It has been about five days since I posted an entry. This week, up until now, there did not seem to be much to say. I have been busy preparing my first lecture to the second year students on “Clinical Optometric Procedures.” I have been settling in to a routine, doing my work.
Here on the equator in the highlands of Western Kenya, the sun rises at 6:45, the sun sets at 6:45. The day starts out sunny, clear and cool at around around 16 degrees Celsius (60 degrees F) and warms to about 26 C (80 F) in the afternoon. We are in the late summer rainy season. I wake up, shower, and have a breakfast of instant coffee, oats, and fruit. The local fruits of oranges, banana, and mango are plentiful and cheap. It is also common to see apples and tangerines in the high end grocery stores and they are more expensive. Yesterday, I asked a grocery clerk, “Which of these coffees is the best Kenyan instant coffee?” “Nescafe,” he answered. There is an assumption among locals that the big international companies have higher quality food, but there was no way I was going to buy Nescafe. I vaguely remember an incident that happened years ago where Nescafe initiated an advertising claiming that their baby formula was more nutritious than mother’s milk, leading to infant malnutrition and deaths. I went for Gibson’s brand which is made in Kenya, and I have no details about how ethical Gibson’s has been over the years, but have not tried it yet. I once bought Dorman’s brand and it was good.
I ride my bike to work through the back roads. There is a side entrance at the University, closest to my place, that allows bicyclists and pedestrians to enter. I enjoy greeting the security guard with a “Jambo” or “Habari?” As I ride, I frequently hear locals say or sometimes yell “Mzungu!” as I ride by. The look at me and laugh, putting an elbow into their neighbor’s side. “Hey, look at that. There’s a mzungu on a bicycle.” As I have mentioned before, bicycles are for poor people here, and they assume that a mzungu is wealthy. While I have no complaints, and I am still not receiving a salary, I certainly do not perceive myself as wealthy by American standards. I am wealthy by Kenyan standards, however.
As I ride I hear “How are you?,” every few minutes. I am trying to learn Swahili, and will sometimes answer “Mizuri sana,” which means “I am fine.” Oh, they do not like that at all. If someone yells, “How are you?” they want to hear, “Fine, thank you.” So now I say, “Fine, thank you, and you?” as I ride by.
Most mornings I arrive to work and find a place to sit and work. I have no office here and neither does the other full-time faculty member, Richard Donkor, OD, from Ghana. We often sit in the consultation room in the clinic where it is clean, quiet, and there is an electrical outlet to power our laptops, charge our phones. Telecommunications in Kenya are excellent, at least through the company I use called Safaricom. My mobile phone acts as a hotspot, is inexpensive, and reliable. I buy data packages as needed, use it a lot, and have purchased $20 in data so far in my three weeks here.
Lately, I have been working on my lectures. I am partly employed by the Brien Holden Vision Institute out of Australia and have access to their online teaching materials, either in pdf or Powerpoint format. They have extensive teaching materials available and I have enjoyed reviewing their Clinical Optometric Procedures I and II series, which is one of the classes I teach. I have not found any contact lens or visual neurology lectures on their website. For the contacts lectures, I have joined the International Association of Contact Lens Educators (IACLE) group and should have access to their teaching materials soon. I have purchased a neuro-ophthalmology text but it has not yet arrived. That will help me with those lectures.
Lunchtime here is 12:30 to 2:00. Usually, I start getting lightheaded around 11:30 so often reach into my bag for a snack, often peanuts. I always carry my backpack, which contains my laptop, charger, notebook, rain jacket, some cash, and passport. I carry water, and have unfortunately become dependent on bottled water. I must come up with a better solution than buying all that plastic. Sometimes I do not bring my passport, but only a copy of it. It depends on whether or not I might need it for some administrative task. I always carry tissues or toilet paper. The only restroom on campus I have found that has toilet paper is the optometry clinic, so I often use that. The rest, for example, the restroom near the Department of Optometry and Vision Science has no paper products and no way to wash my hands. An individual sized alcohol hand cleaner is helpful.
