As I finish my Global Health Fellows assignment here in Nairobi, I’ve been taking time to reflect on the experience. The following “Top 10” list of hints might help enrich the experience for future fellows:
1. Remember that you are an ambassador for America- and Pfizer
Every day is an opportunity to make an impression -- either good or bad. Like many Americans, I’m proud of our country and the values it represents. But, it is important to remember that cultural practices are different all over the world. None is best; just different. I was careful to avoid saying, “Back home, we do it this way…” or to make judgments on why or how things are done in Africa. I may not agree with certain customs or practices, but I found it more useful to use each interaction to gain an understanding of how and why things were done rather than try to necessarily change perceptions or behaviors. I hope those I came in contact with walked away with a positive impression of Americans as congenial, kind, helpful, and eager to learn.
2. Learn the language. I will never be able to pose as an East African with my limited grasp of Kiswahili, but I will always be grateful that I took a handful of lessons. The smiles on people’s faces as I muddled through “Ni visuri kukujua” (it is a pleasure to know you) or the easier, “Jambo” (hello) made it worth the effort of taking lessons. In some areas, English was not prominent so I gained confidence having a few useful words and phrases under my belt.
3. Embrace your environment and make the most of opportunities presented to you. There was nothing to be gained having a pity party over missing carols and a white Christmas back home. Why not embrace the African summer with a Christmas pineapple and a few Jimmy Buffet tunes? Local friends or a knowledgeable local travel agent can help you see the amazing countryside and opportunities at your doorstep. Accept every invitation you receive; you’ll never regret it. I’ve now had the opportunity to feed a rhino, tickle an orphaned chimpanzee, attend a Kenyan wedding and join a Hindu family as they mourned the loss of a loved one. My GHF work allowed me to see Diflucan at work in a Masai village and to see hope and medical services brought to the hopeless in a crowded Nairobi slum. I wouldn’t have experienced any of this hidden away in my room in Nairobi.
4. Never underestimate the kindness of others. Media and world events can create a “siege” mentality and make you feel like a target, assuming everyone is out to do you harm. I figured, I’m probably safer hidden away in northwest Nairobi than I am in my midtown Manhattan residence. I found that most people will go out of their way to help you if you are in need and are eager to provide assistance or suggestions. When lost, people often walked me to my destination or had me follow them in my car. Sensing my confusion, strangers have helped me in grocery stores, airports, provided phones or rides and many useful suggestions.
5. Go with the flow and find humor in your dilemmas. Assume you won’t understand how everything works immediately. Figuring out things for yourself builds confidence in your ability to adapt and grow. I doubt I will ever master use of the phone in Africa (I don’t think I ever successfully placed a call on the first try). Exchange rates left me befuddled for weeks.
I also hope to be more tolerant of international issues and challenges when I came back to my “day job.” I often deal with international colleagues and would become frustrated when I didn’t receive immediate responses to requests. Now I better understand the challenges placed by time differences, lack of consistent and speedy Internet access and mail, limited phone access, and even differences in paper size.
6. Create a home. While it is important to fully experience your new environment, I found that small, but important things, can help you beat homesickness. In GHF training, one presenter suggested bringing a small album of photos from home. Keeping this on my desk brought a daily smile to my face and provided fodder for discussion with coworkers. The Internet is a God-send. Signing up for daily online updates from The New York Times gave me a quick update on news, politics, sports, and entertainment. Rationed weekly episodes of “24” and “Sex and the City” played on DVD on my computer provided my own “Must See TV” since much of the local programming was in Kiswahili.
7. Let go of your fears. I’m not suggesting taking long walks alone at night in downtown Nairobi draped in jewelry, but I found it important to take calculated risks. Since I was alone much of the time while on assignment, I did many things by myself or risked not experiencing them at all. I’ve gone on safari alone and found that most people will “adopt” a lone traveler. You learn to take obvious precautions but only learn by trying. I forced myself to try foods that normally aren’t a part of my diet. I never did learn to like goat or ugali but now enjoy curries, chapati and mandazis.
8. Make a consistent effort to keep in touch with those back home
I can’t express how much you look forward to turning on your computer at the office to see if “you’ve got mail.” Thoughtful friends provided constant cheerful wishes, updates and photos of growing children, the latest and greatest gossip, and words of encouragement that were greatly appreciated. So many people noted how much they enjoyed my tales and photos from the field. Mail and care packages are often difficult or impossible to receive so email is all the more precious.
9. Keep a Journal. Memories are fleeting and dim with time. Taking time to write down your impressions and capture your experiences will provide a lasting reminder of this once-in-a-lifetime experience. I’ve made a disciplined effort to capture not only major work experiences and adventures but also my impressions of day-to-day life and thoughts while gone. I think my journals will be valuable treasures in years to come.
10. Take a piece of your “new home” home with you. Like “action items” from a meeting, I am taking home tools to help me keep in touch with my new rafikis (friends) from Africa -- lists of e-mail addresses and requests for small items that can be mailed -- so that I can continue these important relationships for years to come. I know that keeping in touch will take commitment, but will be well worth the effort.
