Humanity's Cradle, Humanity's Grave
By Matthew Smeal
(Published as Encounters on the Edge of Survival, Sydney Morning Herald, 25 July 2007
http://www.smh.com.au/news/world/encounters-on-the-edge-of-survival/2007/07/24/1185043117332.html)Onesmus Mmasai is a humble man. He is also a young man at 32. In his village of Shikunga in western Kenya, Onesmus is something of a tribal elder, a leader, a man bent on positive change for his community.
We had agreed to meet at Kisumu airport, somewhere easy enough to find. I had been in Kenya for close to a week – my luggage not quite as long – staying with the French section of Medecins Sans Frontieres (Doctors Without Borders) at their project at Homa Bay on the Kenyan shores of Lake Victoria.
MSF’s Homa Bay project is primarily concerned with the prevention of mother-to-child transmission of HIV or PMTCT. With a 35% prevalence rate, it’s easy to understand why.
“Friday is ‘pick up the dead’ day,” Sandra Sedlmaier, a German-born New Zealander and MSF’s resident midwife and PMTCT expert, told me. “That building there” she said pointing, “is the mortuary. Every Friday the families come and pick up their relatives who have died. The car park is full all day.” The average life expectancy for a man in Homa Bay is 49; for a woman, it’s 46.
Onesmus lives in Shikunga, a tiny village north of Kisumu, Kenya’s third largest city. Shikunga lacks many so-called necessities of life; running water and electricity are just two. It also lacks health care and is one of several local villages with a combined population of 30,000 with no doctors, no medicine and seemingly no hope.
As director of Murudef, a shortened name for Murua Rural Urban Development Foundation, Onesmus wears a few different hats. With business partner Anthony Atika Magotsi, Onesmus has implemented a micro finance office, providing low-interest loans to community members, helping them get a start. One recipient is Anthony’s wife who runs a small tailoring business. She now has three pedal-powered sewing machines and her business is doing well.
On cue, a man enters to discuss loan terms with Onesmus. He owns a boda boda, a bicycle with padded rear seat used as a taxi. He hopes to purchase another and employ a driver – a perfect micro-finance project.
Most of the time Onesmus runs a tiny clinic in Shikunga with nurse Roger Kidika. Every Friday they walk to the village of Shieywi, about 10km away. One Friday I join them. Dr Patrick Ayeka, a Ministry of Health doctor passionate about helping, meets us there. He arrives by bicycle; boxes of medicine are piled on the back.
“Tomorrow you will do much walking,” Dr Ayeka warned me the day before as we shared a Coke. When a Kenyan tells you there's a lot of walking to do . . . Onesmus, Anthony and I had just returned – by foot – from the neighbouring Imulama village. The community leaders were discussing a proposal to use a small building. Built ten years ago it has never officially been used for any purpose. Brick, lockable doors, and three or four rooms, it would make an ideal clinic.
The other item on the agenda was Kenya Aid, a start-up NGO created by four concerned Australians including two doctors. One of them, Dr Ryan Snaith recently spent three months living with Onesmus and treating the people of Shikunga. He is spoken of with glowing reverence around Shikunga, Imulana and Shieywi. Kenya Aid is hoping to provide the much-needed medical care to the area.
Onesmus and Anthony explained that we were in the poorest area of Kenya. Lush fertile fields and endless maize and millet deceptively told a different story. “The landowners don’t own the maize,” Onesmus said. “They lease their land for 1000 or 2000 shillings a year” (roughly ten or twenty dollars). Too poor to buy seed, tools, hire help or work their own land, the crop is owned by wealthy businessmen who sell it to large companies.
That Friday, Shieywi villagers move constantly towards the tiny Assemblies of God church that doubles as a school and now triples as a clinic. A few hundred will come and go during the course of the day.
Dr Ayeka begins by giving a talk on HIV to the first-gathered. HIV, mother-to-child transmission, family planning and sexual behaviour, are topics heard often in East Africa.
After his talk, Dr Ayeka and Roger Kidika set to work consulting the ever-growing multitude who in stark contrast to Fridays in Homa Bay, know that Friday is health day at Shieywi. Onesmus and others are busy sorting medicine from the bulk packages brought by Dr Ayeka into smaller quantities ready for distribution.
I was soon approached by one of the Shieywi elders: “Please, my son is deaf and he cannot speak. Can you help me?” Shieywi is an area that has seen few white people – myzungus. For many reasons, westerners represent hope. In Homa Bay I was met inside the female HIV ward with a half-crazed scream, “Help me American doctor!” Trying to explain that I was an Australian photojournalist seemed ridiculous. In Shikunga the day before, Aquinata, Onesmus' office assistant, saw an opportunity: “Please, I would like to go to university in Nairobi, can you help me?”
The following week in Kampala, Uganda I met Victoria, a young woman I rushed to a hospital last year when she was in labour. I was given the honour of naming her baby, an honour usually given to relatives, elders or carers. It was good to see Sarah, now almost a year old. Victoria approached me humbly: “I have been wanting to talk to you,” she said, “I would like to go to school.”
Back in Shikunga, Onesmus and I sheltered from the pouring rain under an awning and were soon joined by a woman in great pain and limping badly. Once seated she pulled up her dress to reveal her leg, the thigh and knee quite afflicted with Kaposi Sarcoma. The limbs swell and blister, becoming impossible to bend. The skin looks like it has suffered horrendous burns. Kaposi Sarcoma is frightening and just one opportunistic infection threatening those with HIV.
The woman had been in a hospital some distance away. With no money and no one to support her she could no longer afford treatment and had been sent away. When the rain eased, Onesmus and I helped her onto the back of a boda boda and watched her being pedalled away. She was going home to die.
Margaret is HIV positive. She was born with the virus. Until recently Margaret lived with her aunt in Nakasero village, a few hours' drive from Kampala. Her mother died from the virus some years ago. Pregnant, Margaret now stays at Wakisa Ministries in Kampala, a refuge for pregnant teenage girls. Many have been raped; Uganda, after all, has the highest incidence of rape in Africa.
Extremely poor, there are few ways a girl like Margaret can earn money. There is one way, however. Margaret knows the father of her baby. He had been trying to sleep with her for some time. Desperately in need of money to travel to a clinic for medicine, Margaret took advantage of the opportunity. Tragic? Yes. Irresponsible? Yes. Africa? Yes.
Margaret is very quiet, something that belies her anxiety. She, of course, was born with HIV from an HIV positive mother and worries if the same fate awaits her child. With good adherence to her ARV treatment, Margaret’s CD4 count is high and viral load is low. If she can maintain that during birth, there is a good chance her baby will be HIV negative.
As an added precaution Margaret plans on formula feeding her baby so not to transfer the virus through breast milk. After giving birth Margaret will move back to her village but access to clean water is vital if she is to use formula. Margaret gets her water from a nearby, polluted stream. A major killer of babies in East Africa is diarrhoea due to poor water quality.
And therein lies one of the quandaries of PMTCT: breastfeed and risk HIV infection or use formula and risk many other diseases. In areas like Homa Bay, they recommend breastfeeding wherever possible, even with such a high HIV prevalence rate and the reason is simple according to a former doctor: “We get less dead babies that way.”