Lamu

Beaming in the mid-day sun like bright white beacons, the clusters of ancient stone buildings and the starbursts of green palms were all that broke the otherwise endless blue of sea and sky as we crossed the narrow ribbon of Indian Ocean from nearby Manda Island.

We were headed to Lamu; an island ringed by a collar of white sand and renown for its fascinating cultural history and fantastic Swahili cuisine. Nestled tranquilly in an archipelago of the same name that stretches Kenya’s northern coast to Somalia, Lamu and its surrounding islands are dotted with isolated rural villages where the distance, difficulty, and cost of travel make access to health care extremely limited. We had come to conduct an assessment of the malaria health situation and to meet with the local Red Cross branch and Ministry of Health district to discuss a proposed community based integrated malaria prevention, diagnostic, and treatment project.

Lamu is a captivating place where you cannot help but feel transported back through time and absorbed by cultural richness. It is recognized as one of the oldest and best preserved Swahili settlements in East Africa with most of its architecture dating back to the 14th century when it was one of the main ports of the Arab trade routes. Unlike most of the rest of Kenya, the region is almost entirely Muslim, but centuries of Arab, African and European cultural influences are reflected in the diversity of today’s Swahili culture and evidenced in Swahili cuisine’s blend of Indian and Arabic spices with local seafood tropical fruit. Palm thatched roves cap the white stone buildings of the island’s towns that are themselves intricately woven mazes of narrow lane ways where the only traffic is the occasional donkey, a group of giggling children, or a woman gliding past gracefully; her black flowing bui bui garment alluding that she was perhaps just a shadow.

After several weeks of gridlock traffic during my daily commute to the Red Cross office in Nairobi, it was a pleasant change of pace to have only to negotiate the odd donkey-jam during my ‘commute’ along the shoreline from Shella - where we were staying, to Lamu town - where the Red Cross office is located. We met the local Red Cross staff in a small bungalow restaurant over looking the ocean the morning before we were to set out for some of the other islands to carry out our assessment. They were gracious in sharing with us information about the programs they are running and the challenges they face.

As the region is susceptible to both severe drought and flooding, the resulting serious issues over access to clean drinking water, food security, and overall basic health have been their priorities. The Kenyan Red Cross has had an active branch in the region for a number of years and today has over 200 volunteers who have been involved in a variety of disaster response and health programs; including a recent integrated measles/malaria campaign that saw the distribution of Long Lasting Insecticide-treated Nets to all children under five. They noted that having volunteers in almost every village gave them unique access for providing community based health strategies. They also noted that there were virtually no other organizations working in most of the villages. Unfortunately, though they have the capacity, in a region made up of islands, the enormous geographic and logistical challenges mean they do not always have the necessary resources or support.

Following our meeting with Red Cross, the members from the branch arranged for a meeting with the Ministry of Health regional representatives, and after gathering our things, we re-entered the traffic along the break water – men carrying large sacks of dried goods or pushing carts, and of course, more donkeys. We met with both the Public Health Officer and the District Medical Officer who were able to describe to us the overall health picture of the region based on data collected over the years. Malaria has been, and continues to be, the number one cause of out patient visits – meaning it is the leading cause of sickness, and it is the number one killer of children under five. Though the region has a number of health facilities, they have been difficult to staff and keep properly supplied. Furthermore, access to these few health facilities usually requires transportation by boat and often tides, weather and cost are preventative. By their estimates, a full 40% of the regions population has no access to medical facilities and the other 60% may have limited or infrequent access.

The following day we went out to see for ourselves some of the challenges to health facility access and to assess the overall health situation at the village level. There is a near ever-present wind in Lamu that creates a decent swell and even traveling by speed boat there were a number of considerations that had to be given to tidal, and weather conditions. It gave me reason to pause and consider how challenging travel must be given that most boats used in the region are dhows – traditional Arab sailing vessel carried by lateen sails that are as stunning in their simplistic beauty as they are awe-inspiring for their long history of travel between Africa and India.

We first visited the Bargoni area; one of the only areas accessible by road and only thirty kilometers from Somalia. Due to its proximity to the border, there is a large military camp in the area, attached to which is a Health Center. The Health Center was established to serve the military personnel but has also been serving the surrounding villages. This meant that those living here had comparatively better access to health services than most other areas in the Lamu district. However, in meeting with the community based health volunteer who worked at the center, it was clear that they were often under staffed, under stocked, and ill-equipped to provide proper care. Furthermore, serious cases required referral to Lamu town and transport - first by road, then by boat - was not always available.

Nearby we visited the small rural village of Msukani where we were met by curious but nervous children and gracious village elders. We were ushered into a meeting hut where, we were informed, all important village meeting take place – and where they on occasion watch soccer. We were soon joined by all the village elders who came in and took a seat while the children of the village peeked quietly from around the corner of the door. Through our local Red Cross translator we were able to ask them about what they felt to be their biggest health problems, what they did when they were sick, and when and how they were able to get treatment. It was clear in talking to them that there were a number of serious health problems, with malaria and respiratory tract infections being the two most prominent.

While the village was only 12 kilometers away from the health center – as opposed to the 44 kilometer average throughout Lamu – and even with the road, often if someone became ill they would not immediately go to the centre as there is no transport and walking is often to difficult for the seriously ill. Normally when someone in the village becomes sick, they are first treated at home using traditional remedies. If conditions worsen than arrangements are made to get the person to the health center, transporting the person by wheelbarrow if necessary. In serious cases where a person is referred to Lamu town hospital, transportation is an even greater challenge as they rely almost entirely on the good will of the military to drive a sick or injured person to Mokowe where they then have to pay to be transported by a boat, if one is available. It was easy to understand how limited access to proper health services was even here where there was a health center nearby and a road to the nearest port, to say nothing of the more isolates and remote island villages.

When it comes to malaria, access to medical facilities is vital because even with the successful reduction in cases of malaria through preventative intervention strategies like bed-net use, none are 100% effective and once someone has fallen ill with fever, the first 24 hours are critical for acquiring proper diagnostic testing and, if necessary, drug treatment. New drugs such as artemisinin-based combination therapies (ACTs) have proven to be very effective in treating malaria but for those living in remote areas, such as in Lamu, it is necessary for them to be made accessible at the community level without contributing to their misuse that could lead to new drug-resistant strains of malaria developing. New technologies such as Rapid Diagnostic Tests (RDTs) have now made it possible for malaria testing to be done outside of a laboratory and by those who require only basic training. The possibility now exists for RDTs and ACTs to be brought from house to house and administered by a local community based volunteer to those who would otherwise be too sick, too poor, or otherwise unable to make it to a health facility. With the enough commitment from the Ministry of Health, the Red Cross, and other partners, this type of a program could be successfully undertaken by local Red Cross volunteers in regions where there is a clear need; such as here in Lamu.

Catching one final glimpse of the overlapping belts of white sand and azul water from the window of the plane as we began our return to Nairobi, I couldn’t help but feel that the beauty of the region masked a much more complex picture; one that included serious challenges to the health and well being of the people who lived there. It can be overwhelming at times when you begin to consider all the challenges and implications related to developing and implementing basic health programs. I took comfort in an image that will stay with me from our visit to Msukuni village; that of a village elder, physically frail but strong in spirit and full of pride, who spoke with conviction about the health of the children in his village. It is of great inspiration knowing that he, and others like him, are willing to do whatever they can to help others who are in need.

p.s. My apologies to those who had submitted comments to be posted and for the delay of this entry, there were some technical problems with the website that have now been resolved.