MSF Blog: Chiradzulu part 20

These last six months have been somewhat magical. There are a dozen people living in Chiradzulu representing every continent on the planet (except Antarctica). We expats arrived, stripped of our normal uniforms, our usual decorations, our regular badges of career, family, friends, clothes, cars, and neighborhoods. Things that would normally define our status, our place in society, sometimes even our identity. On this mission we are so starkly ourselves.
Perhaps being less inhibited, not as bound to what we are supposed to be doing, leaves us freer to be who we really are. I think it’s one reason everyone is so much more attractive. It’s a bit of a perfect storm, the freedom to be truly oneself, learning about oneself, and making true friendships. Perhaps none of us will realize the magnificence of it all until we are apart. Our nurse from Japan is leaving this week, and it’s the beginning of the exodus. I will leave in a few short weeks and am wondering if I can stay this open and honest when I return to my home country. Is it more fun to live with your guard up, or project an image, or simply being true in this moment?

We went to the lake on Christmas weekend and our doc from Colombia threw me into the water – fully clothed. I was a flash or rage in one moment and then a ball of remorse for shouting the next. Even after apologizing to him I felt like telling everyone sorry for having overreacted. But it’s fun to be human, to feel every sensation. We bear an orchestra of feelings, capable of a symphony of emotions. What a pity to be limited to the select chosen socially-acceptable few. If I have just this one life, I want to feel them all. The key is not to hold onto any, or you risk preventing the next one in full crescendo.

Like the feeling of awe when a Malachite Kingfisher flew into my office on New Year’s Eve. One of my staff caught it and set it free, but not before I could get a picture of it. It’s a beautiful bird with iridescent colored feathers and a bright orange beak. I hope it’s a good sign for the New Year. I try to begin each year with resolutions to become a better me. Five years ago I resolved to call my parents more, but as communication is so expensive here, they’re the ones with the large phone bill in 2008. This year I decided to resolve not to change myself, but give others the space to change. Every January 1st we hope and aspire to be better than we are, and too often we fall back into our regular patterns and habits. Some of that is due to our friends and families expecting that we simply stay who we were. If we gave people the space to reinvent themselves, would they? Even if only for a day. And if they were successful one day, could they repeat it?

I know changing behavior is hard, and removing an old habit leaves behind a gaping hole. Maybe if that void were filled or substituted with something else, the emptiness wouldn’t be so painful and more resolutions would be fulfilled. In that context, I will replace my judgment of others with curiosity; I will substitute expectation with encouragement. Gandhi said that we should be the change we want to see in the world. After all, a waterfall begins with a drop.

In the lead up to World AIDS Day, 2008, on December 1, photographer Brendan Bannon is in Kenya and will be providing images every day of his travels with MSF throughout the region.

Day 8 - WORLD AIDS DAY

Today is World AIDS Day. But there is also Malaria, Meningitus,  opportunistic infections to many to count and of course Tuberculosis.
Outside the hospital as I write this there is a huge public rally to  mark the day. For some it is a day of mourning, for others it is a  celebration and an affirmation of life.

Today is World AIDS Day.

On the wards it is another day of work for the  doctors and  another  day of struggle or reckoning for the patients. Tuberculosis is resurgent in places like Homa Bay-places where people  live in poverty. The living quarters are dark and  cramped with many people sharing  a single room house.

HIV  compromises   immunity and allows TB to take hold. The living conditions contribute to  its  spread. The treatment for TB iscomplex and long.

Lillian, an MSf patient is in the hospital today with a  relapse of  TB. She is  hooked up to a tube that drains the pus from her lungs.  She has  at her bedside table a small purse, a purple plastic cup filled with porridge, a mobile phone charger, many satchets of pills and a small red mirror.

“I want to see my face. So I brought the mirror. In the morning after I wash I look to see myself.3

“I want to see my face. So I brought the mirror. In the morning after I wash I look to see myself. When I loked before I saw some fuzz from the blanket. I brushed them off and  I was amused.”

Her eyes are lively, inquisitive and probing.

“Before when I looked in the mirror I was  fat and more beautiful. Today I see I am thin and not looking like myself.”