12/19/2003: SIKUKUU NJEMA
I guess it doesn’t matter what hemisphere or continent you are on, people enjoy the opportunity to let their hair down and celebrate a bit during the holiday season. AMREF’s annual Holiday Staff Day was held last week and Regina McDonald and I, the two remaining Global Health Fellows here in Nairobi, were invited to participate and help with the planning.
The AMREF staff uses this event as an opportunity to give to those in need during the holiday season. The day-long event began with a beautification project at the nearby Barnados Children’s Home. On this steamy day of 90 degree temperatures, staff teams worked to clean, paint, and plant on the home and school grounds. What a surprise awaits the children when they return in the New Year!
While the staff was gone, we worked a little magic of our own, decorating the facilities and the newly erected tent. My pharmaceutical sales rep skills came in handy when I went to the nearby Uchumi food store for holiday decorations and was able to convince the store manager to sell me the Santa hats off the cashiers’ heads as they had no more in stock.
African holiday parties are much more active than typical U.S. corporate events. Staff members go all out in preparation for the annual costume contest - donning elaborate tribal and holiday garb. After the mandatory speeches were complete, the group moved on to rousing rounds of musical chairs and skits. I can only guess as to their content as they were in Kiswahili! Trivia contests and the highly contested costume contest and karaoke competition had the crowd clapping for their favorites. The well-deserved “Staff Member of the Year” award went to Julius, a consistently pleasant and helpful member of the mail staff. Dancing ensued and continued until late in the evening. We could see office workers across the highway gathered on their rooftop craning to see the antics. Maybe things aren’t that different from our Pfizer holiday parties after all.
Sikukuu Njema, Happy Holidays from Kenya!
12/12/2003 CHALLENGES & SOLUTIONS
Most large international business organizations face the challenge of coordinating activities across borders, sharing existing best practices, and delivering consistent, quality products and programs. It’s no different for a non-governmental organization (NGO) like AMREF, when it comes to developing and implementing workplace HIV/AIDS programs. Working to overcome some of these inherent obstacles is one of the reasons I am here on this GHF assignment.
One way we’re working to improve communication and efficiency across the organization is through workshops such as the one I developed and facilitated recently, here at AMREF’s International Training Center in Nairobi. Participants from the eight African countries in which AMREF operates were joined by representatives from the U.S., United Kingdom, Italy and Swedish National Offices. We gathered to establish direction for AMREF in the growing arena of developing and implementing HIV/AIDS programs for African employers.
Like the population in general, the African workforce has been seriously affected by the epidemic, sometimes disproportionately, due to workplace risk and environmental factors. In some African countries, employers hire and train two to three workers for each open position, sine they anticipate that they will lose one or more to the disease. HIV/AIDS and related illnesses are responsible for declining employee morale and productivity levels and for increased absenteeism, illness and death. Employers are recognizing that it is in their best interest to act aggressively to turn the tide on this epidemic. As such, demand is growing for groups like AMREF to provide expertise to employers in implementing effective workplace programs.
AMREF has been active in implementing workplace programs for more than a decade but mostly on a country-by-country basis, focused mainly on delivering employee education seminars. The new Director General Michael Smalley recognizes that to move into a position as partner-of-choice for African employers, AMREF will have to expand and leverage their internal capabilities as a unified and robust organization. Comprehensive, consistent materials and approaches will help them achieve this organizational goal.
I’ve managed more than 100 new sales reps during my years as a Pfizer sales trainer but working with an audience of participants from diverse countries, backgrounds, experience, and languages brought its own challenges. Many of those participating were new to the organization or had never worked in delivering workplace interventions. Some of the presenters had limited practical experience and had developed their presentations from research materials I’d gathered and provided for their use. Keeping them actively engaged called for lots of favorite “trainer tricks”- group exercises, role plays, Q&A sessions, as well as goodies like Dentine gum and Zyrtec pens for volunteers. This helped ensure active participation.
We were able to review the latest published materials on effective behavioral change programs and compare AMREF best practices, finally agreeing on a consistent framework for delivering programs that would be used across the organization. Then we worked in small groups to determine what skills and expertise the organization currently possessed and developed plans to develop or acquire capabilities not currently available across the organization.
Participation wasn’t an issue when the group was asked what tools we could develop to help them become more effective in the workplace. They came up with a long “wish list” of items- checklists, fact sheets, scripts, introductory letters, modeling tools and posters and brochures- that could be used in promoting and building comprehensive HIV/AIDS programs.
Now our challenge is to make their “wish list” a reality!
12/10/2003: GOLD RUSH
In many ways, the mining industry reminds me of the pharmaceutical industry. As I visit the mining operations in both the Geita and Kahama districts within the Lake Zone of western Tanzania, I am acutely aware of the risk involved in financing the exploration and extraction of gold. Huge financial outlay is required up front ($400 million was required to begin operations at Geita, alone) and the site is not expected to begin making a profit until 2008. It is reminiscent of our huge R&D investments, all in the hopes of finding viable drug candidates.
The communities have blossomed in the areas surrounding the mining operations. Geita Town is now home to over 140,000 people, 80 percent of whom rely on the mine or related services as their source of income. It reminds me of the multitude of businesses that rely on our Groton- New London facilities for their customer base.
