TwoHelp Kenya

Finishing in Nairobi

Amidst the confusion surrounding the collapse of a building, Susan and I returned to Nairobi for the last few days of our trip. Nairobi, like the rest of Kenya, grew on me during my stay. Warnings of danger are worth heeding but common sense is king. I would never wander alone in the streets of an unknown neighborhood in Boston let alone even consider it in a city with which I am unfamiliar. My fear of the city, based on unsolicited warnings from many different people, collapsed into the reality of the way I live my life and I enjoyed the final days I spent there.

The hospitality of the Kenya Red Cross was amazing. In every location we visited we were met with thankful and happy staff and volunteers. All of them were excited to meet us, more than willing to help however they could, and eager to boast of the successes of their programs. Running a volunteer-driven organization is a challenge, the tackling of which requires the motivation and drive of a saint. While the intentions of the Kenya Red Cross are admirable, volunteers need more than admiration to work. In an environment where there is nothing other than peer support and the occasional free T-shirt as incentive, the program managers and project coordinators of the Kenya Red Cross have built volunteer-driven programs more impressive than any other I have seen. Considering the economic status of most of the volunteers (remember: more than 50% of Kenyans survive on less than $1 per day), the Kenya Red Cross has done remarkably.

Of course, there is room for improvement. The output of our project is meant to build capacity internally to help the Kenya Red Cross move itself towards an even better position. As a team, we continue to work with the data we collected and look forward to the chance to apply the impact measurement instrument that we develop to the programs we visited.

As a parting gift to us, Winnie, our contact through the Fritz Institute, arranged for Susan and me to meet the director of the Kenya Wildlife Service and have a special tour of the Kenyan national animal orphanage inside of Nairobi National Park. While the rangers claimed that they were fully domesticated, since they had been orphaned at 3 weeks of age, walking into an enclosure with 3 fully grown cheetahs was nevertheless somewhat intimidating. Their hair is coarse, not soft, and the black spots protrude slightly further than the yellow hair surrounding them. It turns out that when you pet a cheetah behind the ear, it purrs like a regular housecat. They also lick like housecats, raspy tongues and all.

Anybody interested in a film that portrays some of the challenges of working in public health in Kenya should watch The Constant Gardener. Many of the locations in the film are places we visited during our trip and the issues raised, while fictional, are realistic and germane to the work that we did.

Kenya is a fascinating country. The demographics, climate, scenery, and styles of life vary so greatly from Kisumu to Mombasa that it is sometimes difficult to believe they are in the same country. As the dry northeastern portion of the country suffers from a terrible famine, I think frequently of the infrastructure and services that we have in the United States that prevent us from ever being hungry. Had Kenya our roads, food distribution would improve. Had Kenya our economy, purchasing power would improve and famished sustenance farmers would not need to walk away from the food that is available due to inability to purchase it. Had Kenya our sense of environmental protection, many of the drought stricken areas may still be lush forests and pastures.

Hope survives, in spite of the disappointing political situation in the country. As Kenyans come to terms with their young democracy and begin to understanding the power they have in their vote, the international community must also learn that they systems of funding that we have for developing countries need to improve. It is ironic that ‘Band-Aid’ was the name of the 1980’s effort to raise money for famine relief in Africa. Band-aid style relief and development support is exactly what Kenyans do not need. Donor organizations and countries must learn to locate and support Kenyan projects that build capacity and sustainability within the country, instead of bringing it with them from other places. What comes easily goes easily; the aid truly needed in Kenya is neither easy to understand nor apply. More than anything, it must all be undertaken with a slant towards encouraging transparency and the development of internal capacity within existing systems of government.

It is my hope that the project that we helped with contributes to the Kenya Red Cross in this manner - that they may have less need, in the future, for help from outside. I hope you enjoyed reading my updates from Kenya. TwoHelp.org will continue to pursue work in international public health and will maintain websites meant to help inform you of the work that we do. Please check back from time to time for more information. Thank you.

Nakuru, Molo, and Sustainability

Probably the wealthiest city that I visited, Nakuru is at the other end of a very bumpy 3-hour drive northwest from Nairobi. Known for Lake Nakuru National Park, the town and park host more visitors each year than any other park in Kenya. Until several years ago, Lake Nakuru hosted the largest flock of flamingoes in Kenya. Environmental degradation drove them away, and they have only begun to return now that the local authorities are working to preserve the area.

Lake Nakuru National Park feels more like Jurassic Park than the Masai Mara does. The entire area (it is in a crater) is fenced in and the signs pointing drivers towards various roads and paths denote a well-cared-for if not over visited park. The park is the home to the largest herd of white rhinos in Kenya, some of which are currently being relocated to Meru National Park. Incidentally, Susan and I were told that they were hiding, since the rangers were after them for relocation.  Our trip to the park was short, so instead of playing hide-and-seek with the rhinos, we snuck up on some cranky old Cape Buffalo.

Just north of the town of Nakuru is Menengai Crater, an enormous caldera from a long-extinct volcano. Both areas are typical of the geology of the famous Rift Valley, which stretches thousands of miles down east Africa.

The Rift Valley is dry. Dust devils spin across the arid terrain, whipping up dust storms that engulf people, cars, homes, and livestock. From miles away, I could see other roads by the trails of dust that were yellow plumes in the air. While this area is normally arid, the dust was a reminder of the severe drought conditions across all of Kenya.

