathan said, once again in his deep seductive voice. She sat down a few yards away in the corner of the shop and brought out her phone. She had black straightened hair, just above shoulder length, and wore metal rimmed glasses.

Nathan handed me a mirror. “Let’s see what we got here,” he said. He dropped the barber’s bib and rotated the chair to the side. I liked what I saw. He stepped back and took a look. “Oh wait, I’ve got to shape the back right there,” he said, pointing. He picked up the electric razor again, for thirty seconds, ran it across the back of my head once again. I looked down and saw a lot of white, fluffy hair on the floor. “There we go,” he said, “it’s just right now.” He put some shaving cream on the edge of my beard and used a straight razor to clean up the sides. “Perfect,” he said, and it was.

Rita came over and stood by the chair. “Sorry, baby, that it took so long,” he said to her. I said hello and she said hi. I handed Nathan two twenties, thanked him, and headed out the door. As I was leaving I heard him say, “Let’s go get something to eat.”

It had clouded up a little since I had entered the barber shop. A cool breeze had picked up from the north, from Lake Michigan a mile away. I continued walking east to my hotel in Chinatown, looking once again for a place to have lunch.

 

A Colorful World

I was preparing a lecture on color vision testing, looking up information on the internet, finding images, and putting it all together into PowerPoint presentation. I did a Google search on Ishihara plates. This was for a second year class on Clinical Optometric Procedures. Most of my students are from Western Kenya and in their early twenties.

The Ishihara color vision test is commonly used. These high-quality images printed on paper use circles of varying size and shades of colors to make patterns, usually numbers. When a patient has normal color vision a certain number stands out, say 8, but if you have a red-green color defect you will see a 3. The Ishihara test is popular because it can be done quickly and it is sensitive. Unfortunately, it is so sensitive that it often results in false positives, meaning that the optometrist might say a patient has a color vision defect when the patient does not really have one. About 1 in 7 males have a color deficiency, usually red-greed color confusion, much less with females, about 1 in 200.

Optometrists generally do not use the words “color blind.”  Monochromatism, or complete lack of color perception, does exist but it is very rare. We use the term “color vision deficiency” which is more accurate when describing the vast majority of patients who confuse shades of colors to varying degrees.

While preparing the presentation, I stumbled upon an image of Barack Obama that artist Tony Davis had created in the Ishihara style. Just to liven up the lecture, I downloaded it and placed it into my presentation. When the image came on the screen most students did not recognize the person in the image. This surprised me because Obama was well known and very much liked in Kenya. Obama’s father was Luo and from a region just south of Kakamega, land of the Luhya.

“The Ishihara plates test for perception of color and Barack Obama is a person of color,” I said. “What?” I heard murmuring and saw the students look at each other, then back at me. “Barack Obama is considered to be the first black president of the United States,” I said. Most students smiled and some laughed loudly. “He’s not black,” a student said. I said, “He’s a mzungu like me?” using the Swahili word for white person. “Yes,” several students said in unison. “Well, in America, Barack Obama is considered to be black, quite definitely black, although everyone knows he is of mixed race heritage,” I said. More laughter ensued. “He’s mzungu,” one student said loudly, ending the discussion.

I have been in Kenya since August, and have had many discussions about nationality and skin pigmentation. I hesitate to use the word race because there is debate, I have read, as to whether or not race even exists. Certainly there are historical, social, cultural, and physical differences among people across the globe. But what is race, especially in a world with migration, immigration, and increased mixing of people?

Kenya is complex in this regard because until December, 1963, the country was colonized and ruled by the British Empire. My guess is, if I had been here fifty years ago, I might have met some hostility based on my light skin. Not so anymore. The colonizers were kicked out and enough time has passed so that many have forgotten the pain of colonization. Some even look back fondly to the days when things were well-built, organized, bureaucratic but less corrupt.

When I walk down the street in downtown Kakamega, for example, I get a lot of attention. It is constant. I would guess that twenty or thirty times a day, people call out mzungu! to me. Children stare, and mothers lean down looking at me and then their child and say, “Mzungu,” which explains everything. The children nod and repeat, “Mzungu.” When mzungu takes the form of admiration, I feel like a rock star. At other times it feels more like I am being harassed.