Lillian knows that  if the treatment works that  she may  again look like she did before. When she looks in the mirror in the future she may be fat and beautiful once more.

In the lead up to World AIDS Day, 2008, on December 1, photographer Brendan Bannon is in Kenya and will be providing images every day of his travels with MSF throughout the region.

Day 7 - DAILY LIFE

In covering HIV AIDS stories over the last 4 years I am always struck by how much this medical condition is also a social condition.  One way or another the hand  of HIV touches  everybody and everything in a place where  prevalence rates are above  30%.

Weekend rituals include funerals which are usually held on Fridays and Saturdays. For those on ART daily rituals  include  punctuating each day with pill taking and  bi-weekly or monthly doctors appointments.

People adjust. And those that don’t die; or they contribute to the epidemic in ways they may not realize.

Photographing the epidemic is always a challenge. It is vast and  it is everywhere and nowhere  at the same time. The  focus could be the clinics and hospitals where treatment is given. But that is only the most obvious place to look.

There are always opportunities to  make pictures of the  destruction - the destruction of bodies. We know those images well. The  real challenge is to effectively show the way that  the epidemic is infused in daily life. People really do live useful and full lives with HIV. Their continued presence is important to the people they love.

And yet we can not ignore the fact that people are still dying everywhere. Especially in  areas far from clinics. Communities that are not isolated from the spread of the virus are sometimes isolated from the spread of information that may save them.

When they do have the information they may not have the means- emotional or financial- to convert  that  information into treatment or prevention. In order to reach the hospital  some people have to travel 5 Km  just to reach the road and  another 30 Km  on that road to the clinic.

Sometimes you see generational change. I spoke to  a woman  named Jane who  found a way to deal strategically with her life only after she  began ART treatment. She began in the fish business trading her body for the opportunity  to buy fish. “If you didn’t sleep with them  they wouldn’t sell you fish” she told me.

Most of the fishermen and  the fish buyers she knew in  her youth have died.

There is a new generation on the small islands and beach  communities  that has taken its place and will  likely repeat  the mistakes that she made.

“You would need a lot of money to reach these places and organize the women and educate the men” she told me.

Jane’s  story:

“When I started in this business of fish there were so many of us. Competition was strong. Getting fish to sell was a problem. There were men admiring us and  ready to sleep with you in broad daylight. There were women going along and they bought fish very easily. My husband was still alive and had no job. We had children. So it forced me to compromise for the daily bread.”

“If I look for  the lives of my colleagues at that time I cant see them. They have all died.
“When I realized I had the virus I realized I would die if I continued living that way. With the ARVs I knew I would live longer and it gave me a moment to plan.
My husband was dead and I was alone. I needed to respect my children. I had to plan how I was going to live.

“People understand things differently, they perceive things differently. I understood my life differently  than others and decided to live it in my own way.

“What I am trying to say to whoever will listen is that you must think strategically- especially if you are HIV positive. You have to think, take care and not poison other people. There is no reason to die early. Life is how you take it.”

Treatment has changed my life and  replaced despair with hope.”

In the lead up to World AIDS Day, 2008, on December 1, photographer Brendan Bannon is in Kenya and will be providing images every day of his travels with MSF throughout the region.

Day 6 - MILKA’s DREAM

Milka Anyango Odondi wants to be a grandmother someday. Today she gave birth this morning to a healthy baby boy. They are both HIV negative.

“When I was pregnant I wanted to know  my status- I wanted to take every precaution to protect the life of my child. This is my third child and  we are all Negative.
I have been taking care of myself well. I don’t move around with other men and I believe my husband is the same. We stick to each other.

My husband tests every three months and is not going around with other women. We sat together and spoke about our lives and  pledged to concentrate our love in our family.

I encourage  my friends to take care good care and to not move around with other men.
If they stay  healthy they can take care of their children for a long time. If they move around they  might die and  leave their children  at too young of an age.

I want to be a grandmother; I am dreaming of it. I want the pleasure of  seeing my children grow and I  figure that  by old age I’ll have a lot to teach the younger ones.

I have known some wise women and I want  to be among them someday.  I have seen their homes grow well through their wisdom. I wish to be the same.”