The Nakuru Branch of the Kenya Red Cross serves 7 sub-branches. One of these, in a small town called Molo, has well-developed HIV/AIDS programs, supported through funding from the French Red Cross. By this point in our journey, Susan and I had heard the same stories told many times in focus group interviews with Peer Educators and Community Health Workers. Transportation is a problem for all of the volunteers, many of whom serve large areas. There are not enough written resources available for Peer Educators to learn more about HIV. The KRCS training does not cover anti-retroviral therapy in enough depth. Not enough teachers are educated about HIV.

Oddly, we found different problems in Molo. Of all of the locations that I visited, Molo is the only one that was in a hilly area. Yet, through the French Red Cross funding, Molo is the only site where all volunteers have a bicycle. While most branches of the KRCS pleaded with me to help them secure funding for bicycles, volunteers from Molo noted that they were difficult to use in the area because of all of the hills. Furthermore, none of them served clients that were more than 1 km from their own homes.

Other branches spoke of difficulties getting community leaders to accept the KRCS programs on HIV sensitization. Molo works with a village health council that works to integrate HIV learning into the communities and nominates community health workers to the KRCS programs. Where some branches had inadequate facilities, Molo, a sub-branch, has its own office with a meeting room and another large meeting hall that is available for use. Schools in Molo are well-integrated into the Red Cross Club program and students from the area had recently won the national competition on HIV awareness, known as the Chanuka Challenge. Other areas have problems with access to drugs to treat opportunistic infections, but Molo has its own community pharmacy, supported by the KRCS.

It is clear that money injected into programs can bring positive results. While volunteer retention is a problem due to lack of pay, the local population in Molo seems to be hearing and receiving the messages that the KRCS spreads about the dangers of HIV. From initial appearances, Nakuru is on the right track with their HIV program implementation.

Through our visit, the other sub-branches were never mentioned. Incorrectly assuming that they were also working under the French Red Cross funding, Susan and I were surprised when we heard, on the evening of our final day in Molo, that the other sub-branches are suffering greatly. Molo is in the hills, where the drought is not a problem. However, the sub-branch of Lower Subukia is not.

Lower Subukia is a remote sub-branch of Nakuru that covers a larger area than Molo, with fewer staff. The one nurse who serves many of the home-based care clients has to walk up to 15 kilometers to make visits. She has no bicycle. The area is one of the region’s hardest hit by the drought and nutritional complications with HIV are taking a heavy toll on the KRCS clients in the area. What in the world is going on?

The ultimate end-goal of our project is to help the Kenya Red Cross Society build the internal capacity to show donors how their money impacts the community so that they will know that their money is well-spent. Sure, the French Red Cross money is very well spent in Molo — but what about Lower Subukia and the other branches around Kenya that lack transportation? Why are there over 80 Red Cross bicycles in the one area where they are of little use?

The answer lies in the fact that donors are able to specify exactly where they want their funding to go. Molo and Lower Subukia are completely at the whim of the French Red Cross and other external donors. While injecting money into a single community seems like a good idea, it creates a disparity in treatment so stark that people from the other sub-branch areas have moved to Molo for better treatment and KRCS services. The rich are getting richer, so to speak, while the poor are left to fend for themselves.

If that seems like a difficult situation, consider that the French Red Cross funding is set to expire this February. Since the Nakuru Branch of the KRCS does not receive enough funding (or feedback) from headquarters to support the program on its own, the systems set up with French funding will quietly be cancelled and go away if they have not already become self-sustaining. Yet, none of the KRCS programs are designed to be self-sustaining. What Nakuru has is a small natural experiment in what happens when funding is withdrawn.

Their response is to seek further funding from external organizations. They are currently scrambling to secure some Swiss funding, in hopes that the programs in Molo won’t collapse. But what about Lower Subukia and the 5 other under-funded sub-branches? Unfortunately, with nothing to show for progress in those areas, it is difficult to attract funding, causing a aggravation of the vicious cycle that feeds the growth of service disparity in the region.

Nakuru has a chance, though, if only for the bright and devoted staff at the main branch and the sub-branches. They continue to take creative solutions to the difficult problem of program funding and are working on the establishment of a revolving fund to support income generating activities for the various branches and program clients. The village health council in Molo is committed to helping the communities overcome the blight of HIV/AIDS and the peer educators continue to perform exceptional community outreach programs, in the form of drama and puppet shows.

The systems of international aid are complicated and frustrating. While nobody can point a finger at the French Red Cross and say that they did a bad thing by funding the Molo projects, plenty of people understand the price that the other sub-branches of Nakuru paid for the funding influx in Molo. Money dumped indiscriminately on communities can do harm. It is important that organizations like the Kenya Red Cross develop the internal capacity to negotiate with donors to ensure the needs of all of their clients are met. Molo is both a great example of successful community-based HIV/AIDS programs and of the problems inherent in the world of international aid.

Finding Mombasa

It is human nature to take time to adjust to new surroundings. For me, it took me nearly two weeks to adjust to the bustle of Kenyan cities. My disgust for the garbage and pollution and my reactions of horror to the congested mixture of pedestrians and vehicles were at their hight when I first arrived in Mombasa.