When in Eldoret last Sunday I walked into the staging area where the vans and buses meet, called matatus. First one, then another, then another guy came up to me trying to get me to go in their matatu. It made no sense because many of the vans were labeled with placards to places I did not want to go. Within 30 seconds it escalated into a frenzy, with 6 or 7 guys around me trying to coax me into their van. Then one or two started to grab my arm, trying to pull me in this or that direction. I became angry and told everyone to stop and just walked away. While standing on the periphery of the area, a soft spoken guy approached and offered to help. He was looking for business too, perhaps a tip, but he went about it in a comfortable way. I told him where I wanted to go and he accompanied me to a matatu. I paid him a 50 shilling tip and got into a matatu headed for Kitale, paying the 250 shillings for the ride.

In the matatu I was sitting in the front next to a woman. She asked me to take our picture together, so I did. “Will you send it to me?” she asked. “Sure,” I replied. She gave me her mobile phone number and I sent the image.

A day later I got a phone call from an unknown number. “Do you remember me?” a woman said with a thick accent. She said more but I could not understand. I hung up. Thinking it could be work-related, I texted the number and wrote, “If you want to communicate, I recommend a text message. I sometimes do not understand the spoken word.”

The next day I got the message, “hi mr jambo. i am very happy at this particular time to say hi to you, showing you i love you so much. i’m sister rosemary from eldoret. remember the time we met going.”

I responded, “Hello Sister Rosemary. I am working in Kakamega, but will be leaving Kenya soon. Good to meet you.”

The next morning I got this message, “How can i meet you soon? I’m missing you so much. I feel having sex with you soon. pls consider me.”  I responded, “Leaving Kenya very soon. Bye.”

One cannot separate issues of skin pigmentation, or lack thereof, and economics. Most people are lucky to have 50 shillings in their pockets, maybe 100. A small bag of peanuts costs 30 shillings, a meal in an inexpensive but decent restaurant costs 200 to 400 shillings, a ride across town on the back of a motorcycle, 50 shillings. The people I associate with every day, the students for example, have almost nothing. You would not know it because they are friendly, clean, and well-dressed, but they have very little. Students skip meals all the time because they just don’t have the money to buy lunch. If they are lucky, perhaps they will buy a banana for 20 shillings. The local boys and girls in the street buy a chunk of raw sugar cane for 5 or 10 shillings and chew on that to keep the hunger away. Many will chase the fully-loaded sugar cane trucks trying to grab a stalk and pull it from the stack. Not only have some fallen under the wheels of the tractor trailers, they sometimes fail to notice the truck, automobile, or motorcycle coming in the opposite direction and get hit.

The good lady from Eldoret saw an opportunity. Maybe I would take her with me, she hoped. Maybe she would get pregnant and there would be a way to get support for her and her child. At the very least, a mzungu child might have a chance at a better life. Maybe her child would be the next President of Kenya, or even the United States.

The staff where I work, the two administrative assistants in our department, who show up to work Monday through Friday, 8 to 5, are paid very little. I think it might be about ten thousand shillings a month ($100) maybe fifteen thousand, I am not sure. The four Kenyan optometrists I work with have been without a contract, teaching and seeing patients, all without pay since January. When they ask, they are told it will be coming any day now, any week. Just one more signature is needed. They have family in the area, they love teaching and working with the students, so they hold on hoping the contract will come through. They borrow from friends and family to be able to pay rent and eat.

When a person from Kakamega, or anywhere else in the country, sees me walking down the street, they assume I have money. In comparison, they are correct. I almost always have enough shillings in my pocket to buy some groceries, or maybe have lunch at a restaurant for 400 shillings. Some ask for money directly and I usually say no. Most are trying to get my business in one way or another. I usually need to carry a day back, with a rain jacket inside and my laptop computer for teaching, which just makes me more of a target. That is why I get asked about forty times a day, “Where are you going?” by taxi drivers, motorcycle taxis, and matatu drivers. Constantly. “No, thank you, I am walking,” I reply. “But where are you going?” they say. “To the store then home. Asante, but no,” I say. “Where are you going? Where is home?” they insist. “Kakamega,” I say. I get frustrated.

When I get frustrated, I try to remember they are just doing their job. They are trying to get that 50 shilling ride across town so they can put some more gas in the tank of their motorcycle, or buy a bag of peanuts and a mango for lunch. I have not yet felt physically threatened. No one has robbed me. Well, actually, that is not entirely true. I brought a front and back light for my bike from the US. They only lasted two days before I noticed they were missing. But I have experienced worse in Tucson.