Hours after the birth, Milka hadn’t chosen a name for the boy. She hadn’t talked to her husband yet. He works on a tea plantation in another district. In the rush to the hospital she  forgot to bring his phone number. When she speaks to him she will ask if he likes the name Ian Anyango.

In the lead up to World AIDS Day, 2008, on December 1, photographer Brendan Bannon is in Kenya and will be providing images every day of his travels with MSF throughout the region.

Day 5 - 11,622 HUMAN STORIES

Until today single themes or powerful stories emerged organically  giving me something to explore, photograph and write about. This day was different and I was left with several scattered moments that reveal the scope of what is happening  here in Homa Bay.

I visited Pamela, the head nurse, who sits at a large table in a big room lined chest high with filing cabinets.

As  we were talking people pulled out and returned stacks of files and  I became curious.

The cabinets were  numbered and the numbers climbed from left to right in a circle around the room.

The last number is saw was 11,622. “There are more files in another room” she told me. “11,622 human stories.” I thought. And Pamela said “ These are the lucky ones. They can come in for treatment. There are so many more out there in rural areas that don’t ever make it here.”

Earlier in the day Eric Aghan the MSF doctor brought me to see Henry. On Monday  we saw him unconscious- comatose from Meningitus.

Everyone was afraid and half expected that he would die. He had tubes in his nose and   hand.

“Here, when the family sees the tubes go in it’s like watching the  child  being taken to St. Peter’s Gate” Eric told me.

Yesterday Henry showed strong signs of recovery and Dr. Wanjala, the ministry of Health doctor removed  the tubes. “The patient does his part, we do ours and God does his” he told me.The boys mother found Eric on the ward and called him over. “She said ‘look Henry can eat on his own again!” and when she said it she was smiling all the way through. When parents see a child turn back from death they are very happy- it is a remarkable thing that she said.”

“Without proper care,  and if you are in a place where treatment is not  available, you would not be looking at a three year old child- you would be looking at another statistic.”

“There is no better way to thank the strangers who help MSF  here than to show them a child  that is still alive. People have hope not only for living but for living useful lives- going to school, farming, raising families, working. As doctors we have  a way toward happiness- we can properly treat  our patients and help our colleagues” Eric Aghan added.

The work continues. In Henry’s old bed there are two new patients with feeding tubes in.

In the maternity ward Azel was sleeping in the incubator. She was born 17 days ago to Dorothy, 26 years old, HIV positive.

Azel, sleeping in the incubator.

When she was born she weighed 1.92 kg.Now She is eating and gaining weight.

Dorothy found out that she was HIV positive when she was  3 months pregnant.
She told her husband after a few days. “He accepted the news. He told me it was normal. I told him to go and get tested. He didn’t bother.”

When a mother is HIV positive the child  will not necessarily contract the virus.
All protocols have been followed to help prevent the transmission of the virus to Azel. But  Dorothy won’t know for sure wether the baby has the virus for another 18 months.

In the lead up to World AIDS Day, 2008, on December 1, photographer Brendan Bannon is in Kenya and will be providing images every day of his travels with MSF throughout the region.

Day 4 - INVISIBLE CHILDREN

Walter is 12 and Charles is 10. They are alone and they are invisible.

“Nobody comes from the community to visit us here. They just look at us from the outside,” Walter said looking out the door of the house he shares with his younger brother.
They never knew their father. Their mother died in 2002 and  this April thier grandmother died.

“We dig the earth and plant and we go to school. No one is telling is to go. We go because we need more knowledge. I want to be a doctor- that’s why I go,” said Walter.

“Doctors help people and  I want to help people” he continued.

“Do you know any doctors?” I asked him.

“I heard of doctor Chula but he died 3 years ago. People were always talking good about him” he said.

Walter is 12 and Charles is 10. “Nobody comes from the community to visit us here.

I wondered if  during the time his two closest relatives were dying if they  received any medical treatment.

There is a cost recovery system at the public hospitals so people in Kenya who  are sick and poor often go without care believing it to be out of reach.

The boys  told me that when they get sick they wait for it to finish because they can’t afford to go to the hospital.

