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 (www.operationcrossroadsafrica.org) 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