Monday, October 30, 2006

Another Young Silent Death in Rural Kenya

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.

--Kevin Messacar

Chasing Tigers: Adventures in Finding a Tigers' Game in Rural Kenya

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.

As promised...

Tuesday, October 03, 2006

"Deadly Catch: Lake Victoria AIDS Crisis": A Film Documentary

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 , scroll halfway down the page to the film titled "DEADLY CATCH". Let us know what you think...

Jaboya: The Fish for Sex Trade

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.

Living in the "Hotbed" of HIV/AIDS Activity

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.

"Are you coming back...?" ---Our efforts in the beaches with IMC

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…?”

-----John Kurap

Anyone care for another round of Chang'aa?

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.


Monday, October 02, 2006

Acting Out Against HIV

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.

-----John Kurap

Taxing the Poor: Corruption on the Local Level

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.

-----John Kurap

Monday, September 11, 2006

Back to the Islands

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.

Kevin and John

Friday, September 01, 2006

Fundraising Stint: Moviestars in 'Africa Mon Amour'

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)...

Tuesday, August 29, 2006

Kageno 2 (Banda, Rwanda): A New Place of Hope

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.

Saturday, August 26, 2006

Partners in Health: Doing Whatever It Takes to Provide a Preferential Option for the Poor

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.

Rwanda--A nation revitalized after genocide

"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.

--My thanks to Kapuscinski

---written by JK

Thursday, August 24, 2006

Uganda/ Rwanda Road Trip

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...

Kevin and John

Thursday, August 17, 2006

Meet Clyde....

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....

Nairobi National Park: Go Tigers!

Spreading love for D-Town all over Africa... we may have to fly home for game 4 of the World Series when the Tigers are about to sweep.

Dignity in the Face of Poverty: A Day in Kibera

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.

A Spirit that Cannot Be Broken: Esther (part 2)

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.

Monday, August 14, 2006

New Project: Returning to Lake Victoria with the International Medical Corps

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.

Wednesday, August 09, 2006

Goodbye to the Crossroads Africa Group!

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!

Stepping Stone HIV Positive Support Group: A Rural Community's Response HIV/AIDS

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.

Speaking Out: Talking to Secondary Schools about HIV/AIDS

One of the most rewarding projects we have undertaken as a Crossroads Group has been speaking at local secondary schools on sex, HIV/AIDS, and other sexually transmitted infections. The students have been attentive and endlessly curious. Each session is started with an introduction about the way things are in the US--describing that sex and HIV are spoken about openly and explaining how this has helped to break the stigma of the disease. We stress the importance of abstinence as the only 100% effective measure, and realistically educate the students that condoms are the best method of preventing disease if they choose to be sexually active.

Through anonymous question slips we have been able to uncover and combat many of the myths circulating about HIV, including: "HIV can't be transmitted through sex with a virgin", "HIV can be transmitted through toilet seats, sharing towels, or kissing", and that "HIV is a virus created in a US lab to destroy Africa". We received great but difficult questions to answer such as: "If a young person is HIV positive can they ever have children?", "How can I know if my boyfriend/girlfriend has HIV?", and "If 2 people are positive, can they have unprotected sex?"

The female students, in particular, loved hearing from the girls in our group. They noted it was great to hear from women who could speak openly and honestly about difficult sexual issues. We received a warm welcome in nearly every school we visitied, although it was unfortunate that some administrators were stuck in the mindset that talking about sex and condoms promotes sexual activity. Educating young minds on HIV and opening discussions on sex will hopefully spur these students to continue to ask more questions and expose the issues not talked about in many communities. These youths truly are the ones with the ability to change the course of HIV in Kenya.

Mobilizing Preventative Health Measures: A Mobile Clinic for Women and Children in Kendu Bay

It was a breath of fresh air, both literally and figuratively, to work with the mobile clinic run by the nursing school at Kendu Bay Adventist Hospital. This well-focused, well-organized, and well-run effort reaches women and children in rural areas who could not otherwise reach the local hospital for health checks. The back of a truck is opened to an attentive audience of young mothers and pregnant women sitting in the open air in fields and under trees outside of local primary schools.

The true success of this effort lies in it's focus on education and prevention. The clinic is started each day with a health talk on issues concerning pregnant women, including: HIV mother to child transmission, nutrition for pregnant women and young children, anemia, and malaria. For children, growth charts are created to monitor development and immunizations are administered to protect against polio, measles, TB, HIB, pertussis, tetanus infections. Pregnant mothers receive antenatal checks, as well as iron and folate supplements.