The brothers live in a 2 room mud and stick house on their grandmothers  200×200 meter plot.

Scattered around the land are signs of industry and initiative. There are the rows of maize, smaller plots for green vegetables and next to the house Charles has made a small nursery for tree seedlings. “this is my experiment,” he told me.

Walter is 2nd of 49 in his class  at school. Charles the younger brother is 5th out  of thirty.
In the face of an incredible tragedy these kids have and incredible resolve. And they have each other.

Charles said “My older brother is always  giving me advice. He tells me ‘We should love each other and not destroy the things we have.”

Walter added “ we still have a few problems- Sometimes  there is not enough food so we go to sleep hungry; The other problem is clothes- we don’t have clothes to wear to church.. or shoes. And sometimes we can’t afford the fees for our exams at school.”

After we face all of these problems and if we are able to succeed I hope the community  will see that we are people too.”

MSF Blog: Chiradzulu part 18

My staff started playing Christmas songs during the day. I guess it’s expected, but as the days get hotter approaching full summer mode, hearing Silver Bells sounds a bit off kilter. I suppose the entire southern hemisphere celebrates Christmas in summer. Is it necessary to change hemispheres just to see another point of view?

Billboard on AIDS prevention in Chiradzulu (photo by Rupa Kanapathipillai)

Next Monday is World AIDS Day. I know I ought to write something, considering I am on an HIV/AIDS mission in sub-Saharan Africa, but I don’t know what more to say. I’m grateful for the change of perspective gained from living here. I see first-hand the challenges of running an HIV/AIDS program, which seems to have as much to do with inadequate infrastructure and poor motivation as insufficient resources.

I won’t repeat the tale of irregular electrical and water supplies, or the inability to regulate the lab temperature, or the incapacity to process x-rays, and I don’t even know how the surgical ward copes. Even with a laundry list of infrastructure problems, this is one of the better hospitals in the country, mostly because people know MSF is here. Why does motivation to run a functioning hospital have to come from foreigners?
Our hospital doctors and nurse come home each day as if spent in a boxing ring. (I try not to complain when they are around.) They see Death daily; he walks hand in hand with the apathy of the underpaid, under skilled hospital staff. It’s difficult for me to understand how government clinicians and nurses see their job as a 9 to 5, clock-in clock-out, how-little-can-I-do position. The patients suffer, and then die. Even providing water to the hospital takes cementing pipes into the ground to prevent villagers from dislocating them and taking water for themselves. I don’t know what it’s like to have scarce water – or none at all – but you’d think people would respect the hospital’s water source. Then again, maybe it’s not about respect but rather survival. When you’re living for today, it’s hard to think about tomorrow. HIV has kept life expectancy around 40 – so how concerned can one be with life at 55?

View of shops in front of the hospital in Chiradzulu (photo by Rupa Kanapathipillai)

Many of us come to Africa with enough answers but few questions. It’s a cyclical story of short-term goals, insufficient collaboration, recurring apathy, and eventual burn-out, or the politically correct term, “donor-fatigue.” How long are we supposed to care about a continent when we don’t feel like they care themselves? But is it about how we feel they feel? Within a few months, or even years, have we gained enough experience to unravel motivations for all kinds of behavior and practices? Surely our post-graduate degrees have conferred some knowledge on us to understand why people do what they do. In the words of a Hollywood movie, we come to Africa with our hand-sanitizer, malaria prophylaxis, bed nets and laptops and hope to make a difference. Perhaps hope is not a strategy.

In graduate school, my friend had written on her mirror in lipstick to remember how to get through each day: First understand, and then be understood. We are all biased by the impressions put upon us since childhood, whether religious, cultural, or societal. Yet we use our own background as criteria to judge others, despite the differences. It’s easy to judge someone based on our own standards, but much harder if you understand their entire history. Does having a little patience and understanding take more effort than changing hemispheres?

Sandy, from Chiradzulu in Malawi

In the lead up to World AIDS Day, 2008, on December 1, photographer Brendan Bannon is in Kenya and will be providing images every day of his travels with MSF throughout the region.
Day 2 - A DAY OF CONTRASTS
Today was  a day of stark contrasts. It is incredible to see two  sides of a disease so seemingly different. One  harrowing and horrible the other colored by hope in the face of tragedy.

