Thank you to all of you who have continued to support our work through the years. As we are both currently working through residency, John in family medicine at Duke and Kevin in pediatrics at The Children's Hospital Denver, we encourage you to support the work of Kageno and Partners in Health in Kenya and Rwanda. Please see links to the right for more information about these two organizations. As always, if you are interested in becoming more active in the areas where we have worked, please send us an email and we would love to talk, email@example.com and firstname.lastname@example.org
The only health care available in Banda is “The Strategy,” a 2-room outpatient health clinic. It is staffed by one nurse on rotation for two months at a time from the local health center. The office is only open weekdays, often for morning half-days only. There is no emergency health care available after hours.
Services offered are minimal. Vaccinations are brought monthly from the health center, and there are antibiotics for treatment of minor infections. There are no maternity services offered. The medication supply (pictured above) is minimal and unreliable.
The Strategy has a poor reputation amongst the community, and with good reason. It is understaffed, undersupplied, and has insufficient hours. The nearest “referral center” is a 2 hour walk from Banda to the district health center. Pregnant women often make this hilly walk while in labor, only to find that there are no services available to manage a complicated pregnancy. The only choice for at risk or complicated deliveries is to continue the walk 4 more hours (6 hours total) to the district hospital.
During my month in Banda, 2 young children (that I knew of) died in the village, both complications of childbirth that would be easily treatable at a hospital. I would estimate that an average of 20-40 lives per year would be saved by the presence of an ambulance in Banda.
Kageno has built a beautiful new clinic and pharmacy for the Banda community. The facility houses 3 examination rooms, a laboratory and sterilization room, pharmacy and insurance office, as well as medical offices.
Throughout the month, we met with local officials, referral centers and partners to help in the creation of an operating model for the clinic. We gained approval from the government to be run as a Poste De Sante, which will allow us to accept the government Mutuelle De Sante Health Insurance. For the equivalent of 2 dollars per year, a person is covered for their clinic and hospital visits, as well as medications. They need only to pay 10% of medication costs and a minimal fee for inpatient stays. The hope is that this system will allow access to the clinic for all members of the Banda village. In addition, the community has a program enlisting those in extreme poverty on Mutuelle through a social welfare program, extending this service to those most in need. The government will be providing nurses and laboratory staff for the hospital providing the baseline government services. In addition to this, Kageno has hired 3 motivated Community Health Workers to supplement the government services. These health workers will receive training through Partners in Health, and will provide community health education, home visits, and assist in the day to day running of the clinic.
In addition to the clinic, the clean water project and school feeding program seek to drastically improve the level of health and quality of life in Banda. Thanks to your support, large strides have been made towards this goal.
After living with our 'Rwandan family' for a week; eating meals, going to church, taking walks around the neighborhood, I got lulled into feeling that life in Rwanda was "back to normal" after the genoside. But a few words was all it took to instantly be shocked out of this illusion.
After a night celebrating the birthday of a fellow volunteer over pizza with our Rwandan family, we were feeling right at home, life as normal. As we drove back to the house, our Rwandan mother and father were talking. We asked what they were talking about. Very nonchalantly our mother mentioned "Oh we were just noting that this was the place we were stopped by a road block while fleeing to Congo from the genocide. They were checking ID's for ethnicity and taking the Tutsis to be killed. They checked the first five IDs, those of my husband and children, which were all Hutu. Just before flipping to the next one, mine, which is Tutsi, the man said 'That's enough' and let us pass. God was with us that day."
Life as normal driving home from pizza quickly changed to life that can never be normal. I can't imagine trying to live a normal life when every time I look around my neighborhood I recall flashes of immensely painful memories.
Another normal night, another family dinner, this time at home... normal conversation, casual questions, "When will you come back to visit us?", casual replies, "We'd love come back as soon as we can." Normal dinner, normal conversation. "Well we think within 2 years the rebels will come back across the border, so you better come back soon..."
Normal life shattered once again. The constant fear of renewed war... The persistent worries of rebels grouping outside neighboring borders storming back... The painful memories of her brothers and sisters murdered... her flight to Congo... her country torn apart.
The amazing people we have met here live as close as they can to a normal life. But in reality, life cannot be completely normal after living through the murder of a million of your fellow countrymen.
Erinne was born to two loving parents, Elize and Anastasia, who invited us to partake in the traditional ceremony welcoming their baby into the family and community. It was a joyous celebration, packed with friends, relatives, and neighbors. Cases of Coke and Fanta, plates filled with rice beans and potatos, and most importantly, jugs of urwagwa (locally produced banana beer) were passed amongst the crowd.
After the jugs made several rounds, the speeches began. One half of the room, the mother's side, addressed the other, the father's side, with thanks and gratitude; and gifts of urwagwa. The father's side answered with welcoming words. Each speech was greeted with rounds of clapping. Each speech ended with more gulps of urwagwa. Each speech got longer, louder, and more emotional.
Finally, long after dark, the celebration ended with a rousing song bringing everyone to their feet, clapping, dancing, stomping their feet to celebrate and welcome this new life to the family. Coming down from this rowdy celebration as we walked back through the pitch dark, we were abruptly detoured by a man approaching saying "Baby sick". We were taken to a small house near the road where a crowd was gathered inside. My heart, previously racing from the dancing and singing was now racing from the concern for this newborn struggling to breathe in this remote valley. When we arrived at the house, we were told that we were too late. The infant had already died.
We entered the house. It was strikingly similar to the ceremony we had just left: a room packed with the family's closest friends, relatives, and neighbors passing a jug of urwagwa around the crowd. The only difference was the painful somber looks on all of the faces glowing in the lantern light.
One new life, one unfortunate death. Both the joy and the pain shared amongst the community in a uniquely African manner. While Erinne will hopefully live a healthy and happy life, the poor nameless child unlucky enough to be born in a place with no access to basic health care will never have that chance.
After attending a beautiful church service, we were invited to attend the district's annual genocide memorial service. Each year the government designates a week dedicated to remembrance of the over 1 million killed in the 1994 genocide. Though the country has a week off of work, most people spend this time in quiet reflection around their homes. At the end of the week, all of the local towns gather for a public memorial service.
We walked nearly an hour to the nearest town, which was even more remote than Banda. Inside their local church gathered an overflow crowd of the surrounding villages. At the front of the ceremony was an impressive collection of local clergy from all of the local religions as well as local leaders. Heading the ceremony was a university educated man from Kigali, as part of the government program to lead the discussion.
The ceremony was much more than a remembrance; it was an interactive seminar, a thought-provoking discussion on how to make the post-genocide slogan of "Never Again" a reality. The moderator gave a history of genocide to educate the children who were too young to have lived through it. Then the community contributed to the discussion of the causes of genocidal ideology, and what can be done to move beyond genocide.
The theme throughout the discussion was to "remember and forgive" because "we are all Rwandans". The ceremony came to a powerful close as a young man orphaned by the genocide sung a stirring tribute to his family members who had been killed. This was followed by a woman who gathered a crowd of 7 people in front of her. "Can you tell who here is Tutsi and who is Hutu?" she asked the crown in Kinyarwandan. No one could. Then she asked those who had lost family members killed in the genocide to raise their hands. Four of the seven raised their hands. Next she asked those who had been released from prison after serving time for murder during the genocide. The other three raised their hands. They then stuck out their hands to each other and embraced.
Forgive and remember. I cannot imagine shaking the hand of someone who may have killed my family. But this powerful and effective ceremony demonstrated to me just how much must be done to move beyond genoside and revenge, and the proactive way the government and local communities have been addressing it.
Two years ago, John and I had the pleasure of visiting Banda village and helping with the initial community assessment. What we found was a very special village tucked into a beautiful valley bordering the Nyungwe Forest. The people were enthusiastic and embracing of the idea of an organization to assist them in development. We visited the future site of the Kageno project, trying to envision what this area would look like in 2 years.
Two years later, I drove down the valley to Banda to find some amazing advances made by the cooperation of Kageno and the community. The continued enthusiasm of the Banda people was evident as they gave me a tour of the new Kageno clean water project. A groundwater source of water is now piped to various cisterns throughout the community, eliminating the spread of parasites and waterborne disease.
