Disruption

I am uncomfortable. My senses did their job in Kenya. They collected sights, sounds and information for me to wrestle with. My mind will not be the same. Old beliefs and realities cannot accommodate the new information. The process of reconciliation is not tidy. It won’t work for me to come to simple explanations and conclusions. I will need to sit in the dissonance for a while and build new constructs of thought.

My world at home has changed. The face of my son, his bright eyes are no different the eyes of the children I spent time with. Would we ever allow a child in our country to sleep on the street? I consider that there are nearly a million orphans because of HIV. This is just one of many looming injustices for me to consider...there must be a balance of witnessing these truths but not being paralyzed because of them.  

I have an ache. The Community Health Workers (CHWs) of the slums are with me. No official title, no formal education, no clear certification and no governing body. They choose to work for as volunteers. They choose to comfort the dying in the middle of the night, they wash the bedridden. Where is their honor? Why are they invisible? I remembering learning of times when nurses where invisible...handmaidens. The correlation between the CHWs and Nursing resonates in my chest and I feel accountable. How would the health status of a slum change if the CHWs were honored and treated as health providers and problem solvers?

I will continue to collaborate with Tatua. My energy will be aimed at empowering and supporting the Community Health Workers in the slums of Ngong, Ngando and Rongi. It isn't enough to provide mission work to the slums. The solution has to grow from within. The CHWs are uniquely positioned as access points to healthcare. My mind can rest on this.

A new chapter begins for me here with the CHWs.  

Elizabeth: “I like your hair, can I braid it?”

I am sitting in a community gathering in Ngong. I can feel my hair being gently tugged. I turn around and see a young girl smiling at me.  She is holding the ends of my hair. “I like your hair, can I braid it?” Her name is Elizabeth and she is 11 years old. Her first language is Swahili. She also speaks English. When she talks, her voice is soft and she chooses her words carefully. She is open and receptive, curious and inquisitive. Her eyes flash with intelligence. Everything about her is refreshing.

She asks me if I have children. I tell her I have a son and she asks to see a picture. When she sees his face she giggles and says ‘he looks like you’. She studies the picture for a few minutes, then she asks me what his name is. I say Cole…and she repeats it over and over till she gets it just right. “Cole” looks happy.

I ask her about her life. She tells me that she loves science and math. She is the most excited when she says, “I like to make art, I am an artist. I am learning how to weave baskets." I ask her what she does after school. She says that gets home at 5:30 and depending on if there if food for dinner or not, she goes to bed. “I know if there was no food for dinner, there will be no food for breakfast.” I try not to react as she shares her world with me. Her mom doesn’t have a stable job, and her dad “went away” when she was 7. She says that she wishes her dad would come back and help her mother. I just listen.

She braids my hair, and I listened to her talk about how she likes to “be creative”. She tells me more stories about life. She is a good story teller. My heart swells bigger and bigger. She asks me if I would come and visit her again so we could talk more. I can’t find words to answer. I will be working with Tatua Kenya in the future from the states. I will not be able to return to Ngong to see her. Our hands clasp before I leave. I tell her I loved hearing her stories. I tell her how special she is and that I thought she was smart. She understands and nods her head yes, receiving my words. We smile together.

I knew coming into this experience, that it was likely that my immediate impact would not be sustainable. I continue to struggle with that. Did I create any value on this trip? Is this more about me? In this moment the answer is yes. It is about me. My time with Elizabeth disrupts me. It makes me ask questions about children. I saw light, intelligence and resilience in Elizabeth. I imagine her future as a woman, as a leader? Elizabeth needs more the foreign aid and free hand outs. She needs to be developed by the community around her. She needs to be challenged and mentored. I ask myself uncomfortable questions, and I don’t receive quick or easy answers.

I am clear that I have an obligation to Elizabeth. When we got together for a photo, she put her arm around me so tight. I can still feel her hand on my shoulder. I want to be a better person because of Elizabeth. I am going to take the energy, love and meaning I received during my time with her and pour it into my world at home. 

"Wewe ni rafiki yangu sasa" -You're my friend now.

Sara (to the right in the picture above) shares a story in our group forum today. To this community, sharing stories is sharing life. 

Sara receives a call in the middle of the night. Her HIV patient, who has been bedridden for months, has slowed his breathing and will soon pass. She willingly rises from her bed and leaves her family to go to his bedside. When she arrives where he lay, she comforts his family. He passes in the early hours of the morning. It is her job to coordinate the transfer of the body to the hospital. She soon learns that there are no ambulances available. Sara uses her own money to pay for someone to drive the body to the hospital.

