Encounters on the Edge of Survival

Matthew Smeal

July 25, 2007
In villages burdened with chronic poverty and death caused by widespread HIV infection, Matthew Smeal discovers that persistence can be the best medicine.

ONESMUS Mmasi is a humble man. He is also a young man at 32. In his village of Shikunga in western Kenya, Mmasi 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 as long - staying with the French section of Medecins sans
Frontieres (Doctors without Borders) at its project at Homa Bay on the Kenyan shores of Lake Victoria.

MSF's Homa Bay project is mainly concerned with the prevention of mother-to-child transmission of HIV. With a 35 per cent 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, told me. "That building there," she said, pointing across the car park, "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.

Mmasi 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 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 Muma Rural-Urban Development Foundation, Mmasi wears a few different hats. With a business partner, Anthony Atika Magotsi, he has started a microfinance office, providing low-interest loans to community members, helping them get a start. One recipient is Magotsi's wife, who runs a small tailoring business. She has three pedal-powered sewing machines and her business is doing well.

On cue, a man enters to discuss loan terms with Mmasi. He owns a boda boda, a bicycle with a padded rear seat used as a taxi. He hopes to buy another and employ a driver - a perfect microfinance
project. Most of the time Mmasi runs a tiny clinic in Shikunga with a nurse, Roger Kidika. Every Friday they walk to the village of Shieywi, about 10 kilometres away. One Friday I join them. Patrick Ayeka, a Ministry of Health doctor passionate about helping, meets us there. He arrives by bicycle, boxes of medicine piled on the back. "Tomorrow you will do much walking," Ayeka warned me the day before as we shared a soft drink.

When a Kenyan tells you there's a lot of walking to do …

Mmasi and I had just returned - by foot - from the neighbouring Imulana village. The community leaders were discussing a proposal to use a small building. Built 10 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 non-government organisation created by four Australians, including two doctors. One of them, Ryan Snaith, recently spent three months living with Mmasi and treating the people of Shikunga. He is spoken of with reverence around Shikunga, Imulana and Shieywi. Kenya Aid is hoping to provide the much-needed medical care to the area.

Mmasi said we were in the poorest area of Kenya. Lush fertile fields and endless maize and millet told a different story. "The landowners don't own the maize," he said. "They lease their land for 1000 or 2000 shillings a year" (about $15 or $30). Too poor to buy seed, tools, hire help or work their land, the crop is owned by wealthy businessmen who sell it to large companies.

That Friday, Shieywi villagers moved 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. 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, Ayeka and Kidika set to work seeing the ever-growing multitude who, in contrast with Fridays in Homa Bay, know that Friday is health day at Shieywi. Mmasi and others are busy sorting Ayeka's medicine into smaller quantities 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. For many reasons, Westerners, any Westerners, represent hope. In Shikunga the day before, Aquinata, Mmasi's 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."

At Wakisa Ministries in Kampala, a refuge for pregnant teenage girls, lives Margaret, who was born HIV-positive. 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. Many of the girls staying at Wakisa Ministries have been raped. Uganda, after all, has the highest incidence of rape in Africa.

Extremely poor, there are few ways a girl such as 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. Tragic? Yes. Irresponsible? Yes. Africa? Yes.

Margaret is very quiet, something that belies her anxiety. Being born with HIV from an HIV-positive mother, she worries if the same fate awaits her child. With good adherence to her anti-retroviral
treatment, there is a good chance her baby will be HIV-negative. As a precaution Margaret plans on feeding her baby formula so as not to transfer the virus through breast milk. After giving birth Margaret will return to her village but access to clean water is vital if she is to use formula. Many babies in East Africa die from diarrhoea due to poor water quality. Margaret gets her water from a polluted stream.

And there lies one of the quandaries for mothers: breastfeed and risk HIV infection or use formula and risk many other diseases. In areas such as Homa Bay, MSF recommends breastfeeding wherever possible, even with such a high HIV rate. The reason is simple, says one doctor: "We get less dead babies that way."

In Shikunga, Mmasi and I sheltered from the rain under an awning and were soon joined by a woman who was limping badly. Once seated she pulled up her dress to reveal her leg. The thigh and
knee are swollen and blistered. She cannot bend her limbs. Horrendous lesions such as these often affect 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, Mmasi and I helped her onto a boda boda and watched her being pedalled away. She was
going home to die.

Matthew Smeal travelled to Uganda at the invitation of Wakisa Ministries and to Kenya with assistance from MSF.

Copyright © 2007. The Sydney Morning Herald.

 

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