Community Efforts by Community Members

Even for someone from the west coast of Canada the recent rhythm of the rain has seemed an almost foreign sound after months of straight sunshine. It signals the beginning of the rainy season, and with it, an increase in mosquitoes harboring the malaria parasite. In preparation, the Kenya Red Cross has mobilized its volunteers for an intensive ‘Hang Up’ campaign to encourage the use of mosquito nets.

When properly hung over sleeping spaces, insecticide treated nets prevent malaria by providing an effective barrier to mosquitoes. In July and September 2006, the Kenya Red Cross - in partnership with the Kenya Ministry of Health, distributed approximately 3.5 million long-lasting insecticide treated nets free of charge, but now they must promote proper usage by those most at risk – children and pregnant women. Over the longer term, a ‘Keep Up’ program will be conducted through periodic house to house visits by volunteers to continue to promote net use as well as communicate other health messages such as prompt treatment of fever and completion of immunizations.

The Kenya Red Cross, like other national societies, is a volunteer based organization rooted at the community level. This enables Red Cross to be effective in social mobilization - a process to reach, influence, and involve all relevant segments of society to affect positive behavior and social change. However, organizational capacity does not guarantee program success and it is therefore critical to gauge and evaluate programs in order to adapt approaches and strategies and become more effective. The Kenya Red Cross and the International Federation of Red Cross and Red Crescent Societies, with technical support from the American Red Cross, will be conducting an evaluation of the “Keep Up” program to assess its effectiveness, and I have been working to support Dr. Patricia David - Senior Health Advisor with the American Red Cross prepare the initial survey.

In order to prevent inaccurate results, a great deal of thought and attention must be put into the careful wording of every question asked in a survey of this nature. It is critical to rely not only on the advice of professionals who specialize in the field of data collection and analysis, but also on people with local knowledge who understand the cultural context. Questions must be easily understood, even by those with little or no education, but must not be overly leading, or they risk encouraging false responses.

This baseline survey will provide information about current net ownership and use as well as gauge the level of general malaria knowledge. When compared against the final survey, the results will reveal the impact and effectiveness of the program and will provide information that can be used to develop guidelines and training materials for future Red Cross programs and for other civil society organizations wishing to implement similar initiatives.

Outside of work, and through a strange twist of fate, I have had the opportunity to link up with a grassroots women’s group from Kibera – one of Nairobi’s slums, and one of the largest in the world. There are nearly a million people living in Kibera, approximately one quarter of the population of Nairobi. Though they pay rent, they have no legal entitlement to the land on which they live. They are forced to seek protection from forced displacement through political or tribal patronage, or they risk having their homes dismantled or burnt down. With each wave of migration towards the urban center and away from the problems of rural underdevelopment faced throughout the country and the region, Kibera has become home to residents from all the major tribal and ethnic groups. This multi-ethnic make up combined with the system of political and tribal patronage has been the source of many violent and volatile conflicts over the years.

The group I met was formed spontaneously by women representing all of Kibera’s tribes and major religions who came together despite that their differences were often the source of conflict, with a common desire to provide protection and support to women being targeted for rape and abuse during the tribal warring of 2000. Since then, they have grown to nearly 200 members and evolved into a branch of a broader movement called the Vision Sisters. Today, the Kibera Branch meet regularly and are involved in everything from support and care to people living with HIV/Aids to pooling funds to acquire legal entitlement to land.

As the lack of land ownership is one of the main reasons for the marginalization of those living in Kibera, the primary goal of the Vision Sisters is to raise funds to purchase legal land and shelter outside of the slum for all of its members. However, in recognition that this will take time, they have also turned their attention to meeting the immediate needs of the most vulnerable among them, and within the broader community. To support their initiatives, they run a catering service for local weddings and celebrations that provides a source of revenue they use to rent a meeting room and fund their activities and land purchases.

Until now, the group has been entirely self-funded and independent, but through meetings with local contacts and introductions to other contacts, the group is beginning to tap into some of the resources and support structures that they can access through partnerships and collaborations. As a result of their networking, several members were invited to participate in last summer’s World Urban Forum held in Vancouver. When Mama Hamza, the group’s Chairlady, shared with me her thoughts on the conference, I could see the pride and confidence the experience had instilled in her. At the World Urban Forum, they were able to meet with other grassroot groups as well as major organizations from all over the world to share ideas and learn from each other. These women, most of whom are of a generation that didn’t have the opportunity to attend school beyond primary level, now speak the language of development; talking about organizational capacity, income generation activities, and good governance. With the support of a local contact with the United Nations Development Programme, occasional access to a public computer for email and typing, and a small budget for printing, they are now preparing to write a proposal for funding to build a women’s shelter and have interest from a major international donor.