The community boasted of the new roads built through community service during public works days. Troups of men and women could be found on any given day digging out roads to assist in the construction of future community projects. The plot of land we visited 2 years ago now housed a new clinic, pharmacy, and office building, with the foundation for a nursery school being created. Plans for a community center and ecotourism lodge to bring in tourists to the area for income generation were also touted by the local people.
In just 2 years, Kageno and Banda have made great strides. It was exciting for me to return and see the progress made since my last visit. I look forward to returning in 3 more years to see the Banda community thriving.
“Every [child] has the right to the highest attainable standard of health.”
“The right to health not only encompasses access to health care, but also the underlying determinants of health, such as safe water, adequate sanitation, a healthy environment, health-related information, and freedom from discrimination.”-UN Committee on Economic, Social and Cultural Rights, General Comment 14.
Key Objectives: Address all aspects of child mental and physical health and development Utilize local people and local resources for long-term sustainability Direct outside projects towards education and development, rather than short-term direct involvement in patient care Start with Kageno nursery school children and grow as Kageno grows to encompass older children, adults Initiate record-keeping system to monitor magnitude of problems, efficacy of interventions Provide orphans with the same access to resources as those children whose parents will ensure they have access Do whatever it takes
Model: Following the Partners In Health Model of doing “whatever it takes”, this initiative will seek to address all aspects of child mental and physical health and development through a primary, secondary, and tertiary prevention approach. Primary prevention involves providing conditions which promote wellbeing and prevent disease from ever being contracted. Secondary prevention involves screening and early detection of those at risk for disease to ensure proper early intervention before the disease advances. Tertiary prevention involves detecting those with disease and ensuring they have access to adequate treatment and care. This model not only works to prevent disease, but to promote well-being, encompassing the belief that “health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right” –Declaration of Alma-Ata.
The major issues facing the well-being of children in the Suba District of Kenya are outlined below with proposed interventions following this model.
Issues: I. Malnutrition: Adequate nutrition is essential to healthy physical and mental growth and development. In the Suba District, kwashiorkor (due to protein deficient diet) and marasmus (due to protein and calorie deficient diet) are rampant amongst children. Many children receive one or fewer meals per day, and this often consists of ugali or porridge, both of which are very low in protein and micronutrient content. Orphans are at particular risk for malnutrition, and families who take in multiple orphans have the increased stress of providing food for a large household. Without proper nutrition, these children may have stunted growth, abnormal brain development, and a weakened immune system leaving them susceptible to infection. Micronutrient deficiencies, including iron, vitamin A, and vitamin D can lead to anemia, blindness, and deficient bone development, respectively. In addition, hunger is a distraction to education in the many children struggling to pay attention to class with an empty stomach. a. Primary Prevention: i. Meals program: One hot meal per day is currently provided free of charge for all Kageno school children. The food is purchased locally or grown on site, and local women are employed for preparation. This meal needs to be protein and micronutrient rich, fortified with supplements if necessary. . ii. Vitamin A administration: Children will receive vitamin A supplements with their immunization schedule as outlined by WHO guidelines. iii. Nutrition Education: Teachers will provide parents with nutrition education on local sources of high protein foods: such as fish, beans, and lentils (which often have comparable price to ugali and porridge). Information on how to grow protein rich foods in home gardens will be provided. b. Secondary Prevention: i. Growth Charting: Teachers will chart the height and weight of each Kageno student 4 times a year on growth charts. They will be educated on how to identify children at risk for malnutrition. ii. Targeted feeding program: Those children identified as at risk for malnutrition will be assessed by the Kageno nurse and will receive a home visit by the runner, who will assess the family situation. Families who meet criteria will receive food support with nutritious staples, such as beans and lentils. iii. Orphan feeding program: Families who have taken in orphans will receive additional food support to ensure 3 nutritious meals per day to their family. c. Tertiary Prevention: i. Kwashiorkor/ Marasmus Treatment Plan: Those children assessed by the nurse to have a diagnosis of kwashiorkor or marasmus will be placed on specific diets to treat their malnutrition. They will receive increased calorie meals fortified with micronutrients and their progress will be followed weekly by the Kageno nurse.
II. Acute Diarrheal Disease: Diarrheal disease leading to dehydration is one of the leading causes of morbidity and mortality amongst children in the Suba district. Most children drink directly from Lake Victoria which is contaminated with human and animal waste. This leads to frequent bouts of diarrhea, as well as epidemics of diarrhea due to cholera and typhoid. Children are especially susceptible to dehydration from diarrhea, which can be easily treated through oral rehydration, or IV hydration, if severe. a. Primary Prevention: i. Access to Clean Drinking Water: Kageno provides clean, filtered drinking water to the local community free of charge. ii. Access to Latrines: Kageno provides sanitary latrines to decrease the spread of fecal-oral microbes contributing to diarrhea. iii. Health Education: Teachers will incorporate lessons on hygiene, water sanitation, and latrine use to school-age children. Teachers will also provide health education to parents on clean water, recognition of diarrhea and treatment with oral rehydration. b. Secondary Prevention: i. Identification of Students with Diarrhea: Teachers will be educated on recognizing signs of dehydration and symptoms of diarrhea. They will identify those students with active diarrhea for ORT, and those with dehydration will be referred to the Kageno nurse for evaluation. ii. Oral Rehydration Therapy: Oral rehydration packets will be available at the school as well as the clinic. Children identified to be having diarrheal symptoms and/or mild dehydration will be sent home with ORT packets and instructions for use. c. Tertiary Prevention i. Referral for IV Hydration: Those students determined to be moderately to severely dehydrated will be transported to Mbita Health Center to receive IV fluids. ii. Reporting of Cholera Outbreaks: During outbreaks of acute diarrhea, the nurse will be responsible for reporting the epidemic to local health officials for early intervention.
III. Parasitic Infection: Parasitic infections, such as schistosomiasis, amoebaeiasis, giardiasis, and intestinal worms, are endemic to the Lake Victoria Region. They are most commonly contracted through fecal-oral spread, through soil-foot transmission, or undercooked food. Due to the drinking of water directly from the lake, which is known to be contaminated with schistosoma, amoeba, and giardia, many children are chronically infected with these parasites. Most children walk barefoot over the beaches contaminated with human and animal waste, leading to chronic infections with soil-transmitted helminthes. These infections are a major cause of malnutrition, and can cause a variety of other health effects including bloody diarrhea, bladder cancer, and organ failure. a. Primary Prevention: i. De-worming and Schistosomiasis Prophylaxis: Per WHO guidelines, students will receive prophylactic albendazole and praziquantel twice per year. This will be distributed by teachers according to dosing height poles. ii. Provision of Shoes: Each Kageno student will receive a pair of locally made akala shoes to prevent the transmission of soil transmitted helminthes. iii. Clean Water and Latrines: As described above iv. Health Education: Teachers will provide health education to students on hygiene, clean water, and latrines. b. Secondary Prevention: i. Identifying Students with Parasitic Infections: Teachers will receive education on the signs and symptoms of parasitic infections. They will refer identified students to the Kageno nurse. In addition, the growth charting will identify students with malnutrition due to parasitic infection. c. Tertiary Prevention: i. Anti-parasitic Treatment: The Kageno nurse will conduct stool or urine studies on those students with symptoms of parasitic infection. Anti-parasitic medication will be provided and the student will be followed until asymptomatic.