Additionally, all mothers are offered free testing and counseling for HIV. If they test positive, they are counseled on ways to take care of their own health as well as prevent the spread to other partners, including their unborn child. These measures include the administration of a single dose of anti-retroviral (ARV) during and after labor, shown to greatly decrease risk of Mother to Child (MTC) transmission. This simple, single effort that can even be utilized for home birth can change the entire course of a child's life. Family planning using Depo-Provera shots is offered at low cost, an important measure in combating poverty in low-income rural areas. It is efforts such as these that are making progress in the battle against HIV in certain areas. The preventative and educative nature of this mobile clinic ensure that it will have a lasting effect of the health of the participants in the years and generations to come.

Kendu Bay Adventist Hospital Then and Now

One of the most pleasurable experiences, personally, in the past two months was returning to Kendu bay after working in the area 3 years ago with Operation Crossroads Africa. Not only was there a very warm welcoming from those who remembered our previous group, but the progress in the hospital was uplifting to see as well.

Tamari, the Head Matron at Kendu Adventist Hospital, had spent a day with me on the first visit showing me what she thought the hospital was lacking, namely a new surgical ward with recovery area, incubators in the maternity ward and toys for the peds ward. She explained that the cost for all additions would be raised by a "harambee", a community party where locals gather to donate to a particular cause.

Upon arriving at the hospital, the progress in the area is clearly evident. A large surgical ward is currently under construction, Catholic Relief Services (CRS) has constructed a center for HIV/AIDS patients to receive counseling and ARVs from a knowledgeable, determined staff, and even the maternity ward is equipped with incubators.

Not only were the tangible changes impressive, but the cultural mindset concerning HIV/AIDS has turned around completely. Community members are receiving ARVs regularly, they are healthier, and this in turn has encouraged others to go and get tested. A positive test is accepted with a sense of relief; now that the cause for recurrent illnesses and overall poor health has been found, they can begin to receive the same effective treatment as their neighbors.

----John Kurap

The Impact of ARVs: A Comparison Between Lake Victoria and Kendu Bay

Lake Victoria Region
To start with a fact: HIV is not being treated on the islands of Lake Victoria, period. After 2 months of working in mobile clinics in this region with a 40% prevalence, we met one person receiveing ARVs (who had to travel at her own expense to a Doctors Without Borders center on the mainland). On the islands HIV is largely not spoken about, stigma is rampant, and there appears to be no easy solution on the horizon.

Our minds began to wander when contemplating the facts: 40% prevalence of an incurable chronic disease in an area with frequent promiscuous sexual practices. What will become of this area? Will it become extict? Abstinence is unrealistic, condoms are ineffective unless used correctly during every sexual encounter, and even ARVs don't provide a cure or definitive method to prevent transmission. What will these islands look like in 5, 10, 15 years?

The only service we could offer our patients was a government Volunteer Testing and Counseling Center (VCT) to find out their HIV status. At first we were shocked at the many emaciated, likely end-stage HIV patients we encountered that stated they had not been treated or tested and had no intention of doing so. We were frustrated by the sexually promisucous youths who outright told us, why would I get tested, it will only increase my stress?

But once we stopped and put ourselves in their situation for a moment, we began to understand their feelings of indifference and futility. Why would they go in to VCT to find they are HIV positive, receive negative stigma from the community, and be sent home to die with no ARVs available? Encouraging patients to go for VCT without having treatment available approaches unethical medical practice. It is comparable to conducting a clinical research study without having available treatments offered to participants.

Kendu Bay
Fortunately, we had the chance to work in another area on the mainland, which has access to ARVs as well as a well-run AIDS center. The situation is this area 3 years ago was quite similar to that in the Lake Victoria region. However when this program began administering ARVs, the community took notice of those that were once wasting away and now suddenly were growing stronger. Consequently people stopped viewing testing as something that just "increases stress", and instead realized that testing could lead to treatment and betterment of their health. We actually sat through several VCT counseling sessions where the patient was relieved to find out that they were HIV positive because now they had an explanation for why they were feeling ill, and could work towards improving their strength with ARVs.