Guide books have a way of misrepresenting the locations they cover and painting them in a cheery light. I am unsure whether that is done on purpose, to convince potential travelers to purchase the guide or if the books are written by people who have an easier time overcoming the shock of new culture than I. Both the Rough Guide and Lonely Planet mention the charm of parts of Mombasa, the allure of the 400-year-old Fort Jesus, and the difference in culture brought about by the heavy influence of the Portuguese and Middle Easterners along the coastal areas of Kenya. These are reported to be most noticeable in Mombasa, an ‘exotic’ city that I had known previously only from a Warren Zevon song.

After 6 brief hours in Mombasa in the middle of the night, before departing for Malindi, I was overcome by the garbage in the streets and the wet heat that hovered around 85 degrees at night. I was glad to leave, disappointed with my initial impression.

Returning to Mombasa made me skeptical. The road from Malindi is a treacherous pitted stretch of disintegrating tarmac filled with speeding matatus (minibus taxis), exhaust-belching trucks, and giant busses of European tourists flying past the locals to reach the walled-compounds of the beach resorts. Three hours in the back of a Red Cross vehicle, facing sideways, sweating, getting covered in dust and exhaust ejected from the vehicles ahead only heightened my skepticism. Kirsten, Winnie, and I arrived in Mombasa sticky, tired, and ready to leave.

It was that evening, after we cleaned up, that we ate a superb meal at the Tamarind restaurant, overlooking the night lights of the city. Things were improving.

Our hotel, the Royal Court, was listed in the Rough Guide as one of the nicest in Mombasa. The seediness of the lobby initially startled me. It reeked of smoke and the sound of slot machines coming from the casino. A sign advertised large bingo prizes, given away several times each day. The air conditioning was off and by the time I made it to my room, I smelled like a smoker and was sweating profusely. The heavy heat was there to stay. It was then I found out that the air conditioner in my room did not work.

At midnight I went down to the front desk to ask for a room change. There was no way that I would be able to sleep with the damp heat. It was like having a large stranger breathing down the back of my neck. I thought that a cold shower would help, but the cold water was lukewarm and the shower head was helplessly encrusted with mineral deposits. The single stream of water that sprayed out went directly in my eye when I turned on the shower. It took 5 minutes to get my hair wet. I felt dirtier after drying off with the mildewed towel provided by the hotel than I had upon arrival.

The front desk refused to give me a new room. Instead, they sent me back up with a remote control and a maintenance man. The maintenance man used the remote control to turn on the AC unit. It was blowing air, but I didn’t hear the compressor. I asked the man to wait until the compressor turned on. We stood and looked at each other for about 7 minutes. The compressor never came on. Finally, he climbed out the window onto the tiny balcony, bent over the compressor, and hit a hidden reset switch. With an unhealthy mechanical groan, the compressor started. The AC began to cool the room. Telling me to not turn it off, the maintenance man returned to the lobby. I brushed my teeth and got ready for bed. As I pulled back the threadbare bed cover, the compressor made a terrible noise, the lights flickered, and the AC turned itself off. Dammit.

It was twenty minutes past midnight when I called the front desk to report the problem. This time, they agreed to let me switch rooms. When the maintenance man arrived with the bellboy, they were alarmed that I had used a towel and pulled back the bed cover. The bellboy took my dirty towel, gave me a dirty look, and escorted me and my half-packed suitcase to another room on a lower floor. Removing the clean towel from my new room and replacing it with the dirty towel, the bellboy departed and the maintenance man made sure that the AC turned on with the switch by the door before leaving. It was blowing hot air. The compressor did not turn on. I was too tired to complain.

Through the night, my growing frustration reinforced my initial impression of Mombasa. By the time that I awoke, severely dehydrated, at 3 in the morning, my bed and pillow were soaked with sweat. The travel alarm clock read the temperature in the room at 33 degrees Celsius. The humidity was through the roof. I took a cold shower (with a slightly improved showerhead) and then rolled around, thirsty, in the sweaty bed, in the dark, for about 20 minutes before calling Alexis. For a country where it is highly recommended to not drink the tap water, it’s disappointing to check into a hotel that fails to provide a bottle of drinking water in the room. I had only been in Kenya for two weeks, yet I was ready to take my suitcase full of dirty clothes and go home.

The next day the sun was a furnace that had glued my clothes to me by 9 o’clock in the morning. Winnie departed and Kirsten and I spent the day visiting the homes of PLWHAs (People Living With HIV/AIDS) in the city slums. All indications were that they had prepared their answers to our questions in advance. We found out that the KRCS Mombasa staff frequently takes visitors to see the same clients. Where we looked for genuine answers, we received rehearsed rhetoric. Everything was presented as perfect. Each meeting ended with a plea for money from the clients we visited.

Nothing is worse than being in a position that restricts you from assisting. For a mere $15, Kirsten and I could have turned around the lives of one family by restoring their soap-making business. They had been forced to spend their savings to put their children into secondary school and were now unable to continue their small business. However, a gift of cash would have created a bad precedent for the Kenya Red Cross, since they are unable to sustain such gifts and are unable to provide them to other clients. For the clients themselves, their neighbors would have accused them of excluding them from opportunities and may have turned to shunning them for having HIV. Many don’t understand why the KRCS helps people with HIV but doesn’t help others. In the worst case scenario, neighbors may have begun to view their HIV status as a way to make money and may have deliberately infected themselves with the disease in order to get handouts.