IV. Malaria: The Lake Victoria region has one of the highest incidences of malaria in the world. Mosquitoes active only during the night transmit the disease from person to person, therefore children not sleeping under nets are at high risk of contracting the disease. It is not uncommon for people in the Lake Victoria area to contract malaria more than once per month. While most adults recover after several days of fever, malaria is a leading cause of death in children. Children are susceptible to cerebral malaria, a condition that can lead to convulsions, coma, and death. In addition, malaria leads to school absence and fatigue from anemia. a. Primary Prevention i. Mosquito Nets: Insecticide treated mosquito nets will be distributed to each Kageno student. Instructions will be given on its use to parents. ii. Health Education: Parents will be educated on recognizing the signs and symptoms of malaria, and to bring their children to the Kageno clinic whenever they are febrile. b. Secondary Prevention i. Identification of Febrile Children: Teachers will identify all febrile children and refer them to the Kageno nurse for evaluation. All students absent from school for more than one day will receive a home visit from the runner, who will ensure that children missing school for illness will receive proper treatment at an early stage. c. Tertiary Prevention i. Anti-malarial Treatment: The Kageno nurse will evaluate all febrile children and provide Coartem for those suspected of having malaria. The children will be examined for anemia and receive iron supplements if needed. The runner will do a home visit to ensure the child is sleeping under an insecticide treated mosquito net. ii. Referral of Advanced Disease: Those children with symptoms of advanced malaria will receive transportation to the Mbita Health Center for IV treatment and supportive therapy.
V. HIV: The Suba District of Kenya has an HIV prevalence of over 40%, one of the highest in Kenya and all of East Africa. The migratory nature of workers in the fishing industry and the practices of jaboya, or fish-for-sex trade, contribute greatly to the spread of HIV in this area. Local cultural practices of polygamy and wife inheritance are likewise contributors. Women and children share the most difficult plight, often orphaned or widowed by HIV, with no way to financially support themselves. Prenatal care is lacking, leading to preventable transmission of HIV from mother to child. In the cases where transmission to the child has been prevented during birth, HIV is often spread perinatally through breastfeeding, due to the lack of available infant formula. Few children are ever tested for HIV and therefore most HIV positive children are undiagnosed and untreated. a. Primary Prevention i. Mother to Child Transmission: Kageno VCT provides HIV testing for all expectant mothers and can refer HIV positive mothers. Prevention of mother to child transmission (PMTCT) programs are conducted by IMC Suba, which provides counseling and treatment. ii. Health Education: Teachers will provide age-appropriate HIV education to students, stressing prevention and stigma-breaking activities. b. Secondary Prevention i. Identification and Testing of At-Risk Children: Children with parents who have died at a young age or have disclosed their HIV positive status will be tested for HIV at the Kageno VCT, with permission from their guardians. ii. Provision of formula to HIV positive mothers: Infant formula will be provided free of charge to all HIV positive women for the duration of infancy. Women can access this resource through the Kageno HIV support groups or VCT office. c. Tertiary Prevention i. HIV treatment: HIV positive children will be referred to the FACES Mbita office which provides anti-retroviral treatment and opportunistic infection treatment. Transportation will be provided by Kageno and oversight of care will be performed by the Kageno nurse.
VI. Tuberculosis: Tuberculosis is one of the most common opportunistic infections associated with HIV. It is transmitted through the coughing of respiratory droplets, and most readily spread when people are living in cramped one room living quarters, such as the majority of residences in the Suba District. Tuberculosis primarily affects the lungs and causes wasting, however it can manifest as involvement of nearly any organ system. Children, especially of TB positive parents, are very susceptible to TB. Treatment involves long-term multi-drug therapy, but is very effective at eradicating the disease and preventing transmission. a. Primary Prevention i. Treatment of Affected Parents: TB education will be provided to parents of Kageno students. They will be educated on signs and symptoms and informed of the treatment available through the IMC Mbita office TB program. b. Secondary Prevention i. Home Modification for Children of Parents with Active TB: The runner will help coordinate home modification to separate rooms in those homes of parents with active TB. ii. Prophylactic Treatment of Children with High-Risk TB Exposure: The Kageno nurse will provide isoniazid prophylactic therapy in children with in-home exposure to someone with active TB. iii. TB testing in High-Risk Children: Children with in-home TB exposure, or signs and symptoms of TB infection will receive transportation to Sindu for chest X-ray and AFB testing. c. Tertiary Prevention i. Treatment of Children with Active TB: Children with active TB will receive directly observed therapy (DOTS) through the Kageno nurse, who will receive medications from IMC Suba.
VII. Immunizable Diseases: In the Suba District, outbreaks of immunizable diseases, such as measles, are frequent. Immunizations are provided by the government, however many children on the islands of Lake Victoria are not reached by these efforts. Recordkeeping is poor, and participation is voluntary, with no effort made to track down unimmunized children. a. Primary Prevention i. Immunization of 100% of Children: Vaccinations provided by the government will be administered by the Kageno nurse to all Kageno students. The following vaccines will be administered: polio, measles, mumps, rubella, diphtheria, pertussis, tetatanus, BCG, HPV, hepatitis B, hepatitis C, HIB, pneumococcus, rotavirus ii. Recordkeeping: Kageno records will be kept in addition to the government records held by families, to provide a permanent reliable source of information on Kageno student vaccinations. b. Secondary Prevention i. Identification of Unimmunized Children in the Community: The runner will be responsible for going door-to-door throughout the community and ensuring that 100% of the children are up to date on their immunizations. This will help to provide herd immunity to the children in the community. c. Tertiary Prevention i. Treatment of Immunizable Disease: Students with signs and symptoms of immunizable disease will be referred to the nurse for medication and vaccination. Appropriate isolation measures will be taken and cases will be recorded. ii. Reporting of Local Outbreaks: The Kageno Nurse will be responsible for reporting local outbreaks of immunizable disease to local health officials to ensure early intervention.
Personnel: Kageno Teachers: Provide health education to students and parents. Track student growth charts, identify students at risk for malnutrition and disease, and refer these students to the Kageno nurse. Kageno nurse: Diagnose and treat students referred from teachers for malnutrition and disease. Monitor students referred to outside organizations for treatment. Oversee vaccination program. Runner: Track students missing from school. Door-to-door monitoring of immunizations. Home visits for at risk patients. Oversee home remodeling TB program. Transport children to referral centers.
Forums: Student Health Day: deworming, schistosomiasis treatment, height and weight charting, vaccinations, distribution of nets, shoes. Educational Curriculum: incorporate age-appropriate health education into daily curriculum Parent’s Day: health education provided for parents by teachers. Home Visits: conducted by runner to homes of at risk students. Door to door monitoring of immunization status. Kageno Clinic: Kageno nurse provides individualized care of students referred Partner Sites: FACES (Family Aids Care and Education Services) provides anti-retroviral therapy, IMC (International Medical Corps) provides prevention of mother to child transmission program, TB DOTS program.
Our friend Benson led us through the entrance of his family's traditional thatch and mud two-room hut where his brother lay dead on the floor. His cachectic body was simply dressed in plain clothes with a bandana tied around his mouth. There was no fancy coffin, no funeral home, no bouquets of flowers, no music, just a silence broken only by the heart-wrenching traditional wailing of his sister knelt at his side.
He was the third of Benson's brothers to die before their mid-30s. As with the other brothers, his body was consumed by tuberculosis, likely spread through cramped one-room living conditions and complicated by HIV. He was receiving anti-TB treatment, but was unable to reach the nearest medical center when complications arose, due to financial reasons. Instead of receiving available and effective treatment, he died silently in his home one night.
His case is not unique. Upon leaving the funeral we crossed paths with a local nurse who was on her way to the same funeral. When we asked where she was coming from, she told us she was coming from another funeral of a young man who died of HIV in the neighboring village. Throughout these islands, one could march from funeral to funeral of young people silently passing from the epidemic of HIV and TB destroying this area.
Over the past 5 months in Kenya, we've met some of the biggest Detroit sport's fans in the world... they just don't know it yet. We've encountered a fisherman on a remote island in Lake Victoria decked out in a Stevie Yzerman Red Wings jersey, a baby admitted to the hospital with malaria still proudly donning her Tigers jersey, and even an elderly man in the slums of Nairobi showing off a vintage 1984 World Series jacket complete with the name "Dorothy" embroidered on the front. Being fellow Detroit sports fanatics, we get extremely excited when we encounter any display of Detroit sports-gear. We'll run up to these folks and enthusiastically explain that Detroit is our hometown, and that we're so thrilled to meet fellow fans. However, the reply is always the same: a blank confused look and "No sorry, this is just a shirt (jacket, etc)." Although they may be merely wearing second-hand clothes to serve a purpose without understanding their significance, we know in our Detroit-heart-of-hearts that deep-down they really are Detroit sports fans... they just don't know it yet.