Once you enter the carefully guarded Geita mining site, you feel as if you’ve entered another world. Like Pfizer HQ, many services are provided onsite for the workers. A school is available for ex-pat employees’ children, a workout facility is onsite and a “duka,” or small company store, provides the occasional Snickers bar and cold Coke. The canteen is abuzz with workers grabbing a quick bite and connecting with co-workers before hurrying back to their jobs. Production is of paramount importance. The livelihood of the whole operation, in fact, that of the community, relies on the small precious amounts of ore that are carefully refined. In 2002, the Geita mine produced 580,000 ounces of gold. Does this sound familiar to Pfizer’s R&D and production processes?
Another similarity lies in the active roles both Pfizer and the mining companies play in supporting the communities in which they operate.
I’m here with AMREF Mine Health Project Manager, Meg DiCarlo, to recognize World AIDS Day at one of AMREF’s most successful community outreach projects. In my Global Health Fellows role, working with AMREF to expand and implement workplace HIV/AIDS programs, it’s particularly appropriate that I’m here.
The owners of the area mine sites have developed long-term relationships with AMREF aimed at improving the health of mine employees and the surrounding communities. Company leadership and AMREF have spearheaded a number of wide-ranging initiatives, designed to prevent and treat a number of prevalent diseases including HIV/AIDS, STIs, TB, and malaria.
At the Geita mine, we were joined by 40-year-old Julius Kaaya. He was diagnosed with HIV more than a decade ago. At small meetings with the miners, held under shade trees near the dig sites, he told his personal story of his diagnosis of the disease and the subsequent stigma (and later acceptance) he faced. Miners listened intently as Julius recounted the loss of family members to the illness and how he has learned to live, and thrive, as a PLHA (Person Living with HIV/AIDS). His story is a powerful one and he cheerfully responded to the numerous questions posed by the workers. Julius was able to speak with nearly 2,000 miners this week and also spent time with area community Peer Health Educators (PHEs) and a post-test club of town residents, some of whom have tested positive for HIV.
The visit was just one of the active programs supported by the mine. Messages on prevention and the importance of testing are reinforced through staff awareness presentations and during employee orientation sessions. The company HIV/AIDS policy is nearing implementation. Recognizing the importance of including families and communities in HIV/AIDS awareness and education efforts, the mine provides financial support to a community HIV Information Center, run by AMREF and its partners. The local project officer proudly gave me a tour of the small but efficient center, providing a wide range of much-needed serves such as VCT (Voluntary Testing and Counseling), STI testing and treatment, and family planning services. Their work is impressive, with about 75 patients treated weekly for STIs or provided with HIV testing and counseling. The staff is pleased with their success so far but admits the needs of the community are great with recent surveys estimating HIV prevalence rates at close to 20 percent in the town.
It’s obvious from visiting the area and facilities that these employers are committed to the fight against AIDS, not just on World AIDS Day, but on an ongoing year-round basis.
11/21/2003: GULU
As I watched AMREF’s documentary on Gulu, I wondered, “How can this be happening and I know nothing about it?”
AMREF’s Italian organization provides financial support for an impressive and much-needed project in Gulu, an area in northern Uganda. They had recently completed a documentary on their activities, which would be used to garner additional donor funding and to increase understanding of the problems and atrocities in this little-known area. I had the chance to view this memorable film.
Gulu is just one of the worn-torn provinces along the Ugandan-Sudanese border that has been deeply affected by a 17-year long civil war. Unlike Rwanda, where there was massive loss of life, in northern Uganda, widespread torture has been rampant. The fighting and torture have been going on for so long, entire generations have never known peace. Many don’t even know the reason for the fighting but know it threatens their safety and welfare and that of their families.
The Ugandan government continues battling with a small but treacherous band of dissidents, the Lords Resistance Army, led by a shadowy figure, Joseph Kuny. The rebels, using guerilla tactics, have been able to elude government forces for years and build the ranks of their army by kidnapping and brainwashing village children. In fact, 60 percent of local children under the age of 16 have been forced into service in the rebel armies. In turn, the children have been taught to kill and torture others- or face death themselves. Fearful of abduction, children in rural areas are traveling into more urban areas in hopes of refuge and safety from rebel forces. This has created a growing problem of homelessness and vagrancy in the towns.
Many of the area’s over 400,000 residents have taken to living in refugee camps. More than 24,000 live in the Awer camp alone. AIDS and other diseases are common in the camps; an Ebola outbreak a few years back killed many. Sanitation and services are poor in the camps but, for the most part, refugees feel safer than back in their villages. Rebel raids still continue sporadically so residents still feel little security.
AMREF and other NGOs are working with the refugees to help them develop water sanitation processes and to implement disease prevention techniques. Centers are in place to help rehabilitate child soldiers who have escaped from the rebels. However, relief work is difficult as relief workers are a risk and have difficulty traveling roads safely to deliver services to those in need. Thirteen organizations are currently in place providing much-needed services but, as the conflict continues and escalates, who knows what lies ahead for Gulu.
11/14/2003: BUSINESSES TAKING ACTION
Many Kenyan businesses are eager to do something to help their employees and their families in the fight against HIV/AIDS. Their dilemma: What do they do and how do they get started?
