Kenya

Having barely touched down in Nairobi after traveling from the easternmost part of Indonesia, I found myself in the air again. This time I was off to Kisumu - a town in Western Kenya perched on the shore of Lake Victoria. We were headed there to help facilitate a visit from a group of Canadian Members of Parliament who had come to Kenya to see first hand some of the major health issues facing not only this country, but all of Africa.

The focus of their visit was on HIV/AIDS, tuberculosis, and malaria; three diseases that have a crimpling effect on Africa, accounting for over 12 million deaths and immesurable human suffering. Statistics like these tend to wash over us without imparting much meaning or having much impact. Often they only have the effect of leading to a defeatist attitude that the problem is too big. A visit such as this gives a human face to these complex health issues and provides an opportunity to better understand the efforts currently underway that are having a positive impact.

Flying in across the great Rift Valley, I could see the vibrant green hillsides drop sharply down to the valley bottom and spread into an ironed flat sea of green grassland that drained out to Lake Victoria where the orange glow of the evening’s sunset mirrored itself in the distance. The shores of Lake Victoria border on three countries that are home to some of the most vulnerable people in Africa. For the Red Cross, this is a priority region and there are a number of programs operating here including an integrated health initiative for people living with HIV/AIDS.

The region has some of the highest levels of HIV infection and those infected and suffering from decreased immune systems are more susceptible to malaria and water born diseases that are also highly prevalent. By integrating malaria, water and sanitation, and HIV/AIDS home based care program, a single village based volunteer is able to address these interlinking health issues during each individual house visit. This approach ensures that those living with HIV have received LLINs (nets), Household Safe Water Treatment Systems and that they are being used properly and that information regarding treatment and prevention is understood.

We visited a village about an hour and a half’s drive from Kisumu called Siaya, where we were greeted at the local Red Cross office by a jubilant group of volunteers who broke in to raucous song as we arrived. Their exuberance was inspiring and was like a contagion of positive energy. Their chairman expressed his gratitude, saying that a visit to their small village by government officials from as far away as Canada gave them hope and encouragement. He explained the many challenges his village faced with high rates of HIV infection, tuberculosis and malaria but also of how his village had benefited greatly from the mobilization of volunteers.

Many of the volunteers are HIV positive but were empowered by the realization that they can play a role in improve the health and wellbeing of themselves and their communities. Through their work, the community itself has been strengthened by the same realization - that there are ways they can improve their own lives and livelihoods whether by making use of a bed net, a water storage system, or by seeking treatment.

The positive impact of these programs was evident in the homes we visited and in the people we spoke with. Beyond the immediate benefit of having received an LLIN, a water treatment system, or ARV drug therapy, the critical benefits of community invovlement were also evident.

By mobilizing community based volunteers in an integrated and interactive, the Kenyan Red Cross has developed culturally appropriate messages and approaches that utilize a variety of communication channels. The effect of this effort has not only been a positive change in behavior amongst the targeted group – those living with HIV, but also amongst the wider community. This was evidence in the open manner in which people in Siaya discussed their HIV status; a sharp departure from the stigma normally associated with the disease.

The homes we visited were mud-grass huts, sparsely filled with a few household items, mostly used for cooking and perhaps a mat or two for sleeping. In between the homes, chickens darted between small gardens where smatterings of corn and root vegetables grew. Children to young to attend school looked at us nervously as they sat between yellow-orange mosaics of grain spread out on the ground to dry in the sun.

This glimpse into rural African life was for some of the MPs their first, and many of them were struck by how basic their living conditions were. Some were at times visibly overwhelmed by the vulnerability of the people of Siaya, especially those living with AIDS. However, they also recognized their strength, resilience and how, with the adoption of a few tools and methods, their overall health and livelihoods could be dramatically improved.

Often it is not a question of not having solutions but of lacking the resources to implement them. The resolve of the volunteers and community members of Siaya can be found throughout Africa, but without the most basic of tools – nets, sanitation kits, and drugs - many villages are unable to carry out successful programs such as this.

The MPs who came to Kenya came by invitation but, they came by choice, and they should be commended for taking interest in issues that often do not receive the attention they deserve. Their attention, as elected MPs, is of course significant because of the role they have in determining how Canada can help improve the health and wellbeing of our global society. However, we all have a role in this; we are all represented by a Member of Parliament. As such, all of our attention to these issues is important as it will determine how Canada will act. Something as simple as taking a few minutes to write a letter to your MP or donating a few dollars to an aid organization can signal your support, and help ensure health issues like TB, HIV/AIDS and malaria are a priority. Collectively our actions shape and influence the world in ways we often don’t even realize.

Papua New Guinea

Getting up at 3:30am is never a pleasant experience… Those that know me know that 3:30am for me is more likely to be a late night than an early morning. Fortunately our early start was for a flight to Irian Jaya - a trip I had been looking forward to for some time.