Despite this immense Detroit following in Kenya, we've had more than a heck of a time trying to catch a Detroit Tigers playoff game in an area where there is no running water, let alone electricity and you can count the number of TVs in town on one hand, let alone those with satellite connection for the MLB playoffs. That's not to say that we haven't been trying...
After asking all around town if anyone carried the baseball games and hearing the reply, "What is baseball? Is it like football (soccer, the only "real" sport according to the people here)?", we had our first stroke of luck at, of all places, a campsite on Lake Naivasha. We were astonished to find a television connected to satellite TV with the MLB playoffs on the schedule for 4 am. We begged and pleaded with the Masai guard to open the bar and turn on the TV in the middle of the night, which was successful after we explained, "watching the Tigers in the playoffs is like watching Kenya in the finals of the World Cup". We awoke at 4 am from our tent, walked past a pod of hippos, and popped on the TV expecting our first glimpse of the Tigers in the playoffs since our childhood. Instead what we found was a group of announcers at the sportsdesk announcing that this evening's game between the Tigers and Yankees was cancelled due to rain. What luck!... but we were not yet defeated.
Over the next 2 series, we struggled on the islands of Lake Victoria without access to any TV, but kept up with the action via text messages over the cellular phone. We would excitedly jump from bed in the middle of the night to find that the Tigers had taken a lead in the first, or had gone to extra innings, or that Mags had hit a game-winning home run. Though this kept us up-to-date on the scores, it couldn't replace actually seeing our Tig's take the field.
Our big break came as we were hiking beach to beach living in fishing villages. Between villages we came upon the sole exclusive tourist resort on the island, run by a British character, whom we have come to know over our stay here. He generously offered for us to crash at the resort for the night for a break. We seized the opportunity and quickly went to work feeding him drink after drink, until he agreed to stay up until 3 in the morning with us to watch the Tigers on his private satellite TV in his house. Needless to say the British chap passed out before the game started mumbling something about "this game is nothing but rounders", and we were left to finally watch our Detroit Tigers in Game 1 of the World Series.
Seeing the men in the Old English 'D' take the field sent shivers down the spine, and watching Comerica Park come alive in a way that Detroit has not seen since 1984 was something truly special. For that brief moment, we were able to forget where we were in the middle of Lake Victoria in Kenya, suspend the intense emotions that we've had to deal with over the past months in working in this impoverished, HIV-prevalent area, and experience a surge of pride and excitement in seeing our hometeam represent our hometown in the center of the world stage. We intently watched the first 3 innings, savoring every pitch as we had worked for weeks to have this opportunity, when the generator power cut out and we were left in darkness. While we didn't have the chance to see a whole game, the chance to catch a glimpse of Detroit Tigers baseball in the middle of rural Kenya was something we'll never forget.
Although we were unable to catch any more games and have received the sad news that the Tigers were defeated, we want to thank the Tigers for the amazing 2006 season. Their efforts were seen and felt literally around the world. From unifying a city ridden with auto-industry lay-offs and tough economic times, to providing those of us away from our Michigan home a chance to escape our situation and join our friends and family rooting on our Tigers, this team has made us all proud! BLESS YOU BOYS!
As we set off to hike Mount Kilimanjaro this week, we will proudly wear our Detroit Tigers' gear and hoist the Detroit foam finger (which, of course, we packed in our luggage 5 months ago) from high atop Africa.
If you have 15 minutes, please take a look at this film documentary on the situation in fishing villages along Lake Victoria. It was filmed in the Bondo district, next to the Suba district where we are working. The situation in the islands is very similar, if not more disturbing, due to their isolation. The website for the film is http://www.irinnews.org/film/ , scroll halfway down the page to the film titled "DEADLY CATCH". Let us know what you think...
Before living on the islands we had known that commercial sex was a problem on the islands leading to the spread of HIV. However, commercial sex to us meant a few prostitutes in the local bar selling sex for extra cash to the fisherman who could afford it. What we have come to understand through living in these areas and hearing the stories of those who live there, is that the exchange of sex is not an isolated practice, but a system which the fishing society revolves around.
The system, locally called "jaboya," involves the trade of a sexual relationship for the ability to obtain fish for sale. The men catch the fish, and women sell the fish locally, where others are sent for export. In order for a woman to obtain fish to sell locally, she must have a relationship with a fisherman. Without a boyfriend, a woman has little chance of having access to fish when the boats come in. The more relationships she has, the more likely she is to be able to obtain fish. If the woman wants to transport her fish to local markets aboard matatus, she often is forced to once again exchange sex with the "tauts" (or men who load the roofs of the trucks) in order to get their fish transported.
It is difficult to describe, but this is a system that goes much deeper than standard prostitution. Indeed, there are still "bar-girls" or commercial sex workers in the bars in these areas. However, the jaboya system is a social and economic system that pervades every aspect of these societies. The jaboya women are forced into having multiple sexual relationships with migrant fisherman and tauts in order to provide what is necessary for them and their children to survive. Often they are women widowed by HIV positive fisherman who have no other way of providing for their families.
In order for change to be made in this area, the structural violence of the jaboya system must be broken. An effective intervention must address the fishing industry, poverty, as well as the medical aspects of HIV.
When the sun goes down on fishing islands like Remba and Ringiti, fisherman back form a hard day of work resort to the nightly activities of drinking and sex. If the catch is big, the local bar is roaring with drunks and the hotel rooms are all full. Reading and being told about the practices that lead to the spread of HIV in these areas is one thing, hearing it bang against the tin wall alongside your bed is another.
For the past few weeks, we have been living the lives of migrant fisherman, traveling island to island. We have been eating what the fisherfolk eat, bathing where the fisherfolk bathe, and sleeping where fisherfolk sleep. Our lodging has been in the tin "hotels" that are the center of the prostitution practices on the islands. (The last we stayed in was called the "Usisime Guest House", translated "Don't-talk-about-it Guest House".) The rooms are little more than a tin box with a bed, and come with one candle, the source of light that lasts as long as most of the activities undertaken in these rooms. Rates are ~75-100KSh/ night (a little over 1 dollar), or they can be rented out for the "short-term" in hourly intervals. Each night, nearly all of the rooms surrounding ours are filled with fisherman and the women that are exchanging sex for fish with them, or prostitutes from the bar. Walking out of our room after one of our first nights in one of these hotels, we were torn between being disgusted by the used condom left in the hallway, and being pleased that at least one was used.
Our clinics providing sexually transmitted disease treatment and anti-retroviral therapy are often held in the same location that the disease was likely transmitted in the first place. We rent either the hotel rooms described above or partition the local bar into patient rooms and treatment areas. After seeing a steady flow of patients all day, we are often left no other option (as there is none available in town), but to sleep in the same room that we have been seeing patients all day. Picture your doctor treating ill patients all day on the same table, then deciding to curl up on that table and sleep for the night-- that will give you a good idea of how we've been living.
The islands have no source of clean water, leaving most to drink water straight from the lake (although we rely on bottled water). As there are no public latrines, you must walk to the end of the island away from homes to relieve yourself. When the rains come and wash the rocky island clean, cholera and waterbourne diseases run rampant as this waste trickles down to the source of drinking water. This also makes bathing tricky, as the water you are to bathe in is likely dirtier than you are in the first place. We have been forced to do our best to find a "clean" point of the island, scrub up, and swim out into Lake Victoria. Food is severd in one "restaurant" in town, which often has a long menu posted upon the wall. However, after ordering you quickly learn that the only available options are fried fish, boiled fish, or fish stew.
The experience of eating, sleeping, drinking, and bathing as migrant fisherfolk for the past few weeks has allowed us to enter into the lives of the population we have been working with. We have seen and heard firsthand the practices that contribute to HIV in these areas. Most of all, the undeniable link between poverty and the spread of disease has been cemented into our consciousness.