A couple weeks ago I went out to Kakamega National Forest for a beautiful sunrise walk. Stayed in the guest houses there and met Caiti from the US, Machiko from Japan, and Ana from Spain. They were here volunteering and traveling in Kenya and all were on a tight budget. We got along great and had a good time together. We came back to Kakamega and I offered to treat them to an early dinner. I chose a nearby restaurant called Sheywe that served very good Indian food. I had been there at least six or seven times, sometimes alone, sometimes with a group. I always have tipped ten percent, which is typical for foreigners and relatively generous here. Most Kenyans do not tip.

We ordered the food and drinks. I got a beer, while Caiti ordered a tequila. The server asked, “Single or double?” She said single and he brought her a glass with maybe a quarter inch of tequila in it. The food was excellent and we all had a great time. It rained but the covered outdoor patio was pleasant. As we were getting ready to leave, I offered to pay but Caiti and Machiko insisted on buying the drinks, so I agreed. When the bill came the server had charged 300 shillings for the tequila. That is a lot here. I asked why it was so expensive, and he responded, “300 for a double.” “Oh, that’s the issue,” I said, “Caiti ordered a single and you brought a single.” “It was a double,” he said. “But she ordered a single.” I said. “Sorry,” he replied. “So, you will charge 200 for a single?” I asked. “No. 300. Double,” he said. “But you made a mistake, and anyway, it looked like a single to me,” I said. “Look, I come here a lot. I like coming here and it is my favorite restaurant in town. Would you please just charge her a single?” “Double, 300,” he replied. “I understand. May I speak with your manager, please?” I asked. “It is Sunday afternoon, there is no manager,” he said. “Okay,” I said, “I am not going to leave my usual tip and I will not come back.” “Okay,” he said. I paid for the food, Caiti and Machiko paid for the drinks, and we left without giving a tip. I have not been back.

I have thought a lot about that interaction, trying to understand the server’s point of view. Why would he struggle so hard for that extra 100 shillings when it was not in his best interests? I believe I understand. Whether or not he intentionally served a double when asked for a single did not matter. Once he had written “Double tequila 300” on the bill he was committed to that course of action. It could and probably would be reviewed later by management. All he knew was that 100 shillings was at risk. If he admitted a mistake he might have to pay for it out of his own pocket. He did not know if we would leave a tip or not, or how much we might leave. He did not know if we would come back another day or not, but that was the last thing on his mind. All that mattered was that 100 shillings. Of that he was absolutely certain. If he lost the 100 shillings, it would be gone forever.

There is so much need here. Small issues get amplified into large ones. I even bought into it myself, perhaps out of pride, getting irritated and arguing over a dollar.

And yet, if you look around, there is clear evidence of abundance. The weather is mild, sunny, with almost daily rain in the afternoon and evening. The soil is extremely rich. Corn, spinach, kale, and fruits like mango and banana grow easily. People grow food on the side of the road, empty lots, and public land. Cows, goats, and sheep graze almost anywhere that is accessible. Chickens run all over the place and seem to belong to no one. I have to dodge full grown chickens and baby chicks when I ride my bike to work. I dodge cows and goats too.

In the homes here there is no need for extra heat or cooling. If you need it to be cooler, open a window. If you need it to be warmer, put on a sweater or blanket. The best home or apartment construction is made of stone with electricity and plumbing, and I live in such a dwelling. Many homes are made of timber and mud with a metal or even a grass roof, put up in just a few days to a week. If kept in good repair, they are quite comfortable in this climate. It would not take too much to make this place a paradise.

People are almost always friendly and often generous. A smile and friendly hand shake are the norm. “May I help you with this or that?” I hear. There is daily chanting or singing, from churches and mosques nearby, and even more on the weekends. The men often wear bright suits and hats with perfectly shined black leather shoes despite the red mud. The women wear many layered garments with vibrant patterns. Flowering bushes and trees are everywhere, with brilliant yellows, oranges, reds, and purples. It is a rich and sensual world here, abundant in every sense. And yet sometimes the colors can seem muted, dull, or deficient in some way. When that happens, it is time to take a deep breath and look around.