In time, people in the Kendu Bay area began to attend VCT freely. In doing so, whether positive or negative they received the full hour-long counseling session explaining HIV, and its transmission, prevention, and treatment. The effect of this intervention rippled throughout the community. With education, the stigma of the disease began to break and support groups popped up amongst those receiving ARVs.

Kendu Bay taught us the epidemiologic utility of providing treatment, even if ARVs are not curative and do not completely prevent transmission. The availability of treatment attracts people to testing, with testing comes education, and with education comes a change in mindsets and actions with regards to abstitence, condoms, and stigma. Needless to say this community was not headed toward extinction and demonstrated to us the path that the Lake Victoria area could head down given the appropriate intervention.

The Future of Lake Victoria
After becoming very frustrated with "doing the best we can with what we have", we are now looking forward to improving what is available in the region so that we can do better. After seeing the effect of ARVs in the epidemiologic course of HIV in Kendu Bay, our goal is to help bring access to ARVs in addition to VCT to the Lake Victoria region through the IMC.

Abuses of the Poor: Extortion on Remba

It is difficult to put a place like Remba Island into words. Upon approach, swarms of hawks circling the island provide a foreboading warning of what is to come. Stepping upon Remba, the feel of barren rock and trash under your feet, the smells of rotten fish carcass in the sun, and the sight of shottily built tin shacks crowded along the beach gives the sense that this is not a very pleasant place to live. In fact, this island is a haven for convicts, prostitutes, and political exiles from the surrounding countries of Uganda, Rwanda, Somalia, Tanzania, and Kenya. It provides a remote hiding place in the middle of Lake Victoria with a readily available source of income in fishing. There is absolutely no respect for permanent living conditions, the environment, or building any type of community. Life on Remba is a day to day existence.

In our mobile clinic, we encountered rampant malnutrition amongst the children, multiple sexually transmitted diseases in the majority of patients, and a large number of cachectic, lifeless young people with the clinical signs of HIV but no previous testing or treatment.
As if life upon this desolate island wasn't rough enough, we heard news after we left the island of a "war" that broke out on Remba. The island lies near the border between Uganda and Kenya, but in Kenyan territory. However, Ugandan soldiers/police regularly stop on the island to harass the fisherman and demand an illegal tariff for fishing in Ugandan waters. They carry lists of fishing boats and search the island registering each fisherman as he pays the extorted 500 KSh per boat. Those who don't pay are abducted upon Ugandan boats until they come up with the money demanded.

Soon after we left the island, the Kenyan inhabitants decided to take a stand against the Ugandan piracy. This time when the soldiers arrived, the Kenyans banded together and refused to pay the fee, demanding their rights. The Ugandan soldiers came out in numbers and made a show of force, scaring the few Kenyan police from the island. Those who protested were abused or abducted and once again forced to pay the fee. Without organization or support from the government, the Kenyans weak stand proved futile as they again had their meager salaries further diminished by this illegal activity. The abuses and extortion of the poor continues to drive them further and further into poverty.

No Way Out: Barriers to Education in Rural Kenya

In the US, a primary and secondary public education is an expected service of the government, and funding for higher education is made possible through government financial aid. However in Kenya, any schooling beyond primary education is prohibitively expensive. Financial barriers prevent many young children from receiving anything beyond a basic education and higher education remains restricted to those lucky enough to have financial backing. Education is often thought of as the best weapon against poverty. However, in Kenya the ability to change one's plight in life is drastically limited as the very young are forced to drop from school and enter lives of manual labor and poverty.

Alfred's Story
As we rode aboard a matatu (public transportation) headed towards Ruma National Park, our friend and local teacher, Dan, noticed a familiar face along the road. It was Alfred, the best student in Dan's school and one of the most driven students he had encountered in his years of teaching. When we pulled over and asked where he was headed, we learned that he was beginning a more than 8 hour walk out of Mbita (the town) back to his rural family home. When he hopped aboard, he told us how he had been forced to drop out of secondary school because his family couldn't afford the funds for his education. Instead of continuing his schooling towards a career in law, medicine, or education, Alfred was being forced home to toil on the family land and likely follow in the footsteps of his farming ancestors. Weeks later we received word that Alfred had temporarily been reinstated in school, as his family had collected half of their annual harvest of beans and grain to bring to the school in exchange for a portion of his tuition. The family had been forced to sacrifice half of its annual sustinence and source of income for the entire next year.