3 years old and HIV positive, suffering from menengitis. (Photo by Brendan Bannon)

In the district hospital I watched doctors and families gather around desperately sick children. Henry, 3 years old and HIV positive, was suffering at the moment from menengitis which left him unconscious. His mother, father and aunt were bedside  and consumed with  concern and anxiety.

Doctors and nurses rushed around him tending to other children equally sick. There were at least 2 children to  a bed- all with tubes inserted for feeding or breathing or intravenous fluids.

Eric an MSF doctor examined Henry’s eyes to see what damage the meningitis  had caused to his nervous system. The boys pupils responded  equally to the light, meaning that  the brain infection had not permanently compromised his nervous system. Chances for a good recovery were still high.

The eye exam showed that chances of good recovery from meninigitis were high (Photo by Brendan Bannon)

This news brought a brief moment of relief,  the family gathered  in  vigil around him.

In the afternoon I visited Clinton, a 12 year old HIV positive orphan who lives with his grandparents. After walking 5 km home from the hospital Clinton effortlessly climbed a few hundred meters of steep hill to his grandparents home.

Clinton walking home to his grandparents house (Photo by Brendan Bannon)

Clinton began treatment in 2003- 2 years before Henry was born. Five years later he is still strong enough not to need ART.

Clinton’s parents died within six months of each other from AIDS. They refused to be tested and never sought medical help. “My own son and his wife would not have died- but they refused to acknowledge this disease.” his grandfather said. Clinton contracted the virus from his mother. At the first signs of illness he agreed to be tested.

Although he is HIV positive, regular checkups and  treatment at the first signs of opportunistic infection have kept him strong. “ Now there is nothing I can’t do,” he told me.

Clinton sorting a collection of rusted nails. He wants to be an engineer when he grows up. (Photo by Brendan Bannon)

He also told me that he wants to be an aeronautical engineer. He sees planes flying overhead and  now he wants to build them. At one point he pulled a collection of bent and rusted nails from his pocket and began to sort and organize them.

“He is very practical and he does things practically. I think he could build airplanes someday,” his grandfather said.

His grandmother, understanding that these pictures would be seen around the world, had a message to share:

The first one (Clinton’s father) died because he did not go for the test.  Clinton agreed to go and he is surviving. So I think everyone should go for the  test. There  is goodness in testing… and the goodness is that I am still seeing Clinton. And I am happy!”

Clinton and his grandmother. (Photo by Brendan Bannon)

Clinton, the future engineer wanted to “ thank the people who design the drugs and deliver them. Without them I wouldn’t be here.”

“Without the drugs  this district would be almost empty now.” his grandmother added.

In the lead up to World AIDS Day, 2008, on December 1, photographer Brendan Bannon is in Kenya and will be providing images every day of his travels with MSF throughout the region.

DAY 1 - HOMA BAY

This is a photography blog about HIV/AIDS in Homa Bay, Kenya.
The idea is that everyday leading up to world AIDS day  you will have a chance to see life unfold along lake victoria in western Kenya.

Homa Bay, perched along the shores of lake Victoria is the  district center. It is a town of between 50-70,000 people.

In Kenya HIV prevalence is difficult to pin point.  Recent government reports put it at approximately 15% in this area.  Among pregnant women  the numbers are higher-22-24% are HIV positive.

Msf runs a program  here providing treatment to 13,000 patients. Roughly 8,000 of these people are  receiving lifesaving Anti retro viral treatment ( ART).

 Of that number there are 1,053 children on ART. Treatment for children remains a challenge. It is not well adapted to children and it is difficult to take. There is still poor identification and testing and parents remain reluctant to  having their children tested.

The numbers alone  are overwhelming but behind each number are thousands of individual human lives for whom  a positive diagnosis is a life changing event.

In the pictures that follow I will  bring you closer to the day to day reality here in Homa Bay, one town among thousands worldwide where the problems and challenges of HIV are being faced daily.

Fishermen in Homa Bay, by Brendan Bannon

In the words of Dennis Okinyi Oluoch a secondary student and former fisherman…..

