From Under the Mosquito Net...

Habari Gani! Firstly, I apologize for the delay in posting this. The Internet is less functional than I expected and we have been extremely busy. We are up around 6:00 daily and fall asleep exhausted around 22:00. The days are packed, as you will read below, but they are fascinating, passionate and inspirational. So far, I have been astonished at the resounding hospitality and kindness of Kenyans, especially the Maasai Mama’s and the incredible Kenyan staff here at SFS. The lack of Internet and limited electricity is actually a blessing. I am thoroughly enjoying sleeping and rising with the sunlight, seeing the stars shining brighter than I ever though possible and having wonderful times around the fire pit, without a cellphone in site. I share a Banda (little hut) with two others, Kasia and Carolyn and we share three bathrooms and three showers (all outside) with twelve students. The showers rarely have hot water and we have to check around the toilets for snakes before going in. The other inhabitants of the camp include two different baboon herds, lots of large bugs, snakes of various breeds (you’ll hear more about this later). I have decided that this time in Africa is a perfect time to try things that I normally wouldn’t. So, every afternoon so far I have played soccer and have been pushing myself to try new things whenever I have the opportunity. Anyways, the following seven pages (on Word) are my collective entries from the first five days here in Kenya (it is so bizarre that I’ve only been here for five days)! Also, the internet is not strong enough to post pictures with this, apologies. Enjoy :)

After a collective 17-hour plane ride not including layovers, myself and the other SFS students arrived in Kilimanjaro Tanzania around 19:00. The plane rides were relatively uneventful, besides a young child perpetually kicking the back of my chair for about four hours (Side note, never fly Delta internationally- worst plane ever). Once arriving in Tanzania and stepping off the airplane, I was greeted with the deep earthy African smells that I’ve heard so much about and smelt a little in Morocco. The earth is so warm from the strong red sun and the scents are irreplaceable. We had to go through a lengthy immigration process but eventually got our visas and bags and loaded them into the rhino (big truck that held the bags), while we climbed into the trucks (land rovers- SFS has a huge herd of them). We drove for about 40 minutes to the Backpackers lodge Kilimanjaro, which was very accommodating. We had dinner at about 20:00 and then promptly fell fast asleep. I slept so well I didn't hear the call to prayer in the morning.

On Tuesday, we rose early to get on the road by eight, which was postponed due to a flat tire (welcome to Africa). We finally got going and after a three-hour drive we arrived at KBC (Kilimanjaro Bush Camp- home to SFS)! My first impressions of the camp were the incredible friendliness of all the staff and the serenity of the camp. When we pulled in, the faculty and staff lined up and we all shook hands introducing ourselves. There are about twenty or so of them so I'm still working on names. We then had lunch, unpacked and began orientation. At night, we crashed quite easily, but jet lag caught up and I was awake from 3 AM onwards. The next day, we continued orientation, getting accustomed to KBC, learning about the hazards; the Black Mamba and Egyptian Spitting Cobra among others are fellow inhabitants of the camp. We also discussed health policies/problems and such. 

Our first public health activity involved a visit to the Kimana Health Center. This center is a government run (public) facility. Before arriving we learned a bit about the center; there are eight sections of the center: outpatient, maternal and child health, laboratory, pharmacy, nutrition department, comprehensive care center, inpatient and the center store. We were encouraged to ask questions, such as what resources are offered, what the common diseases are and who visits the health center. The national Kenyan healthcare system is a six-tiered system. The first level is community health workers who are managed by the health centers. They report back the health centers and maintain relationships with their patients; this initiative has increased both the scope and scale of health access while providing excellent longitudinal data. The second level is the dispensary, where people can receive medications but are not evaluated. The third level is the health center, such as the Kimana Health Center that we visited. Here, they have nurses and a clinic officer who can evaluate, diagnose, administer medications, provide maternity care, provide HIV/AIDS care and basically do all minor surgeries. The fourth level is the district hospital (each district is supposed to have a functioning hospital). The fifth is the provisional hospital, which serves several districts. The final level is the Refaro or national hospital. This is the final stage for referrals before they are sent abroad, which is rare. 

The fascinating thing about the Kenyan healthcare system is that ever since 1 July 2013, healthcare is free in the health clinics. Additionally, at any level of healthcare system, women in labor can go to any hospital to have their baby and will not be turned away. The free healthcare in the health centers is available for everyone and anyone. Previously (and currently since it is still July 2013) only ~30% of women give birth in healthcare centers; ~70% are still at home births. Since the clinic is providing prenatal care (which includes mandatory HIV tests) and a required/recommended four prenatal appointments, women are highly responsive to these new opportunities. After their babies are born, they often return to the center for check ups, evaluations and vaccinations. 