After an interminable day of sick people and focus group discussions, Kirsten and I asked to be dropped off at Fort Jesus, so that we could spend the last 90 minutes of sunlight doing something outside and winding down from the stress of the day. Fort Jesus is a Portuguese fort that was built in the 1590s. Through the years, it has been well-maintained and now stands as one of the most popular sights to see in Mombasa. From the intricately carved Lamu doors, reminiscent of Moorish architecture in Portugal and Spain, to the old Portuguese graffiti that has been restored, the history of Mombasa begins to spring forth.

Mombasa is an old city that has seen many owners. Some evidence places the age of the original Swahili Mombasa settlement at over 2000 years old. Compared to Nairobi, which is a mere 100 years old, there is a lot of history and culture in Mombasa. The Portuguese sacked the city during the 1500s and it proceeded to switch ownership many times. More recently, it was under the control of the Sultan of Zanzibar and the Sultan of Oman. The heavy Middle Eastern influence in the region has left Islam as the predominate religion, a reminder of which are the early-morning chants and prayers broadcast from the minarets on the local mosques.

In Mombasa, Kirsten and I met Sheik Idris, head of the Kenyan National Council of Imams and Preachers. A powerful presence in the local religious and political scenes, Sheik Idris works in conjunction with the Kenya Red Cross (the name of which is off-putting for some Muslims) to educate the Muslim populations of Mombasa about HIV. Through his guidance, imams throughout the region use the local network of mosques to help decrease stigma towards the disease, while encouraging constituents to go for voluntary counseling and testing. With a booming voice, speaking smooth Kiswahili (residents of the coast claim that their dialect is the only true Kiswahili), Sheik Idris patiently answered our questions about HIV in the Muslim community for over an hour, while several dozen people waited to meet with him. Our interesting discussion ended with several other imams popping open some coconuts for us, for a cool treat of coconut juice and meat.

Outside of Fort Jesus is a road that leads into the Mombasa Old Town. The first block of this stretch is infested with tourist shops and pushy purveyors eager to sell cheap wares for far too much money.

However, after a block or two, Old Town turns into the true cultural center of Mombasa and the most culturally genuine and rich area that I have seen in all of Kenya. Perhaps it was the low season or perhaps tourists fear to venture too far from the main roads, but the Old Town of Mombasa is truly charming. White mosques with stained glass windows guard narrow streets with little vehicular traffic, large numbers of children playing and people going about their everyday lives. Every house sports a carved wooden Lamu door and the people that duck in and out of them fit into the scene, men wearing flowing white robes and many women in full black Muslim dress, locally called ‘ninja’ garb.

The children played in the streets. For them, it was fantastic to have their picture taken so that they could see it on the camera screen. Others played tag and football. Almost all of them greeted us with their school-taught English phrases, “Hello! How are you?” and “What is your name?” They wanted to talk, to shake hands, to join us for a walk, and to know where we were from.

Their parents kept an eye on them from local restaurants, food stalls, shops, and porches. Many people waved, smiled, asked how we were, welcomed us to Mombasa, and wished us a nice stay in Kenya. During our hour-long wander through the Old Town, we only saw one other (obvious) tourist. This was the first place I had seen in Kenya where the cycle of mutual exploitation – the tourist vs. the native culture – was absolutely absent. Nobody tried to take advantage of us and we were not there to take advantage of them, only to enjoy a few moments of immersion into their everyday normal lives.

I was tired. I was hot and sweaty. I was filthy from the dust and exhaust. I was lost, wandering, sauntering. Yet, for the first time since my arrival in the city, I didn’t care. I would have thrown my guide book in the garbage right then and there. Finding the charm in Mombasa is not about walking down the correct street or seeing the most interesting museum. Finding the charm in Mombasa is about letting go, accepting the sultry heat, forgetting about being dirty, forgetting about being a different color, engaging the people, and forgetting that you are not from Mombasa. While the scores of European tourists sat confined in their walled compounds along the beach, I was happy to be immersed amongst the people their walls were meant to keep out.

It is an exotic and different place. For me, once I let go of the differences between my life and Mombasa, I found it to be wonderful.

Malindi part 2: Fighting Fear

Tucked away behind the tourism and bustle of the main street in Malindi is a district of deeply rutted unpaved roads, slum housing, and little economic hope. For each of the Germans and Italians prawling along the beaches and the streets of the old town, there are thousands of Kenyans living in abject poverty, just out of the line of sight.

In one of these slum districts, a daily market convenes, with women selling lettuce, cassava, okra, coconuts, mangoes, potatoes, and several other fruits and vegetables. Upon our arrival to this market, there is a little bit of suspiscion and a lot of staring. There is one easy way to immediately discover how many tourists visit an area in Kenya.

Although it sounds crass, all you have to do it to pull out a camera and try to take a picture with people in it. In areas that tourists visit, the people in the photo will demand money for having their picture taken. They will cover their face, command their children to move out of the line of sight of the camera, and make make you, the cameraperson, feel very uncomfortable.

I’ve been on the other side of these cameras before. Travelling in China during the summer of 1991, shortly before the onslaught of Sino-American business deals, there were many areas that I visited where Chinese people had never seen a white person. I posed for photographs with many familys and was frequently photographed just standing alone or with the others whom I travelled with.