One of the two objectives for our mission to Indonesia has been to develop a proposal for Canadian Red Cross and the Canadian International Development Agency for a bed-net campaign in eastern Indonesia where malaria morbidity and mortality rates are extremely high and where there is currently no prevention strategy in place. We’ve come to Irian Jaya to assess the malaria situation and get a better understanding of field conditions in this remote part of Indonesia.

Irian Jaya is a recently created province on the island of Papua New Guinea, at the far eastern edge of the vast Indonesian archipelago. This island is one of the most remote regions on earth where isolated and marginalized communities suffer the highest rates of malaria morbidity and mortality, maternal mortality, and malnutrition in Indonesia.

We were joined on our early morning flight by our UNICEF – Malaria Program counterpart, Dr. Endang, who acted both as our guide and our translator. Joining us once we arrived was the local Ministry of Health - National Malaria Control Program representative. Together we made our way out of the main town site to the more remote rural villages to conduct house to house visits in order to speak with community members.

As we drove, glimpses of crashing waves caught between the passing palms made it impossible not to be awestruck by the island’s sheer beauty. Home to one of the oldest and most biologically diverse rainforests on earth, an alluring sense of mystery seemed to emanate from the dense jungle hillsides that rose abruptly from the island’s coast.

We arrived in a small rural village made up of a scattering of 40 or so homes; basic wood structures raised on stilts that peeked out from the dense forest.

Our arrival drew attention from many of the village’s children who came to check us out while their mothers peered shyly from windows and door frames. We were welcomed graciously into their modest homes where we sat crowded round on the floor listening as Dr. Endang asked them about their family’s living conditions and overall health.

They explained that they and their children were often sick with fever and many families reported having lost children who had died following fevers. This confirmed the high prevalence of malaria in the region though it was clear there was little understanding of the disease. Many attributed fevers and other illness to ‘spirits’ and when asked if they sought treatment when they or their children were sick replied that they relied on traditional spiritual healers.

When asked if they would ever seek treatment at medical centres, some said they would but only if illness persisted for longer than three days; much too late given how critical the first 24 hours from the onset of malarial fever are for treatment. Others said they were not able to reach medical centres as there were none close by and the cost of travel to the nearest facility was too expensive. When treatment was sought, and when it was available, often it was not effective as most places were only able to treat with chloroquine, an older treatment method whose effectiveness has been compromised by drug resistance.

These testimonials underlined the need not only for better access to malaria treatment but also for grassroots education around malaria; its cause, its symptoms, and its treatment and prevention. The lack of knowledge of the link between malaria and mosquitoes was one factor why most people we spoke with were not familiar with bed-nets, the most effective and affordable form of prevention. As such, any bed-net distribution would surely have to involve a great deal of education and socialization on net use.

Information gathered from these types of visits seemed invaluable for formulating a regionally and culturally appropriate malaria prevention strategy. For example, sitting on the slatted wood floor of a stilt-raised home, I noticed how easily mosquitoes could pass up through the floor between the slats. Given that most villagers slept on very small mats or directly on the floor, consideration would have to be given to the design of the bed-net to ensure their effectiveness.

The responsibility to ensure aid and health programs are regionally and culturally appropriate cannot be overstated. While societies such as the ones here in Irian Jaya are able to adapt (and do), cultural changes should occur on their terms. Mostly isolated until the turn of the last century, the remote villages of Irian Jaya now reflect some of the cultural shifts seen round the world.

The juxtaposition between the spears and bows leaning in the corner of one home we visited and the television set beside them provided evidence that even the traditional hunting and subsistence societies found here are part of our increasingly interconnected world. The tattered poster of Avril Lavigne that hung as the sole decoration in another home served as an equally good, if not somewhat more perplexing, example.

While it is probably fair to question the value of either a television set or a poster of a Canadian pop star, for me they are positive signs for what is possible; the exchange of tools and ideas. There are valid concerns with the pace and manner in which cultures shift, but when it comes to preventing children from dying there is little room for argument when proven and effective prevention and treatment strategies exist.

In one house we visited a young child pulled herself awkwardly across the floor, her emaciated legs unable to carry the weight of her ballooned, worm filled stomach. A de-worming tablet costing less than three cents could very well save her life, but without it she would likely die within a week.

Images such as this stand out as a reflection of the reality here, but so to do images of local community members who have the willingness and capacity to help. There is a danger in allowing the former to overshadow the latter, as for every example of tragedy there are equally as many of hope.

From Africa to Asia...

The heady smell of clove cigarettes and durian fruit lingers in the air, a constant reminder that I now find myself transplanted in Indonesia nearly 16,000 kilometers from where I began my mission in Sierra Leone.

I have come to work alongside Marcy Erskine, the Canadian Red Cross malaria program advisor, to assist her in supporting the Indonesian Red Cross, the Indonesian Ministry of Health and UNICEF with malaria prevention.