Antiretroviral (ARV) Therapy has been getting a lot of press in Africa these days. Media and medical reports consistently tout ARVs as an effective, life-prolonging approach and note the ongoing price drops are putting drug therapy within reach of more patients.
I had the opportunity to attend a training session designed to help local businesses implement employee ARV programs, sponsored by the Kenya HIV/AIDS Private Sector Business Council. This loosely-formed group of Kenyan businesses has been formed to encourage businesses to join and lead the fight against AIDS, rather than wait for government interventions and solutions.
Many businesses have avoided considering ARVs as they believed they couldn’t afford to implement a program. Required monitoring, lab tests, accessing and distributing the drug cocktails, and the necessary counseling all made the idea of ARV treatment seem too complex for the average business to consider. By pooling information gathered from member businesses, the business council was hoping to demystify the process and show the more than 60 businesses in attendance, concrete success stories from local organizations.
Representatives from the Ministry of Health were on hand to provide a government perspective on ARVs. Handcuffed by limited funds, past government programs have been limited and could only provide treatment for additional patients as more funds become available. As the average monthly prices for ARVs in Kenya have dropped from 43,000 Kenya shillings (about US $600) in 2001 to 2,100 Ksh (US $30) in 2003, the government can now provide treatment to more individuals and has vowed to commit more funds to pay for treatment for the neediest. The official noted that private sector support would be critical to reaching those in need who are still in the active workforce.
Presentations by local employers with ARV programs provided valuable insight. A local hotel chain noted that they were experiencing increased medical and funeral costs, high employee absenteeism and mortality and a drop in productivity- all due to HIV/AIDS. After implementing a company policy and implementing employee education efforts, the company began its ARV program. With guidance from their health care provider, the company used external medical centers to provide necessary counseling, testing, and drug therapy for its infected employees. The company reported that they had seen 35 employee deaths from 1995 to 2000, they have seen no deaths in those 30 patients treated with ARVs.
The Kenya Port Authority also reported similar successes. Beginning in 1991, the organization began peer education efforts as they estimated that one in 12 employees were HIV-positive. Their chief medical officer noted that their progress was due to a move in their upper management levels from an “era of ignorance” to an “era of commitment.” They implemented an ARV program using their onsite medical facilities and have noted similar gains in productivity and drops in costs due to the disease.
What stands in the way of more business jumping on the ARV bandwagon? Many are still grappling with issues of confidentiality and stigma. Employees are still not convinced it is in their best interest to come forward with their HIV-positive status. Cost continues as a concern. Cost models show ARVs to be less expensive than hospitalization for opportunistic infections. Employers are also concerned that once employees leave their employment and retire, they will no longer be provided access to the drugs (government schemes for retirees don’t provide coverage).
The mood among employers was cautiously optimistic and it was heartening to see the interest in providing therapy but so much more needs to be done by both the private and public sectors to get these drugs into the hands of those in need.
11/03/2003: A COMMUNITY WITHIN A COMMUNITY
I must admit, I was a bit nervous as I passed through the first of several security checkpoints at the new US Embassy in Nairobi. Recent online reports of local terrorist activity and the memories of the 1998 car bombing attack on the old US Embassy in downtown Nairobi where 219 were killed, were utmost in my mind. Today, I was invited to attend a “Town Hall Meeting” to meet the new US Ambassador to Kenya.
One of the first things US citizens are urged to do upon arrival in Kenya is to register with the local embassy. Upon completion and faxing of forms and questionnaires, I was added to the email list to receive periodic newsletters, security updates, and invitations (such as the one for today’s event.)
I was eager to tour the newly-opened facility with its local artwork, library and research facilities, and numerous citizen support activities. I was probably most excited by the “comfort store” as I’d heard tales of Oreo availability. Sadly, our guide told me the store wasn’t open today but I felt better after she confided that since the cookies were shipped with other goods, they often tasted of soap.
At first glance, the building looks like any other office building- full of meeting rooms, offices, and busy workers scurrying about their business. Kiosks provided visitors with materials on government, democracy and topics such as intellectual property rights; much like our Pfizer headquarters lobby provides annual reports and company brochures. It was both comforting and unsettling to hear that all the windows and doors were built to withstand bullets and artillery and that onsite housing had recently been constructed to house government personnel, to help ensure their safety and security.
The Town Hall meeting itself looked much like typical Pfizer employee meetings. Chairs and microphones were set for the 200+ attendees. New ambassador William Bellamy briefly spoke to the group then fielded an active Q&A session with attendees. He discussed the recent lifting of “Authorized Departure Status” for Kenya (travel warnings for non-essential travel are still in place but the change in status has allowed for new posting of government personnel to the area.) While questions at a Pfizer Town Hall meeting cover a wide variety of topics, all questions to the ambassador were related to one topic: security.
It was an odd feeling to be part of a group that felt uniquely targeted for terrorist attack. The group debated the wisdom of the newly-constructed onsite government housing- was it a better approach to group personnel in an area that could be more easily defended or to embed personnel in the local community. The ambassador reflected on progress made by the new government to improve security at airports, hotels and tourist destinations and touted their willingness to accept responsibility for improving the situation. He also noted that he hopes to work with American companies to discourage disinvestment in Kenya, as many are concerned by the present political and investment climate.