Yet, if my livelihood consisted of selling eggs for $0.05 each, I, too, would feel like I deserved something for allowing others to photograph me. Tourism can be uncomfortable.

Foreigners had been to this particular market in Malindi. Most likely, they had been foreign guests of the Kenya Red Cross (KRCS) Malindi branch. Since the area was such a tourist hotspot, members of the German and Italian Red Crosses frequently knocked out two birds with one stone by making an official visit to the Malindi branch HQ while vacationing on the coast of Kenya.

About seven volunteers from the local Peer Education team were at the market to perform a puppet show. Their puppets’ heads were the size of a human head, they had long necks, and the hands belonged to the puppet masters, who had inserted them through the cuffs of the puppets’ shirts. Before the show, to gather an audience, the Peer Educators played games of Simon Says (and other similar games) with the children. They also danced to hip hop music. Watching the young boys dance to the music was quite amazing. These kids, 7 to 14 years old, were some of the best dancers that I had ever seen. Where they learned their moves, I don’t know.

By the time the puppet show started, there were about 200 people standing to watch. The puppets are used to discuss some difficult issues because they hold the attention of the kids while taking the edge off of people discussing and acting out difficult problems like incest and HIV transmission.

The Peer Educators in Malindi are nothing short of amazing. Through the difficulties of volunteering in a country with rampant unemployment, the volunteers of the KRCS, in every location that we have visited, drop complaints in lieu of positive energy meant to improve the lives of the beneficiaries of their programs. As I watched the puppet show, I reflected on the attitudes of the people, the struggle to change misinformed and dangerous behavior, and the vast differences between the energy and creativity of the volunteers in Kenya and those with whom I have worked in the United States.

Volunteering is too frequently undertaken as a personal attempt to find satisfaction in helping others. It makes a story that can be told to others, about one’s virtue and willingness to help those in need.

Kenyan volunteering, at least with the Red Cross, is about giving in every way possible. Time, compassion, money, energy – all given selflessly. For many of the volunteers with the KRCS, there is nobody to whom to brag about helping – only more people needing help. It is an endless struggle to take small bites out of an enormous apple, at the core of which is the improvement of society through education, prevention, treatment, and care.

Mirroring the efforts of the Peer Educators is the staff of the medium-security prison in Malindi. During a visit to the prison, we learned that the warden has implemented a KRCS program to educate all of the prison staff and some of the prisoners about HIV. The goal is to sensitize the prison community to the dangers of the disease while reducing stigma amongst the population. The warden wants the prisoners under his watch to reintegrate into society with a larger understanding of the social context of the disease and the knowledge necessary to prevent transmission of the disease. It is a grassroots initiative and a unique program for both the prison and the KRCS – the outcome of which I hope is a successful working partnership and the impact of which I hope is the reintegration into society of former prisoners with better knowledge of how to improve their lives and the lives of those around them.

Through Peer Education, Home-Based Care, Disaster Services, Blood Donor Recruiting, and other programs, the creative and energetic staff and volunteers at the Malindi branch of the KRCS are nothing short of a fantastic example of how to affect a community, deliver a message, decrease stigma, and fight the good fight against the fear that surrounds HIV and AIDS in Kenya.

Malindi part 1: Fear

The woman in the orange head scarf was scared – I knew from the moment that I saw her. Outside of her home, a large group of men drank themselves into oblivion on the local hombrewed beer. One of them had donned a purple dress and a beret. Perhaps the beret was from the security guard job from which he claimed to have just returned. The men were full of histrionics, ocassionally chasing chickens and leaving the young children unattended. They wandered around on the dirt and garbage that was the central square of their village. It was brutally hot and it was only nine o’clock in the morning.

Asha, in the orange scarf, is a client of the Malindi branch of the Kenya Red Cross. Having come under the care of a Red Cross community health worker (CHW), she had been found bedridden, covered with sores, on the verge of death. Jen, the CHW who visited her twice a week, had convince her, some time back, to go to the Voluntary Counseling and Testing (VCT) center to find our her HIV status. The promise was one of prolonging her life. If she qualified, she could go on Anti-Retroviral Therapy (ART).

Malindi is a unique location for the Kenya Red Cross. Most of the CHWs who worked with the branch had been nominated by their village to represent them with the Red Cross. The stigma of HIV is an overwhelming force in any part of the world, but here, respected village members were able to bring the truth of the virus home to the same villagers that had elected them to the program. It takes trust and guts for anybody to reveal their HIV status, especially in some of the impoverished villages of Kenya where it is a commonly held belief that HIV is witchcraft. In other areas, particularly amongst the Luo communities in western Kenya, it is widely believed that having sex with a virgin will cure the disease. Instances of rape and incest have skyrocketed, with most of the victims being young schoolgirls.

Malindi is a predominately Muslim community. It is also a popular tourist destination for Italians and Germans. Most services in the area are geared towards aggravated Germans who prefer that their vacation spot be as similar to their home environment as possible. I sat at the bar at the Eden Roc Hotel, trying to read my book in peace, while 10 feet away a group of 50 or more German senior citizens played Bingo, bad music from the 1980s blared on the speakers, and the evening’s recap of European soccer matches flashed on the television. The view was one of beautiful palm trees and through the sultry heat of the evening sky the full moon provided extra light. All of this: utterly spoiled by tourism.