We knew we needed to head back to the islands of Lake Victoria after being very frustrated with the limited accessibility to health care for patients who were obviously stricken with HIV/AIDS during the mobile clinics with Operation Crossroads Africa. We wanted to work more on the public health level of the beaches to increase the HIV prevention and education efforts being done in the islands.
With the International Medical Corps, (IMC) we have been given the chance to get back the beaches where we ran mobile clinics in June and July. IMC has started a Condom and Other Preventions Effort, to reach beaches that have not been previously reached by any kind of HIV education or treatment outreach effort. It is our hope to pair these beaches with other organizations that are doing Voluntary Counseling and Testing (VCT), so that they can receive Antiretroviral treatment, (by groups such as FACES) in the future. Branches of IMC currently do mobile VCT in the lake region as well as mobile efforts to curb Pregnant Mother To Child Transmission (PMTCT). IMC Home Based Care services are beginning in Suba District as well, so that families can be counseled and tested in the comfort of their own home.
As part of the IMC Beaches Program, we initially meet with the Beach Management Unit (BMU), the local system of government for each beach. This is the point of access to each of the 12 beaches in the pilot program we are running. With their approval, we can enter the beach and ask different groups such as fishermen, fishmongers, teachers, youths, shopkeepers, and bar owners what they feel are the main contributing factors to HIV on their beach specifically, and how we can best work to solve those problems.
It is the individual interviews with different segments of the population that best help to elucidate the problems of HIV on the beach level. We take individuals aside to question them on the main issues facing their particular segment of the beach community, and we are continually struck by the responses that we get.
I spoke with a man named Michael on Remba, who was 35 years old and had completed his highschooling in Kisii. He had worked for Glaxo Smith Kline in Nairobi for a short time as a salesman. After his contract expired, he returned to the beach communities to fish, an opportunity that had its own droughts, but rarely led to unemployment. Michael noted that, "when a fisherman gets his money after a catch, before he thinks of his stomach, he thinks of a woman." There is the desire of immediate gratification on these islands with little hope for the future.
Okayofred, a 25 year old male from Milundu beach on Mfangano told me about growing up with 17 friends his same age. Now he is the only one left. "People want to give it (HIV/AIDS) to others" he said, "so that they don't have die by themselves."
When I asked Johnson, a teacher on Mfangano Island, what he thought were the main factors in the community contributing to HIV/AIDS, he thought for awhile and then responded with, “Well...the biggest factor is poverty.” His hesitation at an immediate response, and thoughtfulness showed how poverty was truly the major contributing factor to HIV was in the beach community. Lack of education, lack of access to health care, the fish for sex trade; it all comes down to poverty in the area.
On Remba Island, a woman stuck her head out of her small shop, as we passed by with luggage and medical supplies on the way to the boat, heading to the next island. "Are you coming back...? We'll be here dying...", she said. All we could answer was "yes." Then the sinking feeling began to set in.
We have since come back to the islands after that initial stage of preparation for further HIV training and condom distribution. Over October 7th, 8th and 9th, groups of nearly 40 beach leaders got together in at Ringiti, Sena beach on Mfangano and Luanda Rombo beach on Rusinga, respectively. The purpose of these meetings was to set up an HIV/AIDS Subcommittee so that locally, the beach could coordinate efforts between the Ministry of Health and other NGOs as well as oversee the condom distribution, HIV education, and health services offered by IMC on their beach. The most fruitful portion of the meetings turned out to be having the groups of women, fishermen, youths, and Beach Management Units (BMUs) work together to come up with the specific successes of their beach community, the problems they still face, and how to go about specifically reaching their group with HIV education. We realized that this kind of joint meeting between beaches for the sole purpose of exchanging ideas on how to best combat HIV had probably not been done before. We found that as groups were able to discuss the problems of the beach community leading to HIV such as Jaboya, the “fish for sex” trade, they could formulate reasonable solutions locally.
Still, we will be leaving the islands of Lake Victoria, Mbita, Suba District and the rest of Kenya in early December, and we don’t always know how to answer the question, “are you coming back…?”
Instructions: Take water, molasses, and cornmeal; add to 5-liter bucket with lid. Secure lid and wait 36-40 hours. Then take your pick; either drink the liquid straight as a porridge or distill it to the point where the fumes from your drink will make the tin shack walls around you rust and crumble.
This is chang’aa, the moonshine of Kenya. Typically a beverage taken by village elders when sitting around and telling stories of the old days, chang’aa is also a very cheap and very potent beverage of choice for many fishermen on the beach.
We have never tried the stuff for fear of immediately going blind, but there are many people around here who drink it daily. There is no sense of savings or planning for the future in the beach community, so after a bountiful catch, the bars and hotels are full with men spending their recent earnings on chang’aa, until the money is all gone. Two days in a row on Rusinga Island we attempted to have a meeting with the Beach Management Unit (BMU); the integral government channel for access to the beach. Two days in a row we evidently interrupted the early morning chang’aa session, and encountered most of the BMU to be drunk.
We met with the Secretary of the BMU, to discuss the future plans for setting up an HIV/AIDS Subcommittee as part of their local government, so that future prevention and treatment efforts could reach the beach. While able to speak English, Chang’aa English was what the Secretary of the BMU was fluent in that day. A series of unintelligible slurred phrases came out, with “America,” “mzungu” (white man), and a little saying about he and his wife’s nightly activities--that isn’t fit for anyone to read--being the majority of the intelligible phrases. We were later told by this man that by merely educating people about HIV/AIDS at the beach level, “the program is going to fail, because you aren’t putting money in anyone’s pocket.” This is someone in a position of leadership in the beach community, and one of the few that speaks English. He could be greatly influencing the health of his community, yet his mind cares more for the chang’aa in his cup.
There seems to be more patience here for public drunkenness than there is in the States, but there is no tolerance for men drunk on chang’aa who harass the mzungus on the beach. We are watched over in the communities with a great deal of respect, and are either led through the maze of tin shacks or are consistently pointed in the right direction. When staggering men approach us with bloodshot eyes, we know its only a matter of time before they are thoroughly disposed of by one of their peers on the beach. The man in the photograph, above, got himself into two fights in one day by persistently approaching us, claiming in a mix of broken English and Swahili to be a long-lost friend.
Yet tomorrow, after another catch, he’ll probably have his glass raised high, asking for another round of chang’aa.
When people are constantly surrounded by atrocious living conditions it may be human nature--as some sort of survival instinct--to mentally wall oneself off, so that you are not continually exhausted by what you are experiencing. People are often able to resist the realities around them, and only when those realities are observed in a different form--be it films, photographs, or other media--are people able to truly comprehend a dreadful situation.
Videos, such as Deadly Catch (see link) or others that I have seen about certain areas of Kenya have always made the day to day experience around here powerfully tangible. When you can watch it on the screen, and then take a step outside and see the same fishing boats, the same women exchanging fish for sex, the same patients being carried from their car to the health center, and back to the car again, it really makes you take the situation to heart and realize where you are.
On Remba and Ringiti, a theatre group of trained community health workers uses drama as this conversion of reality to demonstrate topics related to HIV affecting the beach community. We watched two performances by residents of these islands that covered topics such as; the promiscuous nature of life in the islands, wife inheritance, going to a Voluntary Counseling and Testing Center (VCT), finding out about a positive HIV test result, becoming ill and haggard as a result of the disease, and confronting family members about one’s status.
The performances drew a large audience of interested community members. By using humor to address a disease most people at the beach level still fear because of a lack of understanding, the performance achieved its goal to make people think about HIV and its treatment methods.
One skit in particular was about seeking different methods of treatment for someone whose promiscuity had led to her to become very sick with HIV, but had not been tested yet. In the skit, the actors went from a church, to a witchdoctor, and finally to a VCT for the confirmatory test. There was a big roar of laughter from the crowd after the actors supporting the ill “patient” left the witchdoctor (played by an actual witchdoctor from the community). His line was, “I'm a witchdoctor, I can’t do anything for these people…that woman evidently has AIDS, she needs real medicine. But I still got their money…hahaha!” By focusing on such topics of the local culture, these theatre groups not only solve the issue of idleness on the beach for a few hours each week, but also reach people personally in a way that makes them stop and understand the problems affecting their own community.