Once someone has been infected  with the virus the whole family will be effected.
Here the men make thier living fishing and if the man gets sick the whole family suffers because he can not work.”

HIV transmission is linked to poverty. If there is a fisherman and he has money  he will give  the money or even fish to have sex with a local woman.
It’s like this: a friend of mine was a total orphan. Both parents died from AIDS when she was 17. At the time she was in secondary school.

She was the eldest and when her parents died many  friends and relatives ran away, they didn’t help her. She had younger siblings to  care for and no options for  a job. She found big friends to help. She was bold and would tell you her problems and offer you what ever you wanted  if you would help her. She was beautiful and what  they wanted was to sleep with her. She started getting sick and soon she died.”

Before the drugs were introduced very many people were dying.
Now with the drugs its hard to see people in town looking ill. If you walk along the lake you won’t wee one of these skinny people. Town folks who are positive can eat and will take their medicines.

There’s a lot of money from  fishing but it is used extravagantly. They spend  it on women.

Money is used as a weapon to win the heart. There is no true love on the lake only lust. If there is any love it is the love of money. Girls can’t fish and if you cant fish how do you get money?”

MSF Blog : Chiradzulu part 14
There is a growing and global lack of health care professionals. Countries such as the USA and France import skilled workers from other countries. But in countries like Malawi, there is a serious brain-drain occurring. Malawi has about 12 million people, and one medical school (since 1991) which, as of 2007, has graduated 254 doctors — ever. Many, if not most of these doctors, leave the country for more lucrative opportunities elsewhere. That leaves approximately 2 doctors per 100,000 people. Here in Chiradzulu, if our MSF doctors weren’t here, we’d have one doctor for the district of 300,000 people.

Of course one can’t blame the doctors, as anyone would prefer an international, better paying position. In Chiradzulu we have focused on task-shifting to provide adequate health care to patients. Task-shifting means clinical officers and nurses take on responsibilities that might otherwise be covered by a physician. More serious cases are referred up, but those with less training are asked to perform tasks where staff are in short supply. Task-shifting isn’t the only solution, but it is helping get medical care out into rural areas where patients might not always have access.

Mauwa Health Centre, Chiradzulu. Photo by Pat Carrick

 It’s not an ideal situation, but MSF is trying to make it work. Sometimes it feels like we’re paddling a boat upstream, especially when we calculate that one clinical officer may still see about 80 patients in a day. For them it becomes part of their normal work schedule, but maybe we should stop and ask what do we accept as normal these days?

 I know asking for a definition of normal can be a clichéd question, but perhaps we can dissect how something becomes normal. Could our impression of “normal” just be a collection of habits? Is it repetition that makes an act habit? My brother once told me that if you do something 12 times in a row, it becomes habit. I’m not quite sure where I’m going with this, but repetition, habit and normalcy seem to be on the same highway. If so, then I think I prefer the slower country roads where you might encounter something different, every once in a while, that could lead to something unexpected. Maybe it starts with opening our minds to the possibility of a different idea – one that we aren’t used to – one that’s not normal.

 How much complacency has set in when we discuss the era of the AIDS pandemic? Do we question the role of our own government’s policies that may be fueling the spread of the pandemic? More than 10 years ago, an editorial (AIDS 1995, 9:539-546) questioned the role of free trade promotion in declining sustainable rural subsistence economies (farming) that leads to more rural poverty and thus pushes people towards migrant industries. This also includes less employment for unskilled work, the kind that women with little education and low status rely on. In such situations, women often turn to prostitution. If you mix increasing migrant work with increasing prostitution the equation quickly leads to more sexually transmitted infections, which then contribute to higher rates of HIV transmission. Pardon the simplification of a very complex issue, but you can see how assuming the “normal” progression of AIDS in Africa may simply be us getting used to the idea of a continent being decimated.

If something is repeated multiple times, do we then take it as truth? Maybe it’s not about doing something different just once, but rather realizing the possibility of ideas that aren’t “normal.” It’s letting go of beliefs, and then sharing ideas. There are 6 billion people on the planet. Is it possible that the other 5,999,999 are doing it differently from you?

Sandy A. from Chiradzulu in Malawi