In Indonesia, approximately 100 million people (nearly half the entire population) are at risk of malaria infection, with an estimated 42,000 dying of malaria annually. Health care is often not affordable in a country where an estimated 18 per cent of the population lives below the poverty line and 49 per cent of the population live on less than US$2 per day. In some regions, basic health services are not even available.

Following the tragic Indian Ocean tsunami that took the lives of 150,000 Indonesians, fears of a malaria outbreak amongst survivors and the availability of money led some UN agencies and Non Governmental Organizations to conduct malaria control efforts in tsunami-affected areas. This has stimulated government Ministry of Health efforts to also improve malaria control outside of the tsunami-affected regions, to areas where the malaria burden is as high as the most malaria-endemic regions of Africa.

In the isolated and marginalized communities of Indonesia’s outer islands, approximately 43 per cent of two – nine year olds were infected with malaria, while infection rates for all age groups were found to be in excess of 60 per cent. High malaria incidence contributes to the high rates of anemia and malnutrition, and in Indonesia 40 per cent of pregnant women, and 48 per cent of children under five are anemic. Anemia, malnutrition and malaria function to contribute to the overall precarious health status of populations in Indonesia, furthering the cycle between disease and poverty.

While statistics such as these highlight the scale of the malaria problem, they often do little to convey the human suffering caused by this brutal disease. In its early stages malaria causes fever, chills, headache, body pains, and anemia that weaken and incapacitate you, preventing you from working, farming or going to school. In its advanced state, painful convulsions lead to an excruciating death and leave families marred by the loss of loved ones, especially young children.

There is an urgent need for rapid scale-up of malaria prevention in Indonesia, especially in eastern Indonesia. Improved diagnosis and treatment, improved community outreach, and some tentative exploration of the utility of environmental management to reduce transmission are under way. However, high coverage of long-lasting insecticide treated mosquito nets is needed to rapidly bring down transmission to ensure that other strategies have maximal impact.

An integrated vitamin A supplementation and net distribution campaign is currently planned for six provinces in Sumatra. Our role in this campaign has largely been to offer best practices and lessons learned from past campaigns in other countries. This type of support has helped ensure success from country to country and is a large part of why Canadian Red Cross is now recognized as an organization that can provide appropriate, timely and successful program support to countries embarking on mass net distributions.

Having arrived in Jakarta late on the 24th of December, Marcy and I enjoyed a low key Christmas day; the only evidence of the holidays, the reindeer antlers we donned to help mark the occasion. Soon we were back at work, meeting with the Indonesian Red Cross Society to help them plan and prepare for the training and mobilization of volunteers for the upcoming campaign in Sumatra. As with past campaigns in other countries, the Red Cross’ focus is on social mobilization, utilizing its vast network of local volunteers to conduct grassroots community and household education regarding the campaign, including the importance of vaccination and the correct utilization of nets.

One of the Indonesian Red Cross’ main strengths is its ability to mobilize a large number of well-trained and equipped volunteers to respond to frequent natural disasters, which affect Indonesia. They also assist the government in preventive health activities and with response to various health emergencies and epidemics. It was clear from meeting with them that involvement in malaria prevention is an area in which they have the capacity to be involved, as well as an area from which to expand further into community based health services.

Following our meetings in Jakarta, we headed to Bandar-Lampung in south Sumatra for the campaign micro-planning meetings. Over two days, regional representatives from the Ministry of Health, UNICEF and the Red Cross planned out the details of the campaign. Marcy was often looked to for technical advice and through a translator was able to help facilitate the planning process. While the meetings were conducted entirely in Bahasa Indonesian, it was interesting for me to see how the planning for a campaign of this scale comes together.

It was also interesting to see the cultural differences in how meetings are conducted. Both Marcy and I noted how acceptable it seemed to be that most of the room was talking while presentations were being conducted. Music was even playing from a lap top near the back of the room. That it was the song ‘Barbie Girl’ added to the oddity of the situation as I find the universal and long lasting appeal of that song a particularly strange phenomenon.

My own aversion to that song aside, that two young women wearing hijab, the Muslim head covering worn by many women, were listening to western pop is, in a way, a fitting example of the cultural complexity of Indonesia. In a country where the influences of both western and Islamic culture have been adopted and integrated in uniquely ‘Indonesian’ ways, there is a diversity here that often goes unnoticed when filtered through the headlines we read back home in Canada. From the modern sprawling cityscape of Jakarta to the remote rural villages of Papua, Indonesia is as varied in its cultural make up as it is in its famed biodiversity.

Indonesia’s diversity is one of many sources of incredible strength and capacity, but Indonesia has also experienced a great deal of tragedy in recent years. Faced with everything from conflict to tsunami, to earthquakes, to flooding, Indonesia has been marred by disasters, and often it is the most vulnerable who are affected. Malaria is one of the contributing factors to this vulnerability, one that can be greatly reduced by malaria prevention strategies such as the one we are here to support.