For every kilogram of fish that is caught in the lake, the County Council takes one shilling as taxation. In bandas that routinely catch over 10,000 kilos of fish, after a week’s time, this can amount to a sizable sum of money. In the beach communities, that money is supposed to return to the people in the form of latrines built by the county council, or other sanitation efforts. However, this is rarely done, and the money just gets pocketed. On Remba, there is only one public latrine specifically built by the council for the population of about 8000 people. Think about that the next time you are waiting in line at The Big House or Comerica Park for a little relief….In addition, the public latrine is usually locked, forcing people to either track down the councilman with the key, or relieve themselves wherever they see fit.
In every discussion that I had with someone regarding this sort of “taxation without sanitation,” I found that the people in these isolated islands have an overwhelming feeling of helplessness in regards to dealing with anyone from the government. Pair that notion with the transient lifestyle of everyone in these beach communities and their response becomes “well, it’s not really that bad, the government could tax us much worse." The people realize that they are lining the pockets of the County Council and District Commissioners, yet without a unifying voice, they feel utterly helpless in the situation. They know that they’ll be moving on to another beach shortly, so the feeling is, what's the sense of taking care of the area they are in?
The corruption goes far beyond the taxation without sanitation at the beach level. Matatus are only supposed to carry a certain amount of passengers, but when an overcrowded matatu comes to an “official” police check point there are a couple options available. There is either a handshake exchanged with a bit of cash inside or several bills are wadded up and nonchalantly dropped to the ground as “garbage,” which the officer disposes of in a plastic bag as soon as the matatu drives off.
We often head to work out in the beach communities on the back of a motorcycle, known locally as piki-piki. We were delayed one morning during the attempt to leave by the county councilman who chained up the motorcycles until the drivers paid their taxes. I inquired what the taxes were for, and the councilman replied that they were some sort of fee for standing or parking in the certain location. I asked what the drivers get in return for paying the tax, to which the councilman replied, “they will have a shade up by next month.” Two weeks have passed and no efforts have yet been made. The worst case I’ve heard of recently, is that to play soccer in a local field, children have been taxed by this same councilman.
The funniest or saddest one I’ve heard, depending on how you look at it, happened on the streets outside of Nairobi. A buddy of mine in Nairobi was telling me about a time he was stopped by a policeman who accused him of speeding and was asked to pay a fine right then and there or he would be thrown in jail. Tim laughed at the officer knowing how they often act, and said “show me your speed gun.” The officer replied “no,” to which Tim replied, “why, because it’s actually a hairdryer?” Tim had seen that the officer had been holding up a hairdryer, and requiring that people pay for going over medium-warm kilometers per hour.
Just a quick update... John and I have arrived back in Mbita, on the coast of Lake Victoria. We will be working on a project with the International Medical Corps which seeks to extend their HIV/AIDS program on the mainland to the islands. We will be taking weeklong excursions from island to island to start making contact with beach leaders and administer surveys on HIV attitudes and access to care. We may have a tough time getting good internet access, so pictures and updates may be coming slow over the next months. The best way to get a hold of us will be cell phone, and packages can still be sent through Nairobi (see below). Hope all is well with everyone.
With a week between projects, we came across an offer to be extras in a film being shot in Nairobi. The movie, a German film called Africa Mon Amore, is a World War 2 love story based in East Africa. We were outfitted in some goofy looking British civilian costumes, John's hair was chopped into a German bowl-cut, and we were given roles in a train and prison scene. Hopefully the spare change we raise this week will carry us through our work on Suba over the next 3 months.
(The highlight of the experience was definitely the moustache suitcase)...
On our road trip through Rwanda, we had the opportunity to visit the future site of the new Kageno project, the Banda community. After seeing the previous Kageno project and it's impact on Rusinga Island, we were excited to explore the future project at the ground stage.
The Banda community is nestled against the picturesque, untouched Nyungwe National Forest, home to an abundance of rare primates. At the bottom of a valley lies the small community with its farmlands terraced along the banks of the mountainside. This unique location provides Banda with a serene setting, however also contibutes to many of the community's problems due to isolation and difficult geography for agriculture.
The people of Banda were welcoming and eager to discuss the upcoming Kageno project. Community leaders discussed with us the 3 biggest issues facing their town: 1. Health Care 2. Job Opportunities and 3. Education. The nearest clinic to Banda is a 3 hour walk, the nearest hospital 6 hours, requiring a long trek carrying a stretcher over mountainous terrain for any access to medical care. The main and only source of work is agriculture. However, due to the terrain the community cannot grow enough crops to support their own needs, let alone export crops for income. The community has a primary school, yet nearly none of their students advance to secondary school as it is several hours walk away and boarding is prohibitively expensive.
The prospects of a Kageno community center with a clinic to meet health care needs, profit generating activities marketed towards the increasing flow of tourists through the national forest, agricultural and conservation education, and improved nursery and secondary school access, are greeted with excitement by the community.
This community made it quite clear that they are not looking for a handout, they want to make the Kageno project their own. Over 15 community members have donated plots of land for the future Kageno project, an ideal site at the base of the valley between 2 rivers. The community has also offered to provide all labor and supplies for the construction of the center.
Standing on the site of the future Kageno 2 Project (above) with a gathering of the local children, one could picture the future community center and the promise it holds for the Banda community.
After working with struggling clinics and underresourced hospitals for the last 2 months, we finally had the opportunity to see things done right at the Partners in Health Rwinkwavu Hospital in Rwanda. Dr. Paul Farmer has been a champion for health and human rights for the poor and has changed the world's view on providing quality medical care in impoverished areas through his work in Haiti and Peru over the past 20 years. As he became renowned for his work in these areas, the Rwandan government challenged his organization to see if their model could work in sub-Saharan Africa. Rumor has it that the government suggested Dr. Farmer work in one of their marginally struggling areas and he refused, telling them he would prefer to work in the most impoverished area they could find for him, which is how PIH ended up in Rwinkwavu.
The center in Rwinkwavu is an oasis in a valley wrought with rural poverty. PIH has worked hand in hand with the Rwandan government to renovate the old rundown Rwinkwavu Hospital to establish a government facility run through the PIH model. The PIH model is to do whatever it takes to provide the poor with a preferential option with regards to health care. This mindset shows through in everything they do.
ARVs are just the beginning of their HIV program. Patients are tested and receive their ARVs and counseling in groups, in order to give them a source of support throughout their therapy. Each patient on chronic therapy is assigned an accompanateur, a community member paid by PIH to help them monitor and directly observe the adminsitration of their medication. Recognizing that proper nutrition is as important as ARVs or anti-TB drugs, and that one is worthless without the other, each patient receives food throughout their therapy. In some cases, this may be for life. Social workers make home visits to ensure that therapy is progressing effectively, as well as to assess the home and family situation. With HIV and TB, all family members are brought in to the center for testing. If home conditions are inadequate and contributing to their health problems, PIH will simply build them a new house. Recognizing that many patients weak with HIV cannot endure rigorous agricultural labor during therapy, which is often the only available source of income, PIH will hire patients to work at the facility. When you look around at the gardeners, maintenance crew, and food preparation staff you can see how PIH has enveloped their patients and community into their team.
Another problem that we had encountered so frequently and felt so helpless against was malnutrition amongst children. PIH attacks this problem directly by dedicating a special malnutrition program to those children who are failing to thrive. Those deemed severely malnourished receive intensive inpatient feeding, which may last weeks to months. Those with milder malnutrition, as well as those who have succeeded in the inpatient program, go through an outpatient program. Their parents receive education on proper nutrition, as well as instruction in the PIH gardens on how to grow more nutritious high protein crops, such as beans. Home visits ensure that the children are growing properly, and deliver food and formula where needed.