Haircut, Shampoo…

Yesterday, while walking around Eldoret I decided to get a haircut. I have been a little bit hesitant to do this in Kenya because my hair is different than pretty much everyone else around me. I just wasn’t sure what the result might be. There was that fact, along with the sensational reports in the local press about people contracting HIV through a haircut. This could be possible under extremely unhygienic circumstances I suppose, but would be highly unlikely. I selected a place called Executive Cuts in a shopping mall near a Tuskys department store. As I expected, when I walked in all eyes turned towards me. “How much for a haircut?” I asked. “300 shillings ($3).” the barber replied. He was a tall young guy, with a friendly smile. “Sawa,” I said and sat down to wait. A few minutes later he called me up and I sat down. There was the usual, “How do you want it?” “Just shorter. Do your best,” I said. As expected, he brought out the electric razor and selected the longest comb attachment. He looked at me as if to ask, “Is this okay?” and I nodded. He carefully sprayed everything down with a blue liquid that I assumed was some kind of disinfectant. Very soon I was like a sheep being shorn, with white locks falling all around me. It was shorter than I would normally wear it, but he did a good job and even kept it a bit longer with a touch of style in the front. I was then sent to another section where a nice young lady expertly shampooed my hair, then applied faintly eucalyptus-smelling waxy substance and rubbed the heck out of my scalp and neck, finishing with a blow dry and light combing. I thanked both of them and paid my 300 shillings, then left a 100 shilling tip which is a lot here.

When I got back to the hotel I took a nap. When I woke up I had a text message from an optometry student at the university. Many students check in with me every now and then. I wrote that I had gotten a haircut. She wanted to see it. “Take a picture and send it,” she wrote. “You want to see a picture of my bald head?” I replied. It was about dinnertime so I headed to the hotel bar where they served food. I told the bartender that a student wanted to see a picture of me with my new haircut. “Do you have an egg?” I asked. He laughed and thought it would be funny. We both decided that surely they would have an egg in the kitchen. So I headed over to the kitchen and told the chef my plan. He was enthusiastic to help. He brought out an egg, a brown egg. “Um, do you have a lighter one?” I asked. “I am mzungu, after all,” I said. We both laughed. He found a lighter one and I took a picture of it and sent it to the student. I headed back to the bar and soon I got the “Hahaha!!!” I was hoping to receive.

I am having fun in Kenya, and fortunately the people here love to have fun too.

Spectacle Fabrication at the KCMC School of Optometry

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Image 1:  A welcoming sign at the Kilimanjaro Christian School of Optometry

Today we met at the Kilimanjaro Christian Medical Center (KCMC) School of Optometry and discussed the challenges facing optometry programs in Eastern Africa. Once again I mentioned the issue of spectacle fabrication, one challenge we have been facing at the Masinde Muliro University of Science and Technology. One of the faculty members said, “It’s easy. Let me show you how to do it. We use simple and inexpensive technology available all around the world.” We went next door to the optical shop.

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Image 2:  Laying out the spectacle lenses. Here one lens, in the optometrists hands, has already been roughly completed, while the other lens on the cloth is awaiting preparation.

The first step is to find and mark the optical center of the of the lens using a lensometer. Lensometers are not too expensive and are usually readily available. The lens blanks are usually 60 to 70 millimeters (mm) in diameter, and can be made of plastic (CR-39) or glass. It is important to know the interpupillary distance (IPD) of the patient which is the distance between the centers of the pupils. This distance is easily measured using a ruler with the patient present and is usually between 50 and 70 mm, depending mostly on the width of the nose and age of the patient. The optometrist then measures the frame to be used, taking note of the bridge width (B). Using the formula of (IPD – B)/2, and an outline of the shape of the frame, the optometrist can calculate the distance from the inner nasal edge of the spectacle aperture to the optical center of the lens. The optometrist then uses a marking pen to outline size and shape of the frame aperture in relation to the optical center of the lens. It is important to place the optical center of the lens in front of the pupil center. The higher the prescription, the more crucial the optical center placement.

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Image 3:  The optometrist uses a glass cutter tool to etch the glass. The purpose is to remove the excess glass on the periphery of the lens.

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Image 4:  The optometrist uses pliers to grab the periphery of the lens and carefully remove the excess glass. He puts on safety glasses for this step to avoid eye injury.

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Image 5:  The optometrist uses a manual grinding wheel to remove the excess glass and smooth the periphery of the lens. He is careful to grind the lens to the correct shape, making a beveled smooth lens edge. This process is called lens edging.

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Image 6:  Once both lenses have been edged, the plastic frame is heated, and the lenses are carefully inserted into the frame, usually from the front. The whole process takes about a half hour. Metal frames require more precision because metal is less forgiving than plastic. Rimless frames using nylon line require a special indented lens edge that is more difficult to fabricate by hand. The optometrist proudly shows his handiwork. It is in this way that high quality spectacles can be created at very low cost. All that is needed is a bank of lens blanks of varying power, plastic frames of varying sizes and shapes, and the tools and instruments mentioned here. Of course, knowledge of the process and experience is very important. Novice lens edgers tend to break a lot of lenses.