Since many of the Americans in attendance work with relief organizations, they were extremely interested in learning more about the status of US funding earmarked for AIDS efforts in 12 African countries. The ambassador noted that $15 billion in funding targeted for prevention, treatment and care was presently in appropriations voting. It will be interesting to see how the money is put to work on the ground in Africa.
10/27/2003: DIFLUCAN AT WORK IN KENYA
In a country where three people die from AIDS every five minutes, healthcare providers are eager to join the partnership. In Africa, the program has been a huge success. Kenya becomes the 16th African country to join the program which has already distributed over 4 million doses of Diflucan in over 1,200 participating hospitals. Over 15,000 healthcare professionals have been trained in diagnosis and treatment of cryptococcal meningitis and esophageal candidiasis, infections common in HIV/AIDS patients.
Flanked by the Kenyan Assistant Minister of Health Gideon Conchela, Imraan Munshi of Pfizer’s South Africa office noted that, in the past six months prior to the official launch of the program in Kenya, 192 patients have already been treated with Diflucan; 25 healthcare workers have been trained; and over 115,000 Diflucan tablets have been distributed free-of-charge in Kenya. Conchela and Munshi signed a memorandum of understanding, symbolizing this important partnership between private industry and the government in the fight against AIDS.
AMREF is one of the early participants in the program. While visiting AMREF’s health center in the nearby Nairobi slum of Kibera, I had the chance to visit with one of the patients benefiting from the Diflucan Partnership Program. The patient’s thrush had progressed to the point where she could barely swallow food or water. Within two weeks of starting her Diflucan regimen, she could eat again and felt much improved.
10/22/2003: DAR ES SALAAM
I’m loathe to admit it, but six months ago I couldn’t have picked Dar es Salaam off a map. When I considered jumping on a plane for a one-hour business trip, most often it was the Delta shuttle leaving hourly for Washington, D.C. Who would have thought I’d be requesting a Visa and disembarking on this Tanzanian city of over three million people ?
As a next-door neighbor to Kenya, Dar es Salaam is Tanzania’s largest city and unofficial capital. Dar is more Muslim than its neighbor to the north. It’s almost as if it tried to be just a bit different. I forget that in only an hour I’ve moved from high-altitude Nairobi to this seaside city. Unfortunately, I’ve also forgotten that mosquitoes and malaria are a problem in this warmer, moist climate so I’m careful to remember my daily antimalarials.
I’m here to work with the AMREF program director to develop a three-day workshop for personnel from Ethiopia, Uganda, Mozambique, Kenya, South Africa, and Tanzania, the six African countries in which AMREF operates. The goal of the session, scheduled for November, is to help AMREF develop an organizational strategy for confronting AIDS in the workplace and to capture and leverage the organization’s best practices.
Tanzania has had success in this arena. They are one of the partners-of-choice for employers wishing to implement workplace AIDS training programs. But, in this country where many industries see infection rates of more than 20 percent in their workplace, more needs to be done than training. As we build the training agenda, we are sure to include sessions on policy development, and plans to encourage education and testing. Since employees don’t live and work in a vacuum, it’s also important we develop approaches to reaching out to their families and the communities in which they live. Many employers are also considering implementing ARV programs for their employees but need help establishing and monitoring such programs.
In talking with Abdullah, the Tanzanian AMREF workplace program director, I’m impressed to hear how they implement training. Employees attend the four-hour training sessions after work in the evenings or on their weekends. Many of their spouses attend as well. At these sessions they learn basic transmission information about the disease and how they can protect themselves and their families from transmission. So many wives-tales exist about the disease and it’s important that trainers debunk long-held traditional beliefs and customs.
AMREF aims to help organizations build capacity within their ranks so they can carry on future training sessions themselves. Those selected as peer-educators will complete a six-day session to prepare them for their roles. This approach has met with mixed success. Some employers have implemented robust peer education programs with long lasting results. Others have had trouble keeping efforts alive and relevant. At one employer, BrookBond, after a two-year series of interventions, AMREF was able to monitor and document a drop in AIDS within their employee population from 21 percent to 19 percent (all employees were confidentially tested to track incidence rates). The company took over education and training and the infection rate has jumped to 38 percent. Who knows the “why” behind the jump- whether it is the result of a drop in education and training efforts or due to an overall rise in local incidence rates. Regardless, one thing is clear; there is a great need for interventions such as those we’re working to provide.
Entasopia and the Lake Magadi area are rugged areas of Kenya, best known in tourist guide books for the flocks of flamingos who forage for food in the mineral-rich waters of Lake Magadi and for the Olargasailie archaeological site, where man-made stone tools nearly half a million years old were unearthed. Today, these landmarks are not on our group’s agenda. We’re gathered here in a Maasai boma, a small collection of a dozen or so mud huts where members of an extended family reside as a group, to see Pfizer’s International Trachoma Initiative (ITI) at work.
It’s a desolate land for a solitary tribe. The Maasai, known for their nomadic existence, make their living herding livestock in this rocky, dry terrain. It’s a hand-to-mouth existence for many- a drought years back claimed close to a third of the herds and tribe members are just getting their herds of cattle and goats back to normal levels. Water is precious here- local Maasai must travel ten kilometers or more to water containment kiosks. Trips to small villages where they trade cattle for other necessities, such as cloth, are even longer.