PIH sees no patient as noncompliant, sees no obstacle as unsolvable, and sees no task as insignificant scut work. If a patient is not receiving correct care, they will do anything and everything in their power to find a way to make it work. A good illustration of this is the registration of their paitents on the progressive Rwandan government medical insurance plan. It costs only ~$2/year and covers most medical care, yet the majority of their patients were not registered for it. Instead of looking from afar and calling the program a failure, PIH's on the ground approach went directly to the people to uncover the obstacles to their registration. What they found was that the requirement of a photo for identification was the barrier keeping most of their patients from receiving this service. A PIH-er, Luke, took it upon himself to spend his summer going from house to house in the area taking pictures of community members with a digital camera and walking them through the registration process. This simple intervention has greatly increased the number of insured patients in the Rwinkwavu area, and is a great illustration of PIHs relentless dedication to the poor they serve.
Through this Rwandan health center, Dr. Farmer has proven once again that the PIH model works. When people raise arguments of reproducibility or cost-effectiveness, PIH can fall back on the fact that they have done everything possible for every patient that walks through their door. And no one can argue with that.
"Between a half million and one million murdered--that is of course a tragically high number. But, given the hellish striking power of Habyarimana's army, its helicopters, heavy machine guns, artillery, and armored vehicles, many more could have been killed in the course of three months of systematic shooting. Yet this did not happen. Most perished not on account of bombs or heavy machine guns; instead they were hacked and bludgeoned to death with the most primitive of weapons--machetes, hammers, spears and sticks."
--Ryszard Kapuscinski, "A Lecture on Rwanda"
When our matatu unexpectedly pulled over to the side of the road outside of Kigali, Rwanda, we hopped out along with all the other passengers, uncertain as to why traffic stopped. The apprehension began to rise as we looked down the road and saw several hundred people walking towards us carrying pickaxes, hoes and shovels. Now, had this been any other country, we might not have felt as uneasy, but when you anticipate unrest in a country based on recent events, it is only natural to feel uneasy when witnessing such a sight. However, this isn't 1994, and this is a new Rwanda. What happened next made us appreciate the changes that have come about in the country in the last 12 years.
The "mob", carrying their pickaxes, hoes and shovels, walked over to the side of the road and began working. They cleared debris and dug a trench, smiling and joking around with their neighbors. For over an hour and a half we watched them work, and no traffic moved. We found out that the government has instated a mandatory work day for all able-bodied adults on the last Saturday of every month. All must do some community project,(road work was a major one)and all traffic stops during this time. It seems the Rwandan government has taken great strides to change the face of the nation that was devastated by the genocide of 1994. Kigali, the capital, is by far the cleanest major city we have seen in the last 3 months. The infrastructure in the country far surpasses that of Kenya. The roads are exceptional, there is a strong police force, functional sewer systems and even the most rural areas have power lines and running water.
Driving into Rwanda you begin to realize how the landscape of this small nation has played such a role in its bloody history. It is too small of country and too mountainous for cattle herding Tutsis and the Hutu farmers to co-exist peacefully. Historically, the Tutsi were the ruling caste, making up about 14 percent of the population. Belgium backed the Tutsi after taking control of the country following WWI. In the mid-20th century when the Tutsi sought to gain freedom from Belgium, Belgium switched sides and supported the repressed Hutu farmers. The Hutu majority was encouraged to take up arms against the Tutsi cattle herders. In 1959, a peasant revolution overturned the power in the country to the hands of the Hutu. When a group like the Hutu gains power after being repressed for so long, the desire to defeat the enemy is absolute, as is the desire for retaliation. Skirmishes and conflict go on for years without the world taking notice. When the plane of the President is shot down in 1994, the mass uprising begins, and last nearly three months. Tutsis are slaughtered throughout the country, but any Hutus who opposed the regime are slaughtered as well.
There is no easily identifiable marker that shows someone as Tutsi versus Hutu. This is what makes walking around Kigali, and other parts of Rwanda so eerie. Everyone you pass--as long as they are over 12 years old--lived through one of the most concentrated and horrific mass killings in recent history. People live in relative harmony now, and there is no way to tell who played a part in it. The genocide was so recent that is comes up in most closed discussions, but unofficially, race is off limits to discuss.
There are now more workers with relief groups in-country than there are tourists, but many travellers who come to the country pay big bucks to hike the mountains of Rwanda for a chance to spend time with gorillas. Communication in-country was the most difficult that we have encountered thus far, as neither our French nor our Kinyarwandan are up to par. We were also surprised at the expense of everything in-country, from lodging on down, but we attributed this to the fact that the government is trying to instill policies to improve the economy, and change the face of the nation. But still what struck us most, was that the people we met and passed on the street carried with them, day to day, the memories of the horrific killings that took place in 1994.
After traveling for several days through Kenya and Uganda, we have arrived in Rwanda. We are currently in Kigali, Rwanda searching for Dr. Paul Farmer's clinic in Rwinkwavu (see Partners In Health link on right). We will post some pictures and stories from our travels as soon as we get back to Nairobi...
Clyde is the worm that's been living inside my foot. See Clyde crawl. Crawl Clyde crawl.
The Story of Clyde sums up so much of the living and medical experiences of the last 2 months. Hopefully, you'll enjoy and won't be too repulsed.
While in the islands of Lake Victoria with the mobile clinic we were hopping in and out of boats daily, often in sandals, onto beaches that were covered in filth; pigs, goats, cattle all defecated in areas where children regularly played, where people bathed and drank the water and where women came to do laundry. In the clinics on the islands, malnourished children would regularly be brought in by their parent or guardian, with the adult noticing a persistent cough. After listening to perfectly clear lungs we questioned what else could be causing the persistent cough.
For the past three weeks I had developed a similar dry, non productive cough, without any fever or stomach symptoms. Upon feeling some itching in my foot and seeing a distinct "serpentine-like" pattern I realized what might be going on. We searched through the medical texts that we had, researching the soil-transmitted helminths that were common in the area. Looking up the different type of worms we noticed the additional early symptom of a dry cough, which results from the larvae from the worm entering the lungs and setting up camp, before any GI symptoms present.
On Rusinga Island the main effort during the first week of July had been to supply all the children in the area with Mebendazole, a deworming medication. Worms are such a common illness for children in the area, as they regularly play barefoot in and out of the water and in other unsanitary conditions. Somewhere along the boat travel of the first month of our trip, Clyde decided to hop aboard.
We found out what should be used to treat Clyde, but decided on a trip to Nairobi Hospital--a private, clean, well-run facility--for a second opinion. After seeing two physicians and receiving a full lab work-up (at minimal expense) I was able to benefit from immediate treatment while so many others would end up malnourished and untreated.
Clyde has gone now, and the lungs are ready for a trip up Kilimanjaro....
In our search for a possible new project with the CDC, we sought to explore the second largest slum in Africa, Kibera, located on the outskirts of Nairobi. Some friends that we had met in Mombasa worked as volunteer nursery school teachers in Kibera and put us in touch with one of their colleagues, Judy.
We met Judy outside the Olympic Primary School, surprisingly the best performing primary school in the country in one of the most impoverished settings. Judy was a well-spoken, well-dressed 22 year old teacher who gave a friendly welcome to the group. When we told her we just wanted to take a quick look around Kibera, she said she would have no such thing. We were to take a walking tour, visit her school, meet the people in her community, stay for lunch, and hike to the hills overlooking the area for a view of all of Kibera. It soon became clear that we were not taking a quick survey of an impoverished slum to find how we could improve health, but instead we were getting a welcoming invitation into the home by someone proud of and active in her community. And by someone we had never met.
The walk through Kibera is what John and I had come to expect after seeing similar situations in the Philippines. However, having seen similar slums before does not make the experience any less shocking and powerful. A sea of tin roofs covers the mass of houses cramped together to accomodate the 1 million people thought to live there. A mix of trash, dirt, and feces make the base of the passageways between houses, broken only by rivers of sewage which trickle down hill to a river at the base of the slum.
As we were lead through the hear of Kibera, we amazed at the ease by which Judy gracefully and nonchalantly hopped over heaps of rotten garbage and crevaces of waste. Upon reaching Judy's community within Kibera, we were greeted by smiling and respectful children, not asking for candy or money as in other commmunities, as well as welcoming elders busy at work outside their homes. There was a general sense that these people were quite happy and proud to have visitors into their home.