When I was an optometry student from 1989 through 1992, we learned how to complete this process although we did not spend much time on it. Now the spectacle fabrication process is rarely completed by optometrists in the United States, and is usually done by opticians using automated equipment. The KCMC School of Optometry has the more advanced equipment normally used in the United States, but they wanted to show me how to get started fabricating spectacles when the more expensive equipment is not available. This process could be very helpful at the Masinde Muliro University of Science and Technology School of Optometry, given that we currently do not have a spectacle fabrication laboratory.

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Image 7:  After showing me how to fabricate spectacles using inexpensive and readily available materials, we sat down and spent two hours discussing slit lamp biomicroscopy techniques.

The exchange of ideas and information at the KCMC School of Optometry has been very stimulating and rewarding.

Optometry in Moshi, Tanzania

This morning I was picked up by the Head of Department of the Kilimanjaro Christian Medical Center College of Optometry. His name is Focus Maro, a perfectly appropriate name for an optometrist, and one of the most industrious and motivated optometrists I have met in Africa. Not only does he run the optometry department at this large university, he has a private clinic that is associated with the medical center and helps to train optometrists. He told me that the college was started by Swedish optometrists and they often return to visit, continuing their supportive relationship. I met many of the six full-time optometry faculty at this active institution.

The KCMC College of Optometry offers a three year diplomate program and teaches 15 to 20 students per class. With six faculty it is possible to offer a high quality program. Tanzania has regulated optometry, with optometrists required to register with a state-run authority. This gives the College some leverage to require a high level of competence, and they will fail students who do not show the required level of knowledge and skill. They have a high quality optometry and ophthalmology library with several lecture halls and internet-linked classrooms where each student has a computer. They have the ability to run remote training sessions, with lecturers from all over Africa and the world.

The KCMC College of Optometry is closely linked with the Department of Ophthalmology. They jointly run a busy clinic and I saw perhaps 100 patients waiting for eye exams. One interesting point is that Dr. Maro told me they used to see patients by appointment, but that system did not work very well. Now they accept patients all morning and work through the afternoon to see them all. Unfortunately, I forgot to bring my camera during this part of the morning so I don’t have any photographs to share. I will not make that mistake tomorrow.

KCMC is located in Moshi, Tanzania, on the flank of Mt. Kilimanjaro, the highest peak in Africa. The weather now is warm and dry, and attracts trekkers from all over the world. Moshi is known as the cleanest city in Tanzania. This morning as I was waiting to be picked up, I could see homeowners and businesses cleaning up their properties and the streets. The traffic circles have manicured bushes with flowering plants. The College is no exception, offering a clean and beautiful campus, with workers keeping the place up very nicely.

I met the Head of the Ophthalmology Department and we chatted for 10 minutes. He described the program and the many challenges. One challenge is treating patients with dense corneal scarring leading to blindness in that eye. A corneal transplant could correct the blind eye. But corneal transplants using artificial materials do not work well, and culturally it is difficult to obtain human corneas for transplant. He said it was not for a lack of available donor tissue, as there are many cases of traffic accidents and other casualties. It is almost impossible to convince family members, however, in the midst of emotional trauma and mourning to release tissue to harvest. It is not culturally acceptable to gain release in advance, as is relatively common in the United States.

The optometrists and ophthalmologists work together to treat the patients in the busy clinic. The optometrists work seeing the routine patients that need spectacles and eye drops, while the ophthalmologists treat more complex medical eye issues and surgical cases. They have an optical laboratory to make high quality spectacles. One challenge is contact lens care, because they do not have the instruments and laboratory equipment to fabricate rigid contact lenses. Apparently, soft lenses through international contact lens companies are not readily available either.

Dr. Maro and the Head of Department of Ophthalmology briefly discussed the program I work with at the Masinde Muliro University of Science and Technology (MMUST) in Kakamega, Kenya. The Kenyan program offers a four-year bachelor’s degree with 30 students per class. In contrast, we only have three full-time faculty, whereas the recommended faculty to student ratio should require eight or nine faculty lecturers and professors. As I left our meeting, the Head of Department of Ophthalmology told me that we should hire more Kenyan faculty. I reminded him that the Kenyan system requires a Master’s or Doctoral degree to be a full fledged faculty member, and no one in the entire country met those requirements. It prompted me to concentrate on training the most talented newly graduated Kenyan optometrists to get their advanced degrees, so that they can run their own department in the coming years.