Just a few miles away Asha was probably winding things up for the evening. While her neighbors, George and Beatrice (also Red Cross clients), had electricity, Asha’s home was just a 2-room mud hut with a thatched roof and lacked power. It was dark, even during the day. The only light came from the embers under the 3-stone cooking fire, filling the house with acrid thick smoke and the smell of boiling chicken and herbs.

The ART that Asha had received since testing positive for HIV had brought her body back into shape. The final sores on her head were healing and she was able to move around without difficulty. The Red Cross seeks the bedridden and brings them hope and care. Yet, they cannot alleviate the fear. Asha settles into bed with her husband and her four children, none of whom have been tested for the virus. Her youngest daughter hovers around the house, coughing violently – she recently recovered from a bout of malaria. You see, it is not the drunk men in the village that Asha fears. It is the possibility that everbody surrounding her is also HIV positive. It is the fear of knowing her entire family is positive only to know that they are too poor to seek treatment.

So, the problem with encouraging testing in impoverished Malindi continues. Quite simply, for Asha, it is better not to know.

Kisumu

The neglect of Kisumu seems slightly more than recent. In the world of public health, it holds significance for being the primary entry point for HIV - slim’s disease as it is called - into Kenya. HIV blossomed in Kenya, and Kisumu withered from an opulent port on the shores of Lake Victoria into a town most famous for its appearance in research articles about disease.

The Sunset Hotel reflects that change, both in comfort and interior design. Once comfortable mattresses are now saggy hard spring boxes and the threadbare towels are sunset orange in color, matching the hotel’s exterior and dating the relief map of Africa in the lobby, where Angola is still Portuguese, Western Sahara does not exist, Ethiopia and Eritrea are united, and Namibia is little more than a provincial name.

The view of Lake Victoria from the Sunset Hotel is beautiful in the early morning, but fades to the sweltering heat of midday. Small fishing dhows sit still on the motionless water - today the wind has forsaken them. The second largest lake in the world and the source of the White Nile, Victoria is a fragile ecosystem, invaded by Brazilian Water Hyacinth, Nile Perch, and no small amount of raw sewage dumping into its waters, mostly from Kenya.

Introduced to help control mosquitoes, the Nile Perch (which grows to 250 kg) has reduced the number of species of Cichlids in the lake from over 300 to just 8. Shore areas where the Cichlids may have sought refuge are the site of a battle between Water Hyacinth, choking all of the oxygen out of the lake and entangling ferries and fishing boats, and humans, who have introduced a species of Weevil to the ecosystem, certain that it will only consume the plant. But what happens when the Hyacinth is gone? Two-Hundred and fifty kilo Nile Perch don’t eat mosquitoes and I’ll wager that hungry Weevils will find another source of food when the Hyacinth is gone.

The human ecosystem is also in disarray. The Central Kolwa District of Kisumu has good news - the HIV prevalence in the District is down to 25% from 38%. A remote branch of the Kisumu branch of the Kenyan Red Cross is struggling to build acceptance of HIV testing in the area, work being carried out by 58 Home-Based Care workers. Without compensation, they relentlessly visit hundreds of HIV positive people in Central Kolwa, bathing them, changing their sheets, changing their wound dressings, medicating them, and referring them to hospitals for further health care. The Red Cross Branch runs an IGA (Income Generating Activity) based around a poultry farm. Eggs are sold to locals for 5 KSh each (about $0.08) and they resell them for 7 KSh each, for a profit of about $0.03 each. If they are lucky and sell 30 in a day, they will profit $0.90. Other IGAs have recently failed. Floods destroyed a horticulture project and an ill-conceived project to create tailors failed because nobody was available to train locals to use sewing machine.

A small boy walked passed me in Central Kolwa. I waved to him and he approached Kirsten and me. His school uniform was in tatters, with the shirt unbuttoned and his pants were unzipped and he was wearing no underwear. He stared at his feet, which were in tattered shoes. He looked remarkably sad and whispered one word: sweets. Kirsten and I tried to engage him by asking his name and shaking his hand. His uncle, the director of the Central Kolwa Red Cross Home Based Care program, approached us. He told us that the boy had just found out, 5 minutes earlier, that his grandmother had just died from AIDS. He was alone. His mother and father were both dead from AIDS and his grandmother - his caregiver - was now gone, too. This 8 year old boy had nothing but an empty house to go home to. I searched my pockets for sweets, but had none. Kirsten gave him a toy car, which he slid into his pocket as he hung his head and shuffled off into the distance.

Central Kolwa is a catastrophe. The HIV prevalence has only dropped due to deaths and the lack of willingness of the population to be tested. For one young orphan, he is lucky that his uncle is willing to provide him with food and care. For thousands of others, unable to secure food, unable to afford a school uniform, and thus, unable to attend school, the future is not as bright.

I take $5.50 for granted on a regular basis. Whether it is a Venti sugar-bomb from Starbucks or a cup of fruit and yogurt at school, I’m more likely to put the $0.02 in change in the change cup by the register than to take it home. One meal at McDonalds is the cost of putting a child in primary school in some poor areas of Kenya. One bicycle means that 20 more people receive home-based care and potentially, anti-retroviral drugs in Central Kolwa. One more Red Cross volunteer means that at least 20 more people suffering late-stage AIDS can receive hospice care. Time, transportation, and money are everything here. It makes the thought of Starbucks slightly less sweet.