Fortunately, Alfred's story has a happy ending as a local community group, headed by our friend Dan, was able to use outside sponsorship to keep him in school for the remainder of his secondary education. As one can imagine, the majority of children are not so lucky and are forced to fishing and farming once the cost of secondary education becomes prohibitive.

Benson's Story
We first met Benson (pictured above) upon a boat ride from the mainland back to Mfangano island. In talking to him we found he was interested in attending medical school with aspirations to study in the US then return to his home and become a doctor for the islands of Lake Victoria. In an area where there are only 2 doctors in the entire district and none servicing the islands, it is clear that his future could make an immeasurable impact upon the health of the thousands of island inhabitants. Benson was endlessly curious about medical school and life in the States. He quickly became friends with the group and he began to come along on our mobile clinic to observe, learn, and help with translation.

Benson helped us realize the barriers to receiving a university education coming from a rural area. First of all, the lack of communication on the islands made it very difficult to apply for schooling, and next to impossible to hear about the rare scholarship opportunities available. Secondly, the cost of schooling is incredibly high, especially coming from an impoverished, rural upbringing, and there is little hope of government assistance by way of loans. Benson was left to fundraise amongst his family and the community, as well as work to raise the minimum funds before and during school. He described the process as equivalent to a full-time job, in addition to his studies.

At this time, he has been accepted to a Kenyan University for microbiology, a prep degree for medical school in the US. However, he has not raised enough money to start school this semester. In the meantime he continues fundraising and is forced to join local fishing boats for spare cash to survive. It is a travesty that the life of such a bright, driven young man with altruistic goals is being wasted mindlessly pulling fish out of nets from the sea.

Kageno: A Place of Hope

During the first week of July, our group of nine volunteers with Operation Crossroads Africa ( was given the opportunity to head to Rusinga island from Mfangano and take a short break from the mobile medical clinic work that we had been doing between islands in Lake Victoria.

Operation Crossroads sends out volunteers annually for two months to countries throughout Africa to work on various programs from constructing orphanages or schools to teaching projects to working in medical clinics. Our project was based on Mfangano, one of the largest islands in Lake Victoria, with the aim being daily mobile medical clinics on the various islands in the lake. We welcomed the opportunity to come to Rusinga for the week to meet the children and do what we could to help out medically in the area.

The unsanitary living conditions near the lake promote the rapid spread of worms and schistosomiasis. This adversely affects children who are already malnourished, and are trying to focus in school, leading to poor performance. Following WHO guidelines for a deworming project, we decided that the efforts for the week should be tailored towards improving the health of the children in the Kageno area in this manner. Every child over 2 years old was given a dose of Mebendazole to help irradicate worms in their system, as well as a basic checkup. Many of the children in the area still required immunizations and vaccinations, so after contacting the Minister of Health in the area, the site was supplied with oral polio vaccines, measles vaccines, and pentavalent vaccines, in order to officially start a health record on the children in the area.

Difficulties arose as most children in the area are orphans, so if any prior health record existed, they were often unable to locate it. The team from Crossroads saw about 40 children per day for vaccinations and checkups, and saw many from the community with other health problems as well. We were all really impressed with the Kageno site and the efforts of those involved with the project. It is a difficult task to take care of the 186 orphans and provide daily education, but with the construction of two new classrooms, a library, latrine and playground all under way, the development on site shows great growth. We greatly appreciate the offer from Frank to spend some time at the site and thank Alphonce, Zack, Rachel and the rest for their hospitality as well! We wish them all continued success on the project.

(please see link at the right for more information on Kageno)

----John Kurap

Saturday, July 15, 2006

Rural Life

Much of western Kenya resembles the dry, barren landscape of the southwestern US. Lake Victoria often becomes the one source of water if the few wells or riverbeds in the area dry up. Therefore, it is common to see women walking as far as ten miles to fill a 5 gallon jug with water which is gingerly placed atop their head for the walk back home. The day gets stretched into the night as one usually awakes early to begin the walk either to avoid the mid-day sun, or to make it back home in time in the morning for school, which is usually several miles away as well.

We recently stayed on the outskirts of Mbita at a home where the family is beginning to farm peanuts ("groundnuts") . The father in the family--a retired educator for many years--realized the value in grouping farmers in the area together to sell their yield, so has started a cooperative program where different types of peanuts (we tried varieties from Virginia and Cameroon) are grown to see what will thrive best on the land. It was encouraging to see the interest to improve the traditional methods of farming to grow a product that was both healthy for the people in the area and more profitable for the farmers in a communal sense. Too often, subsisting day to day doesn't allow for the ingenuity or open-mindedness to improve on the lifestyle.