Francis Dikir is Maasai and is project manager for the Migadi area AMREF/ Pfizer partnership fighting trachoma. Through the efforts of Francis and his team including local Maasai community health monitors, the program is reaching close to two thirds of the 21,000 area residents.
Trachoma is rampant in the area, most often affecting children and their mothers. It thrives in areas with little water, rampant dust, and excessive light- perfect descriptors of the area. Carried by flies and exacerbated through poor washing and hygiene habits, the disease affects the eye, often resulting in blindness. The frustrating part about the disease is that it is preventable and easily treated, but still is a leading cause of blindness in the region.
They say necessity is the mother of invention. The partnership has developed truly ingenious ways to teach villagers about disease prevention and monitor program progress.
As with other interventions, AMREF has recognized the value of using trusted local community members as peer educators. These community health monitors use a large cloth with images depicting the prevention and intervention process for trachoma to teach tribe members. The cloth depicts a boma with livestock in one area, homes in another, with water kiosks. They use this to reinforce the S.A.F.E. process, an acronym for Surgery (to treat severe trachoma cases); Antibiotics (Zithromax is an extremely effective treatment for the disease); Face Washing (children are taught cleansing techniques); and Environment (separating livestock from housing decreases disease spread).
These Maasai monitors travel to nearby bomas monitoring the spread of trachoma. Using a necklace of colored beads, the monitors examine patients and add a bead based on their findings- white for clear eyes, red for infection, and blue if a tribe member was not available or declined a check-up. AMREF program coordinators can then monitor trends, provide follow-up treatment, and even use the beads to take a census of area residents.
We then visited nearby Magadi Hospital. The hospital and surrounding housing is supported by the government, AMREF, and the largest area employer, Magadi Soda Company, a salt and chemical producing company. Doctors travel to the small cinderblock hospital twice a year to do eye surgery. We arrive as doctors are removing bandages from patients who received surgery for cataracts, glaucoma and trachoma scarring on the previous day. Through AMREF donor funding, doctors were able to insert 13 intra-occular lenses this week. Our guide, a local community health worker, was with us as bandages were removed from his grandmother, one of yesterday’s cataract patients. Her first view was of her grandson. She was so excited that she asked to have surgery immediately on her other eye.
It was so gratifying to see how partnership between the government, AMREF, Pfizer, and the Maasai community could use a simple system of beads and cloth and treatment to help these people maintain their sight.
Smoke billowed over the Kibera slums. Fire is cause for alarm in this Nairobi enclave. With close to one million Kenyans residing in small, cramped wooden stalls and shanties set among narrow dirt alleyways, Kibera is primed for a disaster and residents are quick to take action. Our group had embarked on a tour of an AMREF-sponsored heathcare facility in this inner city area, but we were largely ignored as neighbors quickly tore down structures adjacent to the flames, with hope of avoiding a larger catastrophe. With no roads, fire trucks and ambulances can’t enter Kibera so a bucket brigade was the final resort to save the area if the fire gained the upper hand.
AMREF uses a partnership model when approaching projects such as the Kibera Community Based Health Center. The land where the center now stands was once a trash dump, cleared by community residents and AMREF. Working together, AMREF and residents have built 200 toilets and 17 water collection kiosks (one was destroyed during our visit). AMREF uses community residents as voluntary community health workers, visiting patients in their homes to review TB or HIV treatment plans, doing prenatal checkups, or to reinforce instructions and disease prevention techniques.
At the core of the community stands the health center. It is small, understaffed, overused and greatly appreciated. Mothers with small children bundled in blankets sit waiting on benches outside the center, waiting for their chance to meet with one of the counselors or nurses. The children’s vaccination program has been able to reach close to 80 percent of Kibera youth. With HIV infection rates at close to 15 percent across the nation, the small lab is swamped with testing for HIV and TB. They need an x-ray machine but will have to rely on donor funding to get such basic equipment. With over 120 patients a day, staff work quickly to meet the needs of patients.
For HIV, the center has a strong focus on education, prevention and Voluntary Testing and Counseling (VCT). By partnering with various governmental and non-governmental organizations, the center is now providing anti-retroviral (ARV) treatment for 59 HIV-positive patients and hopes to increase treatment to 300 patients in the future. Staff members are careful not to build up false hope for patients as they can’t be sure they will always have a supply available of the life-sustaining drugs.
The center is participating in the Diflucan Partnership program. We had the chance to speak with one patient, 24-year old Celestin, who is HIV-positive. Celestin’s oral thrush had progressed to the point where she could barely eat, drink or talk. She started on Diflucan and told us she felt better within two days. A mother of a one-year old son, Fred, Celestine credits pre-natal treatment with Fred’s negative HIV status and is currently being treated with ARVs.
10/3/2003 SAMBURU
Human beings constantly amaze me with their capacity to learn and survive. I remember when I first move to New York City from my lifelong home in the South. I learned new NYC “survival” skills- navigating the subways, snagging a cab around Theatre time, and the plethora of acronyms like FDR, JFK, and GWB. I had survived just fine before without this knowledge but wouldn’t fare well in my current concrete jungle without it. My city-survival skills were useless during a recent visit to the northern Kenyan Samburu region. Thankfully, Samaro was there to provide guidance and training.