The most common infections for children under five are respiratory, ranging from URTIs (Upper Respiratory Tract Infection), skin infections, diarrheal diseases, and UTIs. All of these problems can be attributed to social inequities faced in Kenyan's daily lives. For instance, the Maasai have been recently going through major shifts in their livelihood, from pastoral nomads to irrigated agriculture. This is largely due to the restrictions placed on the Maasai's land and the evolving cash based economy, requiring them to move from subsistence farming lifestyles to newer markets such as tourism and engaging in urbanization (which can also lead to a vast increase in STDs, but that's another story). This rapid change to an irrigated agricultural lifestyle has lead to detrimental land use practices, such as contamination of water resources through pesticides, herbicides, over-use of water, and improper use of petrol and diesel pumps to create irrigation systems. 

These detrimental land uses are perpetrating waterborne diseases such as typhoid and dysentery. It also is reducing the overall quantity of water, leaving people no choice but to use unsafe water, further perpetuating the diseases. Additionally, Kimana is facing vast water shortages due to these changes in water usage. This also forces people to use unsafe water that they would otherwise ignore.

Unsafe water usage can lead to diseases such as dysentery and typhoid, which result in unproductive populations. When people are sick, they are less efficient and able to work or go to school. This perpetuates poverty and results in respiratory infections in those too poor to afford proper winter clothing. With the new free healthcare, people can receive chlorine water treatment for free at the clinic.

The other most common diseases in children under five are skin infections and UTIs. The skin infections are found because of the close proximity of children in schools and the contagious nature of the disease.

The maternity care is especially impressive to me, as it surpasses much of the care in the United States. When a pregnant woman arrives at a hospital in labor, it is illegal to turn her away and all hospitals will provide free care (any level). Mothers who come in for prenatal care are automatically given HIV/AIDS tests and are consistently given them in case of contraction during pregnancy. At all levels, nurses are dually trained as midwives, so delivery is very safe and the infant and maternal mortality rates are very low in Kenya, lower than in the U.S.!

The community health workers work closely with the health centers. If people come to the health centers, their village and names are recorded. If they do not come back, the community health workers check up on them. This is a very effective way of maintaining connections with patients who might be further away from the centers.

For me, scale of the national health system is extremely impressive. It is vast and provides free care to anyone and everyone. However, there are problems associated with this free healthcare. For instance, only the least expensive drugs are free and a minimalist and cost-effective method of care can lead to further problems such as the development of multi-drug resistant diseases, chronic diseases and more complex problems. Using a cost effective approach is smart for market incentives, but diseases do not adhere to concepts of cost effectiveness.

After the visit to the health care center we came back home to KBC, had dinner and had a wonderful campfire. We played a game called Mafia, which I’m sure I will soon become familiar with. As I was walking back to my Banda from the campfire, I realized how incredible the stars are here. They are the brightest and most beautiful thing in the world, but it did make me somewhat sad to not be able to see my favorite constellations. Any suggestions for southern hemisphere constellations- Impy??

On Thursday we had classes all day. The morning class focused on the environmental and ecological aspects of diseases, such as the composition of the water and the effects of soil, fecal matter, chemicals, etc. Then we had a lecture on the Kenyan health care system, the six-tiered system as discussed above. We went further in depth connecting the system to the Millennium Development Goals.  We then had a special talk from a member of the local community who worked closely with the Imbirikani clinic in Kenya. This was a mobile clinic that specialized in HIV/AIDS treatment, but eventually reached out to effectively reduce infant mortality rate, reduce maternal mortality rate, reduce mother – child transmission of HIV/AIDS, reduce diarrheal diseases (top 5 causes of deaths in children under five worldwide) and many other factors. This center was funded solely by an American woman: Ann Laurie. This woman had been to Kenya and saw the incredible amount of unfair suffering of Kenyans, particularly those HIV/AIDS positive. Unfortunately, the center was forced to close after 9 years when Ann Laurie mysteriously did return. She skype-called and told the Kenyans that she did not have the funds to support the clinic anymore and was forced to close it.

This is the absolutely infuriating and disturbing aspect of non-governmental organizations. They are not federal, state or local establishments and thus are not required to be sustainable. These organizations can leave in a heartbeat, and in cases like this, when they leave the patients have nowhere to go. Through Imbirikani, they were able to receive free HIV/AIDS tests, free ARVs, free consultation, etc. They were also able to receive other care such as antibiotics and first aid. When the Imbirikani clinic was closed, the rates of HIV/AIDS infection began to rise again and people were left without any care whatsoever.