The KCMC College of Optometry and Department of Ophthalmology accept many foreign students including those from surrounding African countries. As I have mentioned, the entire academic setting here offers an exceptionally high level of training. Today’s experience made me question what strategy might be best for training optometrists. Would it be best to develop new programs such as MMUST, where I am teaching and where we face many challenges including the lack of a spectacle fabrication facility, or would it be best to send Kenyan students abroad but close by for training? I see advantages to both scenarios. Even though Kenyan and Tanzanian cultures seem similar, there might be national rivalries and/or barriers to travel that would inhibit Kenyan students from moving here for several years. Clearly, the powers that be have decided that developing a regional hub in Kakamega, Kenya at MMUST, despite the challenges, would be best. I will continue with that goal in mind. Tomorrow I will start the lectures on slit lamp and ophthalmoscopy for the optometrists on the faculty. The Head of Department for Ophthalmology requested a lecture on refraction for the ophthalmology residents and faculty, and I will do that on Wednesday.

Tarangire National Park

All day yesterday I kept thinking how fortunate I had been. I was getting a private tour of Tarangire National Park with my own guide using a modified Toyota Landcruiser. It was fairly ridiculous really, and definitely wasteful, but here I was about 120 kilometers south of Arusha, Tanzania seeing elephants, giraffes, lions, and so many more incredible animals.

The whole trip could have easily fallen apart. In the days leading up to the trip, my hosts had expressed doubts they could organize a classroom and hands on seminar of slit lamp and ophthalmoloscopy skills. My contact at the Brien Holden Vision Institute, Kesi Naidoo, had left it up to me. If I wanted to go, I could take the chance. If I wanted to back out and reschedule, no problem. I decided to go.

When planning the trip the idea was to arrive late on a Saturday and have Sunday off. Monday through Wednesday I would teach the workshop and head out Thursday to Nairobi and back to the United States. If I was going to have a day off in Northern Tanzania I would make the best of it. I researched things to do on Trip Advisor and found the Arusha National Park. But as I looked into it further, I realized that it was a rainforest park similar to the area around Kakamega where I was now living. If I headed a bit further south, I would be in the high plains area with the opportunity to see animals I had never seen before. Tarangire was not one of the more well known national parks like the Serengeti but it was highly rated, and had a large population of elephants living in the wild.

While traveling in Africa, I have found that it is sometimes hard to know what a fair price is for goods and services. It is a two-tiered system. If I use the local buses called matatus, for example, I can travel a 100 kilometers or more for $2 or $3. I often do this and enjoy it. If for some reason I decide to hire a driver, say I have a lot of luggage to carry, the same trip might cost $40 to $60. When in non-tourist regions like Kakamega I can get a fine meal for $3 to $5 but it might cost two or three times the price in a tourist destination. When scheduling this safari without any local knowledge or contacts, I relied on the internet for information. I had determined that $315 to $400 for a full day trip to the Tarangire National Park was the going rate. It’s a lot I know. But the trip included round trip transportation 120 kilometers each way, a guide with knowledge of the region and wildlife, lunch, and park fees which are $60 a day and go toward preserving this beautiful natural resource. Through Trip Advisor I booked the trip for $315, which was the least expensive of the three I had checked. I decided to go all out on my one day off.

Yesterday morning I was greeted by Anthony of Backpacker’s Safari Company. “Where is everyone else?” I asked. I was expecting a tour vehicle full of other people with a free seat or two available. “You are the only one,” he said. “Okay, let’s go,” I said, astonished that this was really happening.

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Anthony of Backpacker’s Safari Company in Arusha, Tanzania. By the way, you can see the photograph a little bit larger if you click on them.

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In Arusha we stopped and picked up our box lunches. These boys were happy to get their picture taken in downtown Arusha. We headed south about 120 kilometers which took an hour and a half.

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The road is excellent from Arusha to Tarangire National Park. We passed through areas with many Maasai settlements, although many Maasai migrate so the settlements can change. We stopped at the Tarangire National Park headquarters where Anthony purchased the permit to enter.

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The Love Bird

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These giraffes were kind enough to line up for me.

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This large bull elephant was digging in the river bed for moisture. This part of the river appeared dry but I could see the ground was quite moist just a few feet down.

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Here I am, enjoying my private tour. The top of the extended Toyota Landcruiser lifts up to give an excellent and shaded view of the surroundings. We saw a cheetah but I was not able to get a good picture of it. The cheetah was lounging under a tree, but got up when an elephant approached. Anthony said it was very rare to see a cheetah in that area.