Samburu is not a particularly hospitable area. It is semi-arid with little water. Animals and that live here have acclimated to need little water or make frequent visits to the area watering holes. Many animals lay dormant during the heat of the day but many, like lions, hyenas, and leopards, can be heard rambling around at night. Acacia bushes, with their curving, thick thorns line pathways providing painful reminders to pay attention to your surroundings.
Legend has it that the Samburu and Maasai were once of the same tribe but when the Maasai moved south, the Samburu remained in the northern lands. While many Maasai have assimilated into customs of the settlers due to their closer proximity to larger cities, the Samburu remain largely untouched, fiercely proud of their traditions and lifestyle.
Samaro is a Samburu warrior. He, and a dozen or so other young men from his village, joined the warrior ranks in a ceremony held more than five years ago. With this title, comes great responsibility to guard and protect his tribe members and their livestock. As such, Samaro and his warrior friends Saraiyo and Lenderop are highly respected and welcomed in all homes with a special place to sleep. As we walk, he points out tracks of various animals lightly marked on our sand path. “See here,” he points out. “Lion tracks. Fresh ones.” As I plan my escape route into a nearby stream in case of an encounter, Samaro suggests we move faster to get home before dark.
Practical knowledge like this is important in Samburu. As we walk, Samaro, in well-spoken English, points out various plants, reciting their local name, Latin name and tribal use. Sericocomopsis, a leafy plant used for treating malaria; another for constipation. He picks a sprig of cadaba farinose, traditionally placed on the heads of newlyweds to bring good luck. I attempt to use my handful of Swahili words to voice my appreciation.
Samburu is known for its elephants. Its nature park is home to over close to 1,000 of these gentle giants. Samaro can recognize and name several hundred of the permanent residents, just by viewing their unique ear shapes, tusks, and sizes. He shows me the drawings he has painstakingly made to assist with identification.
I listen carefully as he explains various Samburu traditions. Unlike the other warriors, Samaro has short hair under his ornate beaded headdress. He proudly explains he has completed the tribal haircutting ceremony this past September 19. Tribe members take part in this rite of passage in a carefully planned manner. Warriors in each “clan” or family complete the process together. They pour milk on their freshly shorn braids and throw them away into the river to be carried away with the current. This signifies that they are saying goodbye to a period in their life and preparing for a maturing process that will hopefully lead to “elder” status. The next elder ceremony is scheduled for 2005 and Samaro hopes to become an elder at that time.
A complex process must be completed before a warrior can marry his selected wife. Tribe elders must carefully review the family history of both the warrior and his wife-to-be, considering their clans and lineage before approving the union. As a member of the first clan, Samaro could only marry women from the second and third clan. To marry, men must provide a dowry of twelve cows to the woman’s various family members. All three warriors I have met are married. Saraiyo wants to take a second wife to help take care of his goats. I consider asking him if it might be cheaper to hire a goat herder rather than take on an additional wife but decide it is safer to leave my thoughts unsaid. He must hurry to marry before the full moon passes or must wait until the next marrying time arrives.
Samaro proudly shows me the camp where his livestock are kept. His extended family tends to a menagerie of goats, donkeys and camels (well-suited for the terrain). He became a father for the second time just last week. The naming ceremony for his new daughter will not be held for two years but he secretly confides she will be named Lydia.
Burials also follow Samburu traditions. Graves face either Mt. Kenya or the sacred mountain Ololokwe. Graves are placed based on the role the individual played- babies are buried by the front door, fathers in the center of the property, warriors are buried in the bush. When passing a grave, Samburu place a tuft of grass on the grave and recite a verse, “Your head is dry. My head is wet. Soon my head will be dry like yours. My head will follow you soon.”
I can’t imagine a better guide as I pass through this strange and wonderful place.
09/26/2003: KISS, BOW OR SHAKE HANDS
My first week at AMREF coincided with ICASA, the International Conference on AIDS and STIs in Africa. In its thirteenth year, ICASA draws an international crowd of close to 8,000 researchers, members of non-governmental organizations (NGOs), foundations and corporations, students, and exhibitors. AMREF is quite involved in the event, providing numerous speakers, skills-building sessions, posters, and an opportunity for attendees to participate in Voluntary Counseling and Testing (VCT) at AMREF’s display tent. As part of the “I Know” campaign encouraging VCT, AMREF provided counseling sessions and HIV testing services to close to 250 delegates during the four-day meeting.
I had the opportunity to attend several sessions on “AIDS in the Workplace.” Many African employers are partnering with local business associations and NGOs to implement a wide variety of initiatives aimed at stemming the tide on the disease. Speakers described the impact HIV/AIDS has on local businesses. The disease robs businesses of workforce members during their most productive years, increases healthcare costs and absenteeism, and decreases productivity and morale. Some businesses must hire three people for each position- preparing for the fact they will lose workers to the illness.