Still moving…

Things continue to go well, though computers are much further between than I would ever have imagined, considering their prevalence elsewhere.  So, I’m hobbled in posting right now, because the computers don’t support my USB drive.

However, all is well! I’m finishing work on the coast, in Malindi, and will soon return to Mombasa for 3 days before stopping in Nairobi to switch team members for trips to Nakuru and Garissa.
I will post more as soon as I get the chance.

Leaving Nairobi

After a few delays, the team from HHI and Fritz is leaving Nairobi.  Our first stop is Kisumu, and the local towns of Siaya and Busia.  They are in western Kenya, near Lake Victoria.

We will then visit Mombasa, Malindi, Nakuru, and Garissa over the course of the next two weeks.  Issues that we encounter change from community to community.  Our first stop, in Thika, was partially struggling due to poor Red Cross facilities.  The Red Cross branch that we visited today, Karen - Langata (named after Karen Blixen of Out of Africa fame) claims to have some areas near them that have an HIV prevalence of 70%.  Yes, supposedly 7 out of 10 people there are infected with HIV. 

How should a community even begin to approach the problem of providing prevention and treatment services to an area with such a high prevalence?  Yet, a cadre of unpaid youth volunteers tirelessly campaign in schools and around the neighborhood to educate the population about the true nature of HIV and how it is transmitted, and the virtues of abstinence and condom usage.  Incest and rape are serious problems at that branch, where over 10 new cases of incest are reported to the local officals each day — just imagine how many cases aren’t reported.

In the end, there is hope.  The youth volunteers are empowered by the training at the Kenya Red Cross offices and are role models for the community.  It is telling of their success in their campaign that the most popular club at almost all of the local schools is the Red Cross club.  The word is spreading, and the youth volunteers of the Kenya Red Cross Society are the people at the front lines. 

Safari and the Masai

One thing is certain about traveling: people give unsolicited advice and warnings before you depart. This is especially true for ‘exotic’ destination, such as Thailand and Kenya. “Nairobi is the most dangerous city in Africa.” “People will take advantage of you at every given opportunity.” “I hear that they force you to purchase things if you visit a Masai village.”

All of these things may have truth to them. Every warning can be taken for what it is because it is certain that these things have happened at some point. Yet, people are people the world around. I am guilty of succumbing to some of the fear and warnings before departure, but as soon as I arrive in an ‘exotic’ location, several things always dawn on me. First of all, I am and always will be a foreigner and tourist in every country other than the United States. Secondly, people, the world around, are just trying to make a living. Third, foolishness can lead to being taken advantage of anywhere, from Boston to Bangkok. Finally, offering people respect will usually lead to them offering it to me in return.

My arrival in Kenya was late at night, where a cadre of well-mannered taxi drivers waited at the airport, anxious to get a final fare for the evening. The kind man from the Kenyan Red Cross who picked up my party was the epitome of pleasantness and patience. He waited for us for almost an hour while we took advantage of a late-night cell phone store in the airport to buy Kenyan SIM cards for our phones. The service at our hotel in Nairobi was top-notch and we were greeted by everybody with a big smile and the expression jambo, which means hello in Swahili.

However, before we could get settled in, Danny, Susan and I were back on a small airplane, headed to the Mara Safari Club, on the outskirts of the Masai Mara national park. (It is the Kenyan extention of the Serengeti in Tanzania.) We stayed there through the weekend, to go on several guided wildlife safaris before starting work this week. The service at the Mara Safari Club was nothing short of exceptional. From Joseph, our driver and guide, to John, the waiter who served us at all of our meals and remembered our names after hearing them only once, it would have been possible for me to bask in the pleasant company of the Kenyan people all weekend, safaris aside.

Simply put, it is impossible to describe the absolute wonder and splendor of seeing spectacular wildlife in its natural habitat. I could stare for hours at every zebra or each wildebeest (of which there are thousands). Kenya is suffering a terrible drought, which has disrupted the normal migratory patterns of many of the animals and is the prelude to an almost certain crash in the wildebeest population this year. The grassy areas that normally provide calcium for grazing animals have received no rain in over 4 months, and many animals have resorted to eating the bones of dead animals to supplement their intake of calcium. It that proves to not be enough, the next generation of their offspring will suffer birth defects and bone deformities, which makes them easy targets for hyenas and lions. The last time a drought this severe happened, the wildebeest population in the Masai Mara crashed from 1.9 million to 900,000.

The sheer quantity of animals is amazing. Everywhere I looked I saw zebra, antelope, wildebeest, jackals, etc… the list goes on for a while. It is amazing to think that the western plains in the United States used to support similar animal populations, but that they were eradicated through overhunting and developed agrigulture.