Only recently have men begun to move away from the polygamous culture that was the norm for so long. It is traditional for males to come back to their parents homestead and build a home when they have the means. A separate house is built for each wife, and the wife is informed when the husband would visit that house. When a brother dies you inherit his wives and children. The spread of HIV and financial obligations to family are decreasing the desire for polygamy, but it is clearly evident how the culture system lead to such a quick spread of the disease through entire families.

(We also got to milk a cow, see below)

Left to Die

Each day we show up on an island with our mobile clinic, we are presented with a wide variety of medical problems from malaria, typhoid, and measles to tuberculosis, HIV, and end-stage syphilis. Many present with very advanced disease that has been present for years and have never been seen in a clinic or hospital. For example, our first day of clinic, we encountered a 1 year old child with severe failure to thrive. Her frail body, consisting only of bones with loose skin hanging off, looked as if it could barely support her out-of-proportion head due to malnutrition. It was clear that death was imminent within the next few months without intervention. In this case as in many others we are left questioning: Why would these people wait so long to seek medical care? How could this mother wake up each day and look at her child who is obviously wasting away towards certain death and carry on with her daily activities.

We also frequently encounter patients with problems beyond the scope of what we can handle with our basic medications and equipment. Logically, we had been directing those with advanced HIV, suspected TB, tumors and the like to the local hospital to receive more advanced medical care. However we couldn't help but wonder: How many of these patients would actually find their way to further medical care?

All of our questions were brutally answered when a young child was brought unconscious in a woman's arms to our immunization and deworming project on Rusinga Island. The child had been healthy one day prior and now was febrile with eyes rolled back and stiff neck, unable to respond to any stimuli. After performing a physical exam, we immediately suspected bacterial meningitis, a disease that can be rapidly progressive and fatal, where every hour can mean the difference between life, death, and permanent disability.

Sensing this urgency, we attempted to arrange for emergency transport to the nearest hospital. We soon found that not only are there no ambulances in the region, but there were not even any motorized vehicles available. Upon asking the local people how people reach the hospital, the answer became quite clear--- the majority don't and are left to die. Unwilling to accept this, we split up to run through the village and found a single car doing a promotion for herbal medicine in the town. We explained the urgent situation and were astonished to hear "your offer has not been accepted". It took a considerable amount of money and persuasion before we were able to comandeer the car and take the child and his guardian aboard. The ride from Rusinga to Mbita Hospital was nothing short of surreal. Maneuvering around donkey-carts and herds of cattle, we bounced along the rutted and pitted out roads praying every second that the child would reach the hospital alive.

When we reached the "hospital", we were shocked to find it was little more than two cement warehouse-type wards run by a nun and a single doctor. The line of the ill wrapped out the door as we barged in and layed the child down. The doctor agreed with our assessment of meningitis and plan for IV ceftriaxone. Unfortunately, "this is a very expensive medication and the family will not be able to pay" he stated matter-of-factly. Without money for medication, those lucky enough to find transportation to the hospital will be again left to die if they cannot pay for the medication up front. In this case, the guardian of the child was actually his grandmother, as he was orphaned by HIV/AIDS. The family had little to no money to live on a day to day basis, let alone provide an expensive medication. Unable to watch the child die in from of us, our group agreed to collectively provide the funds necessary.

To obtain the medication, we were told to purchase it at the hospital pharmacy and then bring it to the ward to be administered. It was little surprise at this point that the pharmacy was out of ceftriaxone. We were forced to run into town and find a local pharmacy who had stock of the medication, then return to see the medication delivered.

Through this experience our questions have been answered. We now have come to the brutal realization that there is no lack of initiative amongst people seeking medical care, and that likely none of the patients we had referred to the local hospital actually had received medical care. The barriers of lack of primary health resources, transportation, and cost of medication restrict nearly all of these people from the basic human right of health care. Though the child with meningitis did recover after IV antibiotics, it is very scary to think of what would have happened if not for outside help and financing. The harsh reality is that in this impoverished area, most people are left to die of preventable and treatable diseases.