The first thing for me to acknowledge in this story is the stark contrast this story has to my experience as a nurse. It is beyond foreign, it is uncomfortable to think about. I am obligated to consider this as a reality on this earth. I am amazed at this women when she talks...something pulling her to work that isn't related to money or status. It is palpable, I see it, I respect it. She has no white coat, no letters after her name. She doesn't even have a badge. Next disturbing thought..How the hell there isn't an ambulance? I picture the dying being transferred to hospitals in a dangerous bus-taxi-like vehicle. Finally, I settle my mind on the complexity of this story. It suggests problems that are so deeply dug into their society. Money can't fix all this. There is no clear solution. 

I feel confident in this thought...the empowerment of the 'nurse' or Community Health Worker in this society will fundamentally change their baseline health status. I know this because I know what nurses do, how they think and how they impact change. I know that the women I sit with are powerful. How do they realize their power?   

Sara is not paid for her work. Who should pay? The community? The government?

     A basic tenant of any job/profession is the ability to earn money. The concept of the village health worker was established during the 50’s. Different countries have handled the proposition differently. For example, Indonesia implemented CHWs in 1982 that were paid by the community themselves. They had favorable outcomes including an infant mortality rate that dropped by 30%. A review of the literature done by the World Health Report (2007) http://www.who.int/hrh/documents/community_health_workers.pdf suggests that CHW programs that are implemented by the community with funding have a higher likelihood of sustainability. 

What role does data play here? What impact does Sara have on the Ngando community? Is her value reflected in data? What if she could speak to that data and advocate for herself?

    There is no better place to look to than the Crimean War when discussing the power of data. Florence Nightingale and roughly 40 volunteer nurses were sent to solve the issue of the dying soldiers. When they got there they believed that the sanitation practices were contributing to the death rate. Florence was unwavering in her commitment to gathering, interpreting and visually reflecting data to prove her theory. She would bring statistical graphs to British parliament realizing she could bring data to life. This is how she would impact change, and get the government aligned with her priorities.

     The story of how data impacted the outcomes in the Crimean War has profound implications for the CHWs and their slums. There are undeniable similarities. The CHWs have powerful data all around them and it reflects their intrinsic value. If they find a way to organize themselves, collect their data and bring it to life they will find themselves in a powerful position in the community they serve.

A face

I spent a lot of time of time with this little guy in Ngando. He was quick to give hugs and was very interested in playing. When he looked at me, eye to eye, I had to pause.

His mother wanted me to take his picture. When I showed them how the image looked, the mother and son laughed and laughed. My IPhone felt like some magic device.

It will be hard to forget this face and the sound of his laugh. 

"My son died, and then my husband. I have to help another." Healthcare Delivery in the Slums

“I know the pain I see their eyes, I know their pain”—Racheal, a community health worker from Ngong.

These are community health workers of the slum. They are responsible for over ~500 people each. I listen as they tell me their stories. Their faces reflect both pain and joy as they talk. It is clear that they are filled with purpose and they gain great meaning from their work. In the slum, they wash and comfort he dying, assume care of a newborn while a new mother fights infection, and prepare and find food for hungry mouths with their own money. 

These men and women are not paid. They have no way of taking care of their own families.  Why do they sacrifice their money? Why do they tolerate so much suffering? “ I do it because I know the pain I see in their eyes, I know their pain. My son died, and my husband. I have to help another. ”

I asked them if I could share their story and they gave me permission. 

Pregnant at 12 Years Old

Today, I am visiting with an organization called Miss Koch to learn about what is happening to young women in the slum of Kariobangi. Miss Koch is a leader in sexual reproductive health rights for girls/women in this community. As I sit talking with the founder Emmie Erondanga, I hear young female voices singing from outside the window (listen above). Their mesmerizing sound hovers above and around our conversation.

In Kariobangi, girls as young as 12 are becoming pregnant and contracting sexually transmitted diseases. They often enter into relationships with men because they believe that sex equals love. Sometimes, they receive 50 cents for a sexual act. Because financial resource is scarce in the slum, the girls see the money as an opportunity to take care of themselves and their families. It’s worth noting that their sexual partners can be anywhere between the ages of 18 and 45.

Along with pregnancy, sexually transmitted diseases (aids, gonorrhea, chlamydia) run rampant throughout the slum. When a young women becomes pregnant or develops a STD she has nowhere to turn. The girls are told that they are ‘bad’ and that it is their ‘fault’ that they have become pregnant or have a STD. There are numerous health clinics they could attend in Nairobi, but because of the social implications they avoid obtaining conventional medical care and instead they seek out unsafe methods of treatment.