The Masai people are also everywhere. The warriors are easy to spot because of their traditional bright red clothing. They herd cattle around and across the local plains. Some of them choose to open their villages to tourists and charge a modest admission fee to come in and see how they live. We stopped at one of these villages, and while I understand the importance of tourism as an income source for the people living there, I was saddened to see how their lifestyle had changed to accommodate tourism. The Masai people are very interesting - they have embraced a life with livestock in many ways unimaginable to me. Their homes are built of mud made from cow dung and are arranged in a circular pattern, surrounded by a ring of impenatrable thorny bushes on the outside, with several passages through. At night, to protect their livestock from predators, they bring them into the center of the ring of homes. To further protect the young cattle, they have special rooms in their house where they live until they are old enough to join the herd. In some homes, the baby cattle sleep with the children. As you might imagine, there is cow dung everywhere.

During their teenage and young adult years, the Masai are ‘warriors.’ While infrequently warriors in the traditional sense, they now act as cattle herders, bringing the herds across many miles of the plains in search of good grazing. They carry spears for protection.

At my suggestion, we visited the home of the recently-deceased chief of the Masai. Some of his 10 wives and 70 children still live in his former compound. Brian, one of his sons, was kind enough to spend nearly an hour telling us of the lifestyle of the Masai and the story of his life. Like many of the Masai, Brian is very well educated. He graduated from the University of Nairobi and is currently pursuing an MBA in business administration and accounting so that he can run his father’s business. Another Masai warrior that we met, Tombis, commutes 24 kilometers to school each day, on foot across the plains.

Many of the interesting aspects of their culture is still mired in unfortunate traditional practices. Females are not allowed to go to school - in fact, they are responsible for milking the cows, collecting firewood, collecting water (which can come from kilometers away), building homes, they are circumcised when they are young, and must participate the practice of poligamy which is common and accepted in Masai culture. Inside the houses, they cook over 3-stone fires where there is nothing but a tiny hole to exhaust smoke, making them and their children particularly susceptible to the woes of indoor air pollution.

I think there is hope for progression in the culture. Aware of the dangers of diseases such as measles and HIV, young children receive immunization shots and circumcision rites are performed with a disposible scalpel for each child. Unfortunately, disease is common amongst the Masai. Malaria, Cholera, Typhoid, and Brucellosis (from drinking unpasturized cow milk) are common and strain the traditional medicine system. Individuals who fall ill are treated for 2-3 days before being taken to a local clinic.

Our time in the Masai Mara area was very interesting. Making a good connection with Brian, we plan to meet him in Nairobi next week to enjoy dinner together. It will be the first time that I have dined with somebody who has killed two attacking lions with nothing but a spear.

Departure imminent

Alexis left for Atlanta two nights ago and I leave for Kenya in about 36 hours. As is usual with any long trip, I’m having a bit of a difficult time trying to figure out what I should take and what I should pack it in.

The trip to Kenya, as previously mentioned, is through the Harvard Humanitarian Initiative, known as HHI, and is sponsored by the Fritz Institute. To make a long story short, a consortium of sub-Saharan African national Red Cross organizations, known as NEPARC, is working with Fritz support to improve their services and programs. This multi-stage process began with an evaluation of organizational and managerial capacity among the affiliate organizations. The second stage involves evaluating programs and their outcomes. The team from HHI that is going to Kenya will look at the HIV/AIDS programs run by the Kenyan Red Cross and develop a tool for evaluating the programs. This is a pilot of the second phase of the project. The tool that we develop ultimately will be used to evaluate the HIV/AIDS programs run by the other NEPARC member organizations. Since the majority of funding for health services at Red Cross affiliates throughout sub-Saharan Africa goes to HIV/AIDS programs, the outcomes of the evaluation of these programs will stand as proxy for the performance of all of the health-related projects. (Other organizations are evaluating other programs, such as disaster relief services, etc…)

Kenya is located in east Africa. It is bordered on the north by Somalia, Ethiopia, and Sudan, on the west by Uganda, and on the south by Tanzania. The capitol, Nairobi, is a city of approximately 2-3 million people. Uganda and Kenya are former British colonies. Nairobi was founded a little over 100 years ago while the British were trying to build a railroad from Mombasa, on the coast of Kenya, to Kampala, the capitol of Uganda.

There are approximately 35 million people in Kenya, of whom it is estimated that 7% have HIV/AIDS. As with many other countries heavily affected by HIV, the life expectancy is low, hovering around 48 years for both men and women. In 2003 it was estimated that 1.2 million people in Kenya were infected with HIV and 150,000 died from AIDS.

Parts of Kenya are currently experiencing a drought. While famine is an ongoing concern in these areas, it is important to consider that malnutrition can magnify problems with AIDS. People who are unable to take food with their antiretroviral therapy (to combat HIV) can develop stomach ulcers, which makes it difficult for them to continue their treatment. Treatment of any disease is a difficult and complicated process. This is especially true with HIV, which attacks the immune system and makes infected individual more prone to developing other dangerous diseases, such as tuberculosis.

If you stop to consider that approximately 50% of the people living in Kenya survive on less than $1 per day, it is easy to understand why implementing effective prevention and treatment programs for any disease is difficult. In short, there is a lot of unmet need. It is only with the support of organizations like the Kenyan Red Cross that many people in Kenya receive treatment for their ailments or food for their table.

I am thrilled to be a part of the team from HHI that will assist the Kenyan Red Cross (KRC) and the Fritz Institute in their effort to improve the capacity of health services offered by the NAPARC members. Check back here for updates on the work that we do in Kenya and thoughts about other experiences that I have during my time there.