Knowing the language and systems of organizations may seem insignificant, but that knowledge is the key to accessing outside support. With this support, a local group like the Vision Sisters can develop programs that are based on their understanding of the needs and capacities of their community that those on the outside would likely never be able to. While I was not there in an official Red Cross capacity, I helped to brainstorm ways that they could tap into the services and training provided by the Red Cross, such as First Aid training and the HIV/Aids home based care program. In its essence, this is how the Red Cross can best serve the most vulnerable - by tapping into the potential within vulnerable communities and empowering community members to actively improve their circumstances.

Walking through Kibera, the vibrancy of life is evident throughout; its narrow dirt pathways - arteries of activity - wind between the jumble of tin shelters. A butcher hacks at hind quarters along side a barber who cuts hair, and nearby a rough piece of blackboard advertised in chalk a ‘movie theatre’ - a cramped dark room playing pirated dvd’s on a small television. Evident also is the tragic realities of utter poverty; garbage and feces line the paths - evidence of the ‘flying toilet’ - a practice of disposing of human waste by simply tossing away the bag used as there is nowhere to properly dispose of it - and flows into streams used for drinking, contributing to the spread of disease. Substance abuse is rampant, as is physical abuse. Children are especially vulnerable as many have been orphaned by mother’s succumbing to HIV/Aids, a growing problem with one fifth those infected with HIV in Kenya, living in its slums.

It was humbling to see the strength and resilience of those who live there; to see that people find ways to support their families, ways to have their children go to school, ways to feel joy and happiness even when surrounded by hardship. However, it is also discouraging knowing the immense challenges they face, and I can’t help but feel that the slum phenomenon will be one of the biggest challenges the world will face in the next hundred years if globalization continues to further marginalize people through gross disparities of wealth.

…As I looked out over the ever expanding horizon of tin roof tops, feeling overwhelmed and somewhat dejected, Mama Hamza tapped me on the arm knowingly as a close relative would and spoke in almost reassuring tones about the future of Kiberia. She remains optimistic that things can improve, and she has taught me that if women like her, who have seen and experienced so much hardship, can find reason for optimism then all of us should.

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.

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.

Closing a Chapter

Sprawling impossibly up steep coastal mountains, Freetown normally provides for spectacular ocean views, which have of late been obscured by a thick haze. With the dry season, Harmattan, has arrived - the wind that blows in from the Sahara across West Africa to as far as South America. The cool dry wind brings relief from the oppressive heat and humidity of the recent rainy season, but also dust and sand picked up from the desert, creating what’s known as Harmattan Haze.

That particles of desert sand can find themselves transplanted to the lush green hillsides of tropical Sierra Leone reminded me how truly interconnected the world is despite vast distances. I sometimes feel like one of those particles of sand, a foreign object transplanted far from home.

The decision to live and work overseas was never an easy one for me, despite my belief that we have a responsibility to each other that is not limited by regional or national boundaries. I’ve often wondered if working and living in a cultural context that is not my own was the most responsible or effective way for me to work. Recently I have taken solace that like the sand brought by the Harmattan wind, while foreign, I’m also part of a natural force of interconnectedness that has existed since the earliest of human migrations.

Here in Sierra Leone, a migration of sorts is under way for the Canadian Red Cross delegation. With the distribution campaign portion of the Sierra Leone Malaria Program finished, the supporting team members here have begun heading home. As such, the past two weeks have been busy with wrap up, including everything from consolidating finances to writing final reports to conducting debriefing meetings.

For me, the day to day work during the past two weeks has been mostly spent at the office, in meetings or running around town trying to find replacement parts for the Landcruisers. You wouldn’t believe how difficult it can be to find ‘Genuine Toyota Parts’ in Freetown (as opposed to knock off imitation parts that would nullify our insurance).

Shopping here is definitely more of an art than a science. There is no phone book, and if there were, there are usually no phones. The shops are often not well identified and usually stock such a bizarre mish-mash of things that it would take a blind guess for someone who doesn’t know any better (like me) to find something as specific as ‘Genuine Toyota Parts’.

Luckily for me I had the help of one of our drivers, Francis. Like most drivers, Francis is a source of support and assistance and someone we rely on heavily for everything from translating to negotiating. To call them drivers seems, at times, to do a disservice to all the other ways they contribute.

This past weekend we were fortunate enough to enjoy a very rare day off, which we spent at the beach. There are beautiful beaches here, clean white sand stretches out under towering palms into crystal clear water. We spend almost all day everyday in the office and normally continue to work once we arrive home in the evenings to our delegate house, so this trip to the beach was a welcomed break. My impression is that it can be tough sometimes for delegates to strike a balance between work and time for themselves and the results are often cumulative stress and burn out. As such, the few times we can go out to eat or for a walk around town are to be relished for the peace of mind they bring.

For those headed home, it was one last bit of sun before stepping off the plane in Ottawa to what I can only imagine is cold and snow. For those of us staying, it was a chance to say goodbye. I will now stay on and assist Marcy, the Malaria Program Advisor with other malaria prevention campaigns in other countries.

Like the particle of Saharan desert sand, I will gladly go where the wind takes me.