Learning about the Imbirikani clinic and the Kimana Health Center frustrate me immensely because they both have the potential to be successful, but only when the private and public sectors collaborate. The Kimana Health Center does it’s best to establish effective, efficient and equitable care in a sustainable manner. The inherent lack of funding and resources (staff, drugs, facility, etc) are detrimental to its success. Likewise, the Imbirikani clinic was ultimately a failure, despite the high rates of success because of the lack of sustainability in privately run NGOs. The most frustrating aspect is how well the HIV/AIDS patients were responding to the excellent and high quality care. One of my favorite quotes, “Where you live shouldn’t determine whether you live” is entirely applicable here. Just because these people were born in this region, in this time period should not, under any circumstance, mean that if they contract HIV/AIDS they will die when a person in the the North/Western world will lead a perfectly normal life. I find this absolutely unacceptable.

In the afternoon, we visited a Masaai Boma (village). Since this is rural Kenya and absolutely not a touristy area, this is not a tourist Boma and the Mamas usually don’t talk to muzungu like us (white folk- not derogatory). We were able to visit them because many of the staff members are Masaai and their wives, mothers and children live in this Boma. When we arrived, the Mamas, all clad in layers and layers of beautiful colorful jewelry and dress sang us a song. Given the principle of reciprocity, which we all follow here at KBC, we sang one back. This was a last minute plan, as no one told us about this part of the meeting; we did the hokey pokey. It was pretty hilarious and a great time. Afterwards, Daniel, a Maasai and an SFS employee translated (the Maasai mostly speak Maa or Maasai and not necessarily Swahili or English). We discussed the changes in land use due to the restrictions placed upon them as well as the changes in culture given outside influences. These changes have affected their dress (they used to only wear animal skins to their coming of age rituals) and their rituals (the boys no longer kill lions to reach manhood). We were shown the inside of a typical Maasai house; a minimum of five children and parents live in a tiny four room house with no toilet, electricity or running water. Despite this, they are beautiful, happy and wonderful hostesses.

On Friday we had a non-program day. We were supposed to have a community service day and had decided to teach sanitation and hygiene lessons at a local primary school, but the teachers were on strike. Initially, the teachers were excited that they could continue their strike and the students would still get a lesson. However, when they began receiving threats from teachers in nearby villages, we decided to postpone the service day. Instead, we went on an incredible hike almost into Tanzania to a wonderful waterfall. The hike was relatively intense, with a lot of climbing, sliding, trekking and jumping over logs, rocks and corn stalks. We also rescued a drowning mongoose from the waterfall and had a great time despite the heat and bugs.

On our way home we stopped by an HIV/AIDS clinic in Loitokitok, a town in between Kimana and the waterfall. This clinic was one of the most powerful things I have seen so far. These women provide testing for HIV/AIDS, counseling, support groups, monitor ARVs (anti-retroviral drugs), manage microfinance loans and provide overall support for HIV positive women (men are welcome too, however given the stigma surrounding AIDS, they do not- three men come to these meetings). Two HIV positive Mamas spoke to us about their experiences. The first Mama found out she was HIV positive after the birth of her two children and after breastfeeding both. As she said, it was a miracle that neither child was infected during birth or breastfeeding. Both are still periodically tested and so far have been negative.  The second woman had been hospitalized several times with various sicknesses before being tested for HIV. She didn’t believe that she could have possibly contracted the disease, but she tested positively. She felt as though her life was over. Her family completely ostracized her, locking her in her room by herself and feeding her food like a dog under the door. Finally, the women at this clinic reached out to both of these Mamas and took them under their wing. Now, both women regularly take their ARVs, attend weekly support sessions with 40+ women and act as voices for the plight of HIV positive African women.

With the ARV drugs, their livelihoods are vastly limited. While most of Kenya’s economy is agriculturally based, people on ARVs cannot do hard labor in the sunlight. Therefore, this clinic has set up microfinance loans (like KIVA) to help these women make beads and soap to sell to support their families and send their children to school. They also have a small cornfield, established by SFS students, where they give out corn to members every other week. This incentivizes them to come to the meetings.

            This center was directly affected by the closure of the Imbirikani clinic. They saw a massive rise in HIV/AIDS infections after the clinic closed and received many more members. It was incredible to hear these women’s impossibly brave stories firsthand. Their beauty and grace simply shined from within and their empowerment was clear. They had felt as though their lives were over, but with a sense of purpose, an opportunity and a support network they are able to survive. The lasting words of one the leaders was “Thank you for coming, we are so privileged to have you here with us. Please share our stories with your people on the other side of the world. Please don’t forget about us. But know, we will be okay.”

This meeting literally took my breath away. On our drive home, the truck was filled with passionate discussions about the injustices in the world and how to break the cycles of poverty and disease. I feel so fortunate to be surrounded by 24 incredible budding public health professionals, where we can brainstorm ideas that maybe someday will become a reality. The vast enthusiasm shown here will be difficult to surpass anywhere else. I am making wonderful friends, which will last a lifetime, I’m sure.