This is where Miss Koch comes in. Their goal is to educate groups of young girls about the risk of STDs and dangers of a young pregnancy. For one of their recent projects, they have identified 80 girls that are talented ‘football’ players. Relying on the power of sport and structure of team, Miss Koch leads group discussions with the girls empowering them to avoid sex and develop their talents as athletes and minds as academics. They focus on improving self-esteem, establishing positive role identity and developing confidence. The young women have responded positively. Miss Koch gives them a safe place to learn more about who they are and what they can become.

Learnings: Miss Koch is nuzzled in the middle of the slum. The Miss Koch staff members live in the community. They viscerally understand what is going on in Kariobangi a way that no outside person could. Money cannot fix what is happening in the slum. The social norms are rooted deeply into the culture. Shifting the minds and hearts of the young women in Kariobangi has to happen from the ground up, one heart at a time. I hope that Miss Koch achieves their objective so that the girls that wander the slums today are the women that change their own communities in the future.  

The Complexity of the Slum

A SLUM

            You are looking at a slum in Ngong (southwest of Nairobi). It looks as I had imagined. There are tin and wood shacks bundled atop one another. I see goats, roosters and mules roaming around, often pulled by children. The muddy ground beneath my feet takes on a whole new meaning when I considered that there are no sewage systems or running water. A landfill welcomes me at the entrance to the slum. There I find young children playing in the waste while goats dig through trash looking for food.

          My senses register new sights, sounds and smells. There is almost too much new information and I am not sure where to file it away. As one would image, the air is malodorous, but not as potent as it would have been in hotter weather. I see a 3 year-old boy wandering aimlessly. What I don’t see is a mother anywhere beside him.

          I hear ‘It’s a Mzungo’ (white person) screamed out of children’s mouths when I walk by. They wave with urgency and excitement. I wave back and consider how I may look in their eyes. Like some sort of alien invading their space. In that moment I wish I were invisible, not disturbing their world. I become acutely aware of my clean hands, clean shirt, shoes and IPhone in my pocket. A sense of shame washes over me.

SHO SHO

         The older women you see in the picture are sho-shos (grandmothers). They have gathered here today in an empty space where chickens and goats graze on straw-like grass. Their presence signifies their commitment to a movement in the community to send the children of the slum to school. There are ~60 sho shos present today and they range in age from 60-90 years old. They represent ~75% of all of the sho shos in the slum. 

        Noises escape their mouth that sounds like music to me. The language is, in fact, some tangential version of Swahili. They are clearly connected to one another as if they are sisters. They are wrapped in layers of colorful clothing and blankets. Their skin is deep with lines that suggest wisdom and experience.

Abandoned Children

       These old women serve as the primary caretakers to most of the children in the slum. Why? Young girls get pregnant at 14-15 years here. Often, they are shunned and ostracized by their community when they become pregnant. As a result, they abandon their children and they flee the slum. The grandmothers, who are less mobile and unable to leave the slum, are left to care for the children. The average sho sho in this slum takes care of anywhere between 6-10 children.

Blame

       Humans are quick to blame. In this situation my mind rushes to find a clear cause and explanation for all of these motherless children. I think of a vulnerable young 14 year-old girl becoming pregnant. I imagine her hiding her belly as long as she can. I imagine how men and boys may treat her when they see her swell. I imagine the shame and fear that may become her constant companion. I then imagine this broken young girl running away from her own children to protect herself. The story gets more complicated as I considered that the both the children and the mother are victims.

A Miracle

         The young woman that you see in the photo is Rose. Rose was born in a slum called Kware. She tells me that when she was young, the ‘Mzungo’ would come to her slum and she would dance for them and they would give her money. She would give the money to her grandmother so she could take care of the family. All Rose ever knew was the slum. 

        Then, something happened inside of Rose and she saw that things could change in her community. She got involved with Tatua as a community organizer. After spending a few days with Rose, I have great admiration for her. Where did this young woman find her confidence? How did she have the courage to extend beyond her environment and its limitations? Where did she get this sense of responsibility and accountability?

         As you see in the picture, Rose engages the sho shos about the need for their grandchildren to go to school. First, she empathizes with them and connects. Then, she charges them with taking responsibility for the children’s education. Her voice is firm and filled with conviction. The old women respond positively and their faces change. Their eyes open wider, they emphatically nod their heads, and they clap. Rose is like a beacon of light in front of them and the women are lifted up.

I am lifted up.