Most Kenyans bring their lunch, and some seem to not eat lunch at all, as far as I can tell. I get on my bike and ride the 7 minutes off campus to a local restaurant that has a lunch plate with drink for 550 Kenyan Shillings (Ksh), or $5.50. I often get the chicken curry with rice. Another place called Garden View, and a bit further away, maybe 10 minutes, has the same thing for 360 Ksh. I mentioned this to Jennifer, who is the receptionist at the optometry clinic, and she said that was expensive. I have been doing quite well spending about 10,000 KSh a week ($100,) but that includes several items I have needed to purchase but did not have such as an electrical outlet adapter, towel, place mat, and laundry soap. Perhaps by American standards that is reasonable, even frugal, and by Kenyan standards I am wealthy and extravagant. I am living on savings.
I head back after lunch riding my bike on a pedestrian and bicycle path next to the main road. As I ride, I repeat the mantra “Stay left, stay left.” This helps me to remember to ride on the correct side of the road. If I have to ride on the road, as many bicyclists do, I will be passed by motorcycles and cars just inches away. Drivers here are quite good, and used to all sorts of obstacles including cattle and human-drawn carts loaded ridiculously high with all sorts of materials. Today, heading down the pedestrian/bicycle path, I dodged a herd of twenty cattle led by a Maasai caretaker. It seemed perfectly normal to me.
Once back at the department or clinic I work away on one project or another. As the afternoon wears on the skies begin to darken. Usually, around 4 pm, the wind picks up and I hear thunder. It will start raining in about 10 minutes. I continue working until the rain has passed. Today there was half-inch hail mixed in with the rain, which plinked off the metal clinic roof.
For the last couple of days we have enjoyed the company of a visiting optometrist from Ghana, Dr. Angela Amedo. She helped us out with oral qualifying examinations, a right of passage for fourth year students. We spent all day Wednesday as a panel, quizzing the students, one by one, on all things optometry. Drs. Okenwa-Vincent and Donkor, in conjunction with the Brien Holden Vision Institute, have been taking every opportunity to tighten the standards, make the program more rigorous. They have worked tirelessly to increase the quality of instruction and clinical experience, and their work has been nothing short of heroic.
Having said that, currently, the level of optometric knowledge and skill is still fairly basic. For example, while the students attend lectures and gain book knowledge, the clinic volume is very low, between zero to five patients a day. In fact, and more importantly, the clinic construction and outfitting was just completed in July of this year. It has 9 rooms, 8 functioning lanes with instruments. We still don’t have any frames on the frame board or a way to grind lenses. An optometry clinic without a way to fabricate spectacles is like a pharmacy without medicine. As a result, the students have little experience with actual patients. There is something called “attachment” where the students spend time in optometry offices and ophthalmology clinics around the country, but the quality of the experience varies greatly.
The Masinde Muliro University of Science and Technology (MMUST) offers a four year Bachelor’s of Optometry degree and has over 120 students in the program. Despite all of the challenges I have mentioned, this institution offers the highest quality optometry program in Kenya and the Eastern Africa region. I will be the third faculty member, and responsible for teaching, clinic duties, and mentoring Jr. faculty from Kenya that have recently graduated. We are encouraging and mentoring the Kenyan faculty to obtain a higher degree so that they can run their own department in the coming years.
Another important factor is that optometry is not regulated in Kenya. Anyone can open and optician or optometry office. All they would need is some money to buy an autorefractor, some frames, lens blanks and an edger. You see places advertising “Computerized Eye Exams,” and that means using an autorefractor to determine the needed prescription, then making and dispensing spectacles. As a result, whether the student graduates or not, does well or not, they can still open an office. MMUST offers a bachelor’s degree program so they should not call themselves a doctor of optometry, but many do. Even if they do not finish the program, the student will have had much more experience than most. You can imagine, as the head of the department, trying to reign in 30 students per class, many exhibiting the normal arrogance of youth. The head, or faculty member, has very little real influence over the students. If Dr. Okenwa-Vincent, in consultation with Dr. Donkor, decides to fail a student, what real consequence will that have, except for enraging the parents who spent a lot of money to send their child to the University?
Having said that, Kenyans in general show the great respect towards educational systems. The students, for the most part, want to study and do well. The overwhelming majority want to become competent optometrists. The students who work hard often get the best jobs in hospitals, clinics, or working with an ophthalmologist.