Children Without a Childhood

As we pull ashore each beach on our fishing boat, a pack of smiling children runs to greet us. The happy faces and screams of Mzungu (white people) make for a joyous welcome. However, the dark reality sets in as one takes a closer look upon the heads infested with fungus, the tattered single pair of clothes, and the lack of any guardian within sight; that these are children fighting to survive on their own. These faces bring to life the cold number of 10 million children orphaned by HIV/AIDS.

Unlike in the US, there is no governmental safety net for these children. The extremely lucky are taken in by remaining family, usually grandparents. The very lucky are taken in by other families in the community who have the money to support additional children (it is not uncommon for a family to have up to 3 orphan children in addition to their own). The lucky find their way to an orphanage that usually provides schooling and sometimes 1 meal a day. However, many are left to fend for themselves at a very young age. These orphans band together in packs, and it is not uncommon to see a 6 year old caring for a 1 year old who is clinging to her back.

Primary school often brings the few joys of the younger years. We were approached by many children without clothes or food asking not for money or a meal, but instead for books. After primary school, the fees charged prohibit the majority of students, and nearly all orphans without family support from reaching a higher education. Even the best and the brightest students are funneled into the poverty-ridden industry of fishing.
When not in school, children are often found at the lake scrubbing pots and pans, carrying buckets of water, or chopping and collecting firewood from high atop the mountain. We encountered the children in the picture above upon a 2 hour hike to the top of Mfangano Island. These children were carrying ~100 lbs of wood they had chopped at the top of the mountain down a rocky hike in bare feet. The firewood would be sold for 50 Kenya shillings, the equivalent of less than a dollar. When you see how difficult their lives are and how hard they work, it is sometimes easy to forget they are children. However, bring out something as simple as a balloon, frisbee, or soccer ball, and you will see faces light up and flocks of giggling youths. You soon remember that these are indeed children; children who have been robbed of a childhood.

Friday, July 07, 2006

Structural Violence: Fishing, Women, and HIV on Lake Victoria

In the Suba District, where the HIV prevalence rate is over 40%, the women suffer the most devastating plight in life. The islands of Lake Victoria are dominated by the fishing industry of omena (minnows), tilapia, and Nile Perch. In this poverty-stricken area, fishing provides the men with a quick reward of hard cash at the end of the catch, which is often spent the following day. As some days the catch is large and other days the fishermen are left empty-handed, life here is lived on a day-by-day basis. For the women however, there is little to no ability to raise their own income, as the fishing is solely done by men. One of the only ways to raise money is to sell the fish caught by the men. In order to sell fish on an island, a woman must have a connection to a fisherman, usually a sexual relationship, to obtain daily catch for the market. With little other option to obtain money for food, the woman are stripped of their personal agency and forced by structural violence into a life of polygamy, poverty, and HIV.

In search of the best catch, the men travel each week from island to island. As they skip from place to place with little respect for establishing permanent living conditions besides a tin hut, the women, often pregnant with their children, are left to fend for themselves with no source of money. With the migration of fisherman follows the rapid spread of HIV throughout the islands, leaving women wasting away without even the money to travel to the mainland for medication.

The poverty cycle continues as young woman, raised by mothers in poverty, begin to attend school. Often without funds to buy proper clothes, most have no money to provide sanitary napkins once they hit a maturing age. Local teachers note that the young girls often will be absent each month for one week during their period. Others who attend school will need to go down to the beach when their clothes are soiled to wash in the water. These are the same beaches inhabited by fisherman coming back with their quick cash from the daily catch. The young girls are frequently offered money for hygiene products, food, and clothes they could otherwise not afford. Teen pregnancy, HIV, and the poverty cycle continue to propogate.

Tuesday, July 04, 2006

The Island

Someone once said that Mfangano is the farthest place you could travel to in the world and still be on Earth...After the four days of travel from NYC to get here, everyone began to understand the truth of that statement. Much remains the same here as hundreds of years ago. Constuction for the first road on the island was started a few months ago, but most people still get around by way of small single track paths that crisscross the island between villages. Fishing boats carry people between most of the villages and an hour and a half ride will get you to the nearest port city, Mbita for groceries. Fishing is the life blood of the area and with it comes the diseases of the nomadic lifestyle. The Suba District has the highest HIV rate in the nation at around 40%.
Other than the visitors to a very high end resort, few western tourists are ever seen on the island. Therefore, after the look of astonishment disappears we are always greeted very pleasantly in Luo or Kiswahili, and hear high pitched calls of "How are youuu!?" through the cornfields by young children wherever we pass.