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.

A Note from Nairobi...

Sitting on the deck of my apartment in Nairobi earlier today, watching the glow of the late afternoon sun seep through the surrounding trees, I nearly forgot I was in the middle of one of the largest urban centers in Africa. Nairobi is an interesting city - it is like most other modern urban cities in the developing world, but unlike others whose landscape is dominated by urban sprawl, Nairobi’s is partly camouflaged by a blanket of greenery. Although, when caught under a thick cloud of smog, bumper to bumper in the city’s notoriously bad traffic jams, there is no questioning it is a true urban center.

This incongruous dichotomy is epitomized by one of the city’s strangest sites; the large pelicans that fill the trees that line Mombasa Road; Nairobi’s busiest and most congested artery. Despite the noise of the traffic, the pelicans stand somberly in the trees with their heads down as though they were in mourning. It’s a site I observe often as I shuffle along in traffic on my commute across town to the Kenyan Red Cross office.

I have been working alongside the Kenyan Red Cross, where my focus continues to be on malaria prevention, only now within a broader context of health and disaster relief programs. I just returned from a trip to Bora, in eastern Kenya, where flooding occurred in December displacing thousands of people and leading to outbreaks of Rift Valley Hemorrhagic fever and malaria. The Kenyan Red Cross has been working to provide relief to the Internally Displaced People (IDPs) whose villages were washed away and who now find themselves living in camps. Several Red Cross Emergency Response Units (ERUs) - specially designed rapid response medical and water/sanitation units - were deployed from other Red Cross National Societies to provide support. I went there as part of an assessment mission to gauge the impact of the response and to participate in an ERU coordination meeting.

In north-eastern Kenya’s dead flat landscape, the vegetation is limited to dry scrub brush, thorn bushes and low stunted trees. With temperatures normally in the 40’s, it has an extremely hot, dusty, and seemingly inhospitable climate. The people who live there are mostly nomadic goat herders of Somali decent. Their tall slender frames are draped in colorful cloth that reveals only glimpses of their sleek features and light brown skin. The area has historically been prone to drought which has been especially devastating in the past few years. Now, only a few short months after recovering from the most recent drought, severe flooding has washed away many villages, forcing many people to live in camps.

Walking through these camps, I was truly struck by what it means to be vulnerable; it was easy to see why and how camps such as these are the most precarious places to survive. With only the most basic materials for shelter, those affected found refuge on the high points near roads where they were safe from the flooding but where no clean water or food could be found. These people were almost entirely reliant on the aid provided through the emergency relief of the Kenyan Government, the UN, non-governmental organizations and the Red Cross.

Even still there were signs of people’s resilience and strength; something you don’t see in television images of refugee camps. Guided by a local Red Cross water and sanitation volunteer, the men in a camp I visited were digging latrines and the women were gathering and burning garbage. The initiative shown was a clear indication of the desire for self-reliance. With the flooding now over, some people have been able to return to their villages, but others have nowhere to return to and now face the difficult task of resettlement.

In a region of such scarcity, the resettlement of displaced peoples can overwhelm the limited resources available. As such, tensions can mount quickly between newly arrived displaced people and those already living in the area. For example, what little exists in the way of health care facilities can quickly become overburdened with the outbreak of disease that often occurs in camps such as these. While the medical services provided by the Red Cross ERUs help mitigate the demands on local health facilities, they offer only a short term solution. For this reason, close collaboration with the Kenyan Ministry of Health and the Kenyan Red Cross is important to strengthen the local capacity to meet the demand for services.

The links between disasters, migration, disease, and conflict are palpable in regions such as this, perpetuating the cyle of vulnerability. Those who are poor and marginalized are at greater risk of being displaced by disasters such as floods; once displaced they are at greater risk of succumbing to diseases such as malaria – which itself is exacerbated by flooding. Outbreaks of disease in turn put pressure on limited health facilities and add to the competition for limited resources that can, in turn, lead to tension and even conflict. The already vulnerable people are further marginalized and impoverished.

The rise in disasters in recent years in Kenya, and around the world, is evidence of a further link in the cycle of vulnerability; one to climate change. Changes in rainfall amounts and severe weather events are being attributed, at least in part, to global warming. Desertification, drought, even the latitudinal and altitudinal spread of malaria is proving to be caused by increases in the earth’s temperature. Given there is now a general consensus that we all contribute to global warming through the emission of greenhouse gases, there is a link between our consumption habits and the vulnerability of others. This global interconnection highlights how our actions can negatively affect the lives of others, but it should also serve to remind us that we can choose actions with different outcomes.

In this regard, I continue to be inspired by not only those who work here on the ground to alleviate and prevent human suffering, but also by those back home who understand the capacity they have to do the same in their everyday actions. I recently had the opportunity to connect with a group of such people when I was linked in by phone to a conference held in Vancouver by the Red Cross Youth Training in Action Program (Youth TAP).

The aim of Youth TAP is to tap into the energy, creativity and compassion of youth and to provide them with the skills and support to take effective action as global citizens. Youth are often referred to as the leaders of tomorrow, but they are also the leaders of today. The local actions of youth in their schools and communities have been have been at the leading edge of global changes such as the ban on anti-personnel landmines, the international protocol to end the use of child soldiers and the rising attention to the HIV/Aids pandemic.

During the call, the youth participants had the opportunity to ask me questions about life as a Red Cross delegate and about how I became involved. Many did, however, most of the questions were about the bigger issues of malaria andchallenges facing a post-conflict country like Sierra Leone. These young people understand the power of knowledge and are eager to know more about the world they live in so that they can decide how best to act in the interest of humanity. I came to be involved with the Red Cross for the same reason, and while I am now undertaking a career in humanitarian aid, I think of my career choice as only one extension of my commitment to personal action as a global citizen.

One question I was asked was; ‘do I see a difference?’ At the time I think I misunderstood the question and answered only in terms of the impact of the malaria prevention program. Leaving the camps of Bora a few days after the conference call, I thought again about this question and realized that it was perhaps much broader. I got to thinking, is the work being done by organizations like the Red Cross making a difference? While there is always more that could be done, the work being undertaken by humanitarian organizations is making a difference in the lives of those who are vulnerable; people like those displaced in Bora. Are we collectively, in the broadest sense, making a difference? While there is plenty of evidence where more needs to be done, there is hope to be found in the cases where our collective voices have influenced international laws or policy.

As I thought about the question and the youth participants of the conference, I was reminded of a quote by Margaret Mead – “Never doubt that a small group of thoughtful committed citizens can change the world. Indeed it is the only thing that ever has.” The choices and actions we all make are important and the youth involved in the Youth TAP conference should take pride in the role they play in addressing the root causes of vulnerability.