When we arrived at the small tin shack where Judy's family lived, we were welcomed into a cramped, but tidy common room. We were introduced to her jovial brother, Joshua, and her noble father, who was now disabled and unable to work. In the center of an enormous urban wasteland, we sat for an hour in a peaceful oasis sharing a well-prepared meal of meat stew and avacado salad with a family, who taken out of their suroundings was not too different than any of our own.
I am not trying to paint the picture of the bogus "happy but poor" argument that minimizes the inequities caused by abject poverty. There indeed are gross deficiencies in the provision for basic human needs of proper shelter, sanitation, and healthcare. However we have read account after account of the repulsive and disgusting nature of Kibera and other urban slums. What we witnessed that day in Kibera was dignity in the face of poverty, resilience in the face of despair; a group of people that have learned to survive and do their best to lead dignified life in the most minimal conditions.
In speaking with Judy while overlooking vast spread of Kibera from atoop the hillside overlooking the tin city, we gained an appreciation for the respect Judy had for her community. Judy asked me, "So, what do you think of Kibera?" Not knowing what she was expecting as an answer, either: "It's one of the most repulsive settings I've encountered and it angers me that people are forced to live in these conditions", or "You have such a nice family and community, thanks so much for welcoming me into your home"--- the two sentiments I was feeling at the time.
"It's interesting," was my response, followed quickly by "What are your thoughts on Kibera?" now really curious about how she viewed her surroundings. She describes that she viewed Kibera as "a nice place to live." It's safe, most of the time, as the inhabitants self-police the area through vigilante "mob justice." Police don't dare step foot in Kibera. If someone is caught stealing, "they might as well start building their own coffin," she stated. After being raised there, she stated that she doesn't even pay notice to the filth of her surroundings anymore. Her one complaint was of her high rent the Nubian landlords charged, around 500-700 KSh/month (the equivalent of 8-10 US dollars).
It is difficult to process how someone could view such a place as "home", and a "nice" one at that. Is it because she has never traveled outside the Kibera/Nairobi area to see what else is out there? Is it because she has resigned herself to accept the place she will likely live the majority of her life with the difficulty it takes to escape? Or is it because of the amazing family and great sense of community she and her neighbors have salvaged in the face of their difficult situation? All told, this was an incredible learning experience for us and we will never forget the perseverence, strong will, and dignity of Judy and the people of Kibera we met that day.
We received a call this week from our friend, Ester, an openly positive public speaker from the Stepping Stone group (see below) in Kendu Bay. She was now in Nairobi, so we arranged to meet her in the center of the city, quite a change of scenery from our last meeting at her small rural village. After being extremely late to the meeting because of John's worm (see above), Esther greeted us with a glowing smile and sincere excitement to see us. As we sat and talked over some Kenyan fast-food, we were amazed that she had been able to keep her spirits through some extraordinarily tough times. Her husband recently left her because of her HIV status and the way he felt she "put it on display" in the community through her outreach work. He remarried and left her without financial support for her 3 children. This past week, she lost her youngest son, who was HIV positive. Her husband became irrate over the loss, and the stress of the matter forced her to flee her rural home and come to stay with relatives in the city. She has left her 2 daughters behind under the care of her brother and has come to the city with a load of omena, minnows from her fishing village which she hopes will gain a higher price in the city.
After all of these devastating events, Esther continues on with her work. She proudly showed us the lesson plan she was using with her HIV positive groups on how to make "memory letters". Memory letters, she explained, are written by group members for their children to learn the story of their lives and have remembrance of them after they are gone. It includes disclosing their HIV status and how they became infected, as well as teaching their children how they can avoid the same fate. Most importantly, it shares their life story with their children. Inherent in these letters is an acceptance that death will be coming from HIV.
However, acceptance of death does not mean giving up on the fight to live. Despite being in Nairobi, Esther plans to travel back to Kendu Bay (across the country) for her monthly supply of antiretroviral medication, a feat she is struggling to afford without her husband's financial support. "All I want is 10 more years to watch my children grow up" she told us as she was leaving. She hopes to one day see her youngest daughter, whom she considers her "personal doctor" because she ensures she never misses a dose of medication, complete school and reach her goal to become a medical doctor that changes the course of the disease that will end her mother's life.
We are both very excited to return to the Suba District for the next 4 months with the International Medical Corps. We will be working with their HIV/TB program on the public health level of education, prevention, and access to care. We are looking forward to bringing what we have learned back to the islands in order to combat many of the problems and issues of the area that frustrated and angered us the first time around. Check out more info about the IMC on the link to the right of the page. There is more information and articles specifically on our project in the Kenya section. We will keep you updated on our progress.
We'd like to thank Beth, Bianca, Becca, Lauren, Audrey, Ann, and Stephanie for an amazing 2 months. We loved working alongside all of you and learned so much from you along the way. We look forward to hearing the amazing things that are coming up around the corner for all of you in the years to come--- keep in touch, you'll be missed!
Every morning at Kendu Bay Adventist Hospital, we were greeted by a large waiting room full of patients in the Catholic Relief Services AIDS Center. We greatly enjoyed hearing their stories, sharing our stories, and answering their questions on HIV as they patiently waited for their clinic appointment for administration of their monthly supply of anti-retroviral (ARV) HIV medication. When we were invited by Esther, one of the patients in the waiting room (above, center), to come and visit her local support group, we jumped at the chance to travel out into the community to see the efforts against HIV being undertaken. Little did we know about just how far the travel would be.
After a long walk, crowded taxi ride, overstuffed matatu trek, and boda-boda bicycle ride up the mountainside we reached our final destination in the remote village of Gotayaru. After speaking with the women who greeted us, we quickly discovered that the 3-hour trek that we had just completed with the help of various modes of transportation was the same journey that these women walked each month to reach the nearest center to receive anti-retroviral (ARV) medications. They begin their walk the day prior and continue throughout the night in order to arrive for their appointment at Kendu Bay in the morning. We instantly gained much respect and a new-found understanding of the dedication of the patients we encountered each morning at the AIDS clinic.
The Stepping Stone group is a dynamic group of young and old women, as well as a few men, in the very impoverished rural area of Gotayaru. They are all HIV positive and open to the community about their status. The group began 3 years ago, as some in the community noted many people getting sick without an explanation for the cause. Because of their remote location, many died before people began to realize that HIV was the cause of the devastation in this area. The group began to meet to discuss how they could educate others about this virus, as well as break the stigma that they were experiencing in the community.
The group innovatively uses local dances on the beaches in order to attract an audience for their talks. Once people gather around the dancing, they speak out about transmission, prevention, and their experience with treatment of the virus through ARV therapy. Through their openness and outreach efforts, they are helping to break the stigma of being HIV-positive. The group has expanded in size to over 35 and continues to grow as others witness the improvement in their health once starting ARVs.
The main issue facing this group is the destitute poverty that is keeping them from receiving adequate nutrition. Although the ARVs they receive are free, many are still growing weak and ill due to lack of food to support them through the treatment. The difficult climate of the area only allows for one harvest and recent droughts have not allowed them to rely on their crops for sustinence. Their response has been to collectively distribute food amongst the group by each member bringing a portion of their crops to the host of each meeting. This helps to provide those who are too sick or weak to work and harvest with some staples for the upcoming months.
In order to provide income for those who cannot sustain the manual labor of farming due to HIV, the group weaves baskets made from a local plant called lando. Each basket can be weaved in 30 minutes, allowing each person to make up to 20 baskets a day. The baskets are then sold to local farmers for harvest at around 50 KSh (~70 cents) in the local markets. Money is shared cooperatively to provide funds and food for those most ill, however the funds raised are grossly inadequate for the well-being of the entire group.
It was incredible for us to see such a progressive effort in such a remote, rural area. The basic efforts of outreach, collective support for the administration of ARVs, and income generating activities are making a great impact on their community. Unfortunately, they continue to fight an uphill battle to provide for their basic needs in the face of poverty.