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Anthony said, “Look, see how the elephants take care of their baby.” The young elephant was sleeping peacefully.

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There was a wide variety of wildlife to see as we trekked around the dirt roads in the park.

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I am trying to remember the name of this bird. Anyone have any ideas?

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A Baobab tree. They can live up to 500 years, Anthony said, and attract a lot of wildlife.

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Part of the river had standing or even running water. I noticed that the wildebeasts and zebras hang out together. Anthony said that the wildebeasts rely on the zebras to find water because they do not remember where it is.

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We saw several ostriches.

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Baboons.

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We stopped around noon to eat our boxed lunch, and this was the view.

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The Tanangire National Park is known mostly for its elephant migration. Anthony said that during the rainy season in March, April, and May when water is plentiful, the elephants leave to other areas around Tanzania.

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Mother with calf.

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There were lots of wildebeasts, which Anthony called wildebeasties.

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A pride of lions. It seemed that most of the tour vehicles were looking for lions. We were early and noticed these lions just after lunch. As we left the area we were stopped five or six times as the other guides wanted to deliver on the lion viewing experience.

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Lots of flirting going on.

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As we left the area, I snapped a photo of this Maasai compound. To the right is a circular area, bounded by a brush fence, where they put their cattle or goats at night.

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This hastily snapped photo was on the road leading back to Arusha. These 12 to 14 year old Maasai boys were preparing for circumcision in the coming week. Anthony drove me back to Arusha. I have him a 40,000 Tanzanian Shilling tip, which amounts to $20 and was the recommended amount. He dropped me off at the local transportation center and I caught a matatu to Moshi to begin my work Monday morning.

In fact, it is Monday morning now and I am waiting for a local optometrist to pick me up.

Living With Uncertainty

In the post “How Things Work” I detailed two administrative processes I have been completing. One was the work permit application through the Registrar (Admin). I did my part and submitted all that was requested. I was told the Registrar would hand carry the application to Nairobi and submit the application through the Department of Education. This is important because, I have been told, a year or two ago the Kenyan government raised the fees for a work permit from $100 to $2,000. Fortunately, for foreign lecturers working in fields where there is unmet need they would waive the fees, or at least reduce them substantially. I was told they would now accept my official University of California, Berkeley transcripts as evidence of my credentials.

When I asked the Finance Department when I might get paid the administrator reminded me I did not have my work permit. He said, “The Kenyan Immigration people are serious about their jobs. They can be difficult. You don’t want to mess with them.” I nodded my head and left the office. I was starting to think that maybe the University was protecting itself. If I was not paid, then they could say I was not working for them if trouble should arise. I have heard stories about people being incarcerated.

Kesi Naidoo of the Brien Holden Vision Institute told me that he needed a lecturer to give seminars on slit lamp and ophthalmoscopy skills in two or three African countries. He spoke with Dr. Okenwa-Vincent, and they both agreed I would be a good fit for the job. The main issue was that University lectures have started and I would miss three lectures a week for the four weeks I would be gone. I offered to make them up when I returned. In the last days, I have gotten the e-mail addresses of the 2nd, 3rd, and 4th year class representatives and will forward them reading materials, notes, etc to review in pdf or doc format. That won’t take the place of the lectures, but might move them along faster.

The only other issue was getting permission to leave from the Vice Chancellor. I was told that if my Head of Department and the Dean of the College of Public Health, Bioscience, and Technology signed my application, the Vice Chancellor would sign it. It was a rubber stamp, they said.

Unfortunately, that was not the case. The Vice Chancellor put up some resistance my request for leave of absence. I was called into his office, but he was at a meeting. The meetings here normally last at least three hours and there are a lot of them. Some last all day. I asked if I could leave him a note and the administrative assistant said that would be okay. I got out my pen and and asked for some paper. She said that I should complete a typewritten request. I told her that our department did not have a typewriter nor did we have a reliable printer. I reminded her that I was supposed to leave the next day and suggested a neatly handwritten note would be acceptable. Thankfully, she agreed.

I wrote a page and a half, and signed it at the end. I wrote that I am giving lectures, supervising students, and seeing patients. Due to several factors, I did not yet have a work permit yet, and it was technically illegal for me to be working. While unlikely, I could be subject to fines or even imprisonment. By leaving I would be protecting not only myself but the University. While I was gone I would request duplicates of my diplomas, and hopefully the situation would get sorted out in the weeks I was gone. I would return, make up my lectures, and we could put this chapter behind us.