For those of you reading this who are not optometrists, it might be helpful to mention the role of optometry and how the profession has developed. Opticians make glasses, and are good at what they do, but have limited knowledge of optics and the human visual system. Say, a hundred years ago, when it became possible to reliably polish glass and put the lenses into metal spectacle frames, opticians had very little idea on how to match the spectacles to the patient. Imagine a table in an open air market or small jewelry shop offering a variety of spectacles. People would try them on, take a look around. If they seemed to help, they paid the requested fee and walked away.
Ophthalmologists specialize in medicine and surgical treatment of eye disease. Many, and there are clear exceptions to this statement, have limited knowledge of optics and vision. They are highly trained, so there are relatively few ophthalmologists. Access to care, especially in rural areas, can be an important limitation.
Optometry has developed to fill a need, an important role in today’s society where vision is so crucial for optimal function. We are primary eye care practitioners, and can handle the majority of the common and routine ocular and visual conditions. We help to educate and prevent eye problems, such as recommending sun protection to prevent cataracts. We can recommend spectacles, fit contact lenses, treat the majority of red and irritated eyes, and remove superficial corneal foreign bodies. Optometrists are trained in providing magnifiers and other optical aids to people with visual impairments, an area we call low vision.
I have no doubt that optometry in Kenya, and the rest of the developing world, will progress as it has in Britain, India, Asia, most of Europe, and the United States. The need has already been recognized, that is why optometry is here. The quality of education will continue to increase. Within the next decade, optometry will be regulated in Kenya as it is currently with medicine and dentistry. It is just a matter of time. The generation that we are training now are the pioneers of Kenyan optometry, and optometry in Africa in general.
As I have settled into my routine here in Kakamega, Kenya, there has been one overlying issue that has not been resolved. Concerning the job appointment, we have run into an important administrative issue. While I have my official transcripts from the University of California, Berkeley that verify my educational credentials, MMUST and the Kenyan government do not recognize transcripts. I do not know why. As I mentioned, they do not recognize optometry licensure in Kenya, so the hard copy of my Arizona license to practice optometry was not recognized. While my colleagues and coworkers know me and know my work, Kenyan government and university officials do not.
I have been informed they will only accept hard copies of my optometry and doctorate diplomas, and I did not bring those. To make matters worse, I seem to have lost them. I know that might sound odd to many, but as I progressed through the educational system there were many moves, many boxes to pack and unpack, and timetables to keep. For example, I finished the Ph.D. at UC Berkeley on December 21, 2001, and my diploma was not ready. I moved to Tucson over the holidays, and started work at the University of Arizona on January 4, 2002. I provided the University with an official, stamped and signed piece of paper that stated I had finished the requirements for my degree. They accepted that as proof, and I went to work. That was over thirteen years ago. My friend Carl Jacobsen, O.D., who lives in Berkeley is currently checking to see, if by some miracle, they have my diploma sitting an a file somewhere. If not, the Ph.D. diploma and O.D. diploma will have to be ordered and signed and that takes a couple months.
In the meantime, I cannot be hired here at MMUST, and cannot be paid. Working without a work permit in Kenya is a serious offense, punishable by fine or even jail time. Interestingly, this administrative snafu has opened up an opportunity for me. Kesi Naidoo, from the Brien Holden Vision Institute (BHVI), has arranged a 4 week teaching tour including visits to Malawi, Tanzania, and South Africa to give lectures and an practical training sessions on slit lamp examination and ophthalmoscopy. The BHVI accepted my proof of academic credentials long ago and will be able to pay me a portion of the income stream. I will leave in a week for one of those places, then visit Tucson for a few days to visit friends and take steps to getting the paperwork issue cleared up. There is another issue that has arisen with my mortgage. It seems my mortgage company sold the mortgage to another company and the details of monthly payment need to be worked out. It will be best done from Tucson.
After the Tucson visit I will head to the American Academy of Optometry and Volunteer Optometric Services to Humanity (VOSH) meetings in New Orleans, where I will obtain valuable continuing education credits to maintain my license, as well as see friends and colleagues. Then there will be the long flight back to Nairobi, followed by a continuation of the teaching tour to the remaining two African countries. This means that you, the readers, will have plenty of adventures to follow over the next month or so, provided I have the time to write. And I will make the time.