Conference speakers described ways businesses can implement HIV policies to guard against stigma and ensure confidentiality, develop peer counselors, hold educational sessions on-site, encourage VCT, and integrate anti-retroviral treatment (ARVs) as an important part of treatment. I had an opportunity to attend an evening event sponsored by the Global Business Council. It was gratifying to hear the speakers, all business and community leaders, thanking the pharmaceutical industry for their research and urging them to keep up the good work.
We had a bit of excitement here at the AMREF training center as we hosted Kenya’s first lady, Her Excellency Mrs. Lucy Kibaki, for an evening event. In many ways, it reminded me of my “regular” Pfizer job, planning HQ events and town hall meetings. I worked with the team on planning logistics, handling visitors, taking photos, and the like. We actually rolled out the red carpet (they really have a red carpet for dignitaries) for our visitor and had coverage from as far away as the NY Times. Mrs. Kibaki noted that 29 Kenyans die each hour from AIDS and commended the work of AMREF in the fight against the disease. Along with the other two Global Health Fellows, I had the opportunity to meet the first lady and briefly described the GHF program with her.
09/22/2003: WHICH COMES FIRST… THE CONVERTER OR THE ADAPTER
My Mom used to say, “the devil is in the details.” My first weekend acclimating to my new surroundings has proved that. What seems simple never is! I made my first trip to the local Uchumi, the Kenyan Wal-Mart of sorts, to purchase needed household items. I hadn’t quite mastered the exchange rate and was not sure whether my 1,000 shilling bathmat cost me $13 or $142.85, my two closest approximations.
Kenyans use cell phones more than New Yorkers. Here, they aren’t a status symbol of busy Wall Street traders. They are a necessity of life and are more dependable and accessible than local land line telephones. To use a cell phone, you must go to a local store and purchase a “scratch card”. Using the edge of a coin, you scratch off an area of the card, much like a lotto ticket, to reveal your 12-digit code. This code is loaded into your phone and adds “minutes” to your phone, allowing you to make calls. I spend a lot of time buying, scratching and loading these “minutes” into my phone, as a call to the States is an expensive endeavor.
Since the NYC blackout, I am acutely aware of (and value) electricity. Using my assortment of electrical appliances is always an adventure. After carefully reading details on the appliance, I peruse my collection of adaptors, converters, and surge protectors to determine which safeguards will allow me to safely utilize a radio or hair dryer. So far, nothing has exploded or burst into flames.
09/19/2003: TEARS AT 10,000 FEET
At KLM check-in, I was feeling a bit full of myself. They didn’t charge me for excess luggage! The organizer had won- I was now a packing Jedi. I was prepared with several kinds of currency, had carefully perused duty-free shopping, had settled comfortably into seat 6A, and had chatted amicably with my seat mate. Then I opened “the book.”
My husband had placed a binder in my travel bag with strict instructions that it not be opened until we were airborne. What awaited me were a collection of clever poems, favorite photos, children’s drawings, and heartfelt letters from friends and family—all secretly gathered and collected in an album. I was thankful that I had warned my seatmate of a possible reaction. Tears mingled with laughter as I turned each page.
People have often asked me about the hardship of this fellowship. “Aren’t you afraid?” they ask. “Are you worried about getting sick or something bad happening?” This album has confirmed that the real hardship is missing those you care for. But it also makes me realize they are with me in spirit and will be there to share my adventures upon my return. Now I can carry their good wishes with me throughout my journey.
I find it interesting that many people perceive this fellowship as a selfless act. I feel that I will be the one to gain so much more from the people I will come to call “friends” in Africa. The people making the sacrifice are really those that keep things going back home… co-workers who help pick up additional work and family and friends who keep things running smoothly at home.
09/18/2003 ZIPLOCK BAGS… A GIFT FROM THE GODS?
My guest room has taken on the look of the White House situation room. Electronics, cords, and batteries line one wall. Bottles of antibiotics, anti-malarials, and sundry other drugs with prescription labels carefully taped in place, are bundled in an overnight bag. Shoes are lined up like soldiers- all awaiting Scotchgard treatment.
I’m not preparing for military conflict. I’m preparing for my Global Health Fellowship in Kenya.
They say your “real self” comes out when placed in stressful situations. It is now apparent, my real self is an “organizer.”
Since I received the e-mail notifying me of my selection for the program, a tiny sliver of my mind has been continually occupied with thoughts of the assignment and what awaits me in Kenya, where I’ll spend my 5-month assignment working with the African Medical and Research Foundation AMREF) to help develop workplace HIV/AIDS education programs.
I’ve loitered in the Barnes & Noble travel section, reading up on east Africa. I’ve completed cultural sensitivity training provided to all GHF participants. None of this had prepared me for the “real” dilemmas of packing:
• How many flossings will I get from an 80-yard pack?
• Do they sell Q-tips in Nairobi, and
• Will Ziplock bags withstand the rigors of worldwide travel
Living in New York City, you begin to think you are a tough cookie- dodging crazed cabdrivers, overcoming terrorists and blackouts, and conquering the confusing and gritty subway system. Faced with the next five months, I feel more like the Manhattan born-and-bred wife on Green Acres, thrust into a Midwestern farm with her limited city skills. Will a girl from the land of “take out and delivery” make it in Kenya? Stay tuned.