I handed the administrative assistant my hand written note and she attached it to my original paperwork. She then handed the packet back to me. “What should I do with this?” I asked. She said that because of the amended application I needed to get it signed, once again, by the Head of Dept and his boss the Dean. “Oh no,” I said, “They already approved and signed the application for leave. They are in full support of the leave of absence, and besides I will make up the lectures I will miss.” I was on a roll now, but still respectful. “Furthermore,” I said, “You might want to suggest to the Vice Chancellor that he read my note, and then tear it up and put it in the trash. I don’t think anyone, especially the University, wants signed documentation of illegal activity in my file.” I walked away, had lunch, and then gave a lecture from 2 to 4:30 in the afternoon. It was my second lecture to the 2nd year students on Clinical Optometry Procedures.

I have fallen into a morning routine. I sit in the clinic consultation room preparing my lectures. When a patient arrives I do an eye examination, and then go back to preparing lectures. The 3rd and 4th year students have not yet returned from attachment, which is the outside clinic and hospital rotations, so there is no one to teach at the moment.

Most of the patients have been complaining about swollen, red, itchy eyes. I strongly suspect the frequent afternoon rains have promoted mold growth and/or stimulated bushes and trees to bloom in the morning sunshine. I have diagnosed allergic conjunctivitis many, many times in the last week and have recommended topical ophthalmic antihistamine drops.

Today I followed my morning routine but the optometry clinic receptionist, Jennifer, was called into a meeting. Because she was not there, less patients arrived for eye examinations. There has been a steady back log of about ten or twelve patients to be seen, and Jennifer often calls the patients when she knows a daktari will be available. Jennifer returned around two, we chatted, and I left for lunch. I bid her so long for a few weeks, because I decided I was done for the day. I wasn’t supposed to be there anyway, I reasoned. I never did hear back from the Vice Chancellor.

I had lunch at a place in downtown Kakamega called Garden View, which offers a chicken curry plate with rice or ugali for 350 KSh, or $3.50. Ugali is a large mass of white corn meal. It is good, but way too much for me eat so I usually get rice. At Garden View, sometimes the curry tastes like curry and sometimes it is a tomato-based stew with peppers, onion, and garlic. Fortunately, I like both. It depends on the cook and what his or her idea of curry is.

As I was riding my bike back to my place around 3 in the afternoon, I could see the dark clouds rolling in, the wind picking up, and hear thunder. This was a big one brewing. I decided to stop by Golf Hotel bar, an open air but covered bar, to avoid the rain. Fortunately, with my phone acting as a hotspot, I could work almost anywhere. I ordered a Tusker and settled in. While working, I got a message from Kesi on WhatsApp Messenger asking if I could talk. Sure, I responded. A couple minutes later we were talking on Skype.

“There has been a complication,” he said, referring to the upcoming optometry seminar I was supposed to teach in Tanzania. “A few days ago they said it was a go and to make the plans, but today they said it might not work,” he said. He asked if I had made the plane reservations. “Yes,” I said, “Yesterday, I made my plane reservations for Nairobi tomorrow and then to Northern Tanzania near Kilimanjaro Saturday.” “Okay,” he said. I mulled it over for a moment. “Tell you what, Kesi,” I said and I calculated the cost of the trip, “I am going to Tanzania. If they can do the workshop great, we’ll do it and the Institute can reimburse me. If not, I will just make it a vacation. I need to leave Kakamega anyway.” The flights were cheap and and I would stay in an affordable hotel. I had already done the research. “All right,” he said, “I will get back to you tomorrow with more information.” “Thanks, and have a good evening.” I said. “Good evening, Dan,” Kesi said.

So, I am headed to Nairobi tomorrow. I fly to Kilimanjaro Airport Saturday afternoon and have booked a room in Arusha, a mid-sized city in Northern Tanzania. Sunday, I made reservations for an outing at the Tarangire National Park. Monday through Wednesday, I might be teaching optometry slit lamp and ophthalmoscopy skills. If that occurs, it will take a local bus the hour or so over to Moshi, not too far away from the Kilimanjaro Airport. If the seminar falls through I will find a not-too-expensive hotel in Arusha or Moshi and rest for a few days. I can work on my slit lamp and ophthalmoscopy power point presentations because, at one point or another, they will be needed.

I am learning to go with the flow, handle the uncertainty, delays, and changed plans. It seems to happen a lot here. I am definitely not the only one dealing with all this, not by a long shot. The Kenyan people are experts at waiting. They are patient, easy going, and know how to handle adversity. This is just a lesson in doing the same.