Wednesday, August 1, 2007
Marina MacNamara: Reflections from Kenya
Marina Macnamara (left) with local women in West
Pokot, Kenya
Pokot, Kenya
The former Project Director for DOW's HIV/AIDS Project in Kenya reflects on "the best job in the world"
“Do you know that less than 1% of the American population would want your job?” an American visitor asked as we made our way past the dry brush of the West Pokot lowlands. The Toyota 4WD skipped lightly over the sand track that comprises one of the major roads of the District; and outside the window, past the warm wind, sage-green leaves were framed by burnt sand and blue sky, the outline of gray mountains in the distance. A herd of goats suddenly appeared along the roadside, their young herder surely hidden nearby. We had just visited a rural dispensary, about 2 hours north of the District Hospital, for a follow-up visit with a nurse who had recently participated in a DOW-sponsored training on HIV/AIDS testing. The nurse had appreciated the visit; the roads being what they are, few administrative personnel ever venture beyond the district capital.
“Do you know that less than 1% of the American population would want your job?” an American visitor asked as we made our way past the dry brush of the West Pokot lowlands. The Toyota 4WD skipped lightly over the sand track that comprises one of the major roads of the District; and outside the window, past the warm wind, sage-green leaves were framed by burnt sand and blue sky, the outline of gray mountains in the distance. A herd of goats suddenly appeared along the roadside, their young herder surely hidden nearby. We had just visited a rural dispensary, about 2 hours north of the District Hospital, for a follow-up visit with a nurse who had recently participated in a DOW-sponsored training on HIV/AIDS testing. The nurse had appreciated the visit; the roads being what they are, few administrative personnel ever venture beyond the district capital.
“I suppose,” I responded. “But, how could anyone not want this job?”
For two years, I was the Project Director for DOW’s HIV/AIDS program in Kenya. Actually, in the beginning, I was simply the Project Director. I arrived in June, 2005 to open DOW’s office in Kenya - their only office in Sub-Saharan Africa. So, in the beginning, DOW-Kenya was a vision, made more and more concrete by endless preparatory work both in New York and Kenya and approved grant proposals. It was my job to bring it to the next level.
Within 2 weeks of my arrival, DOW’s first office opened in the form of a compound in Kitale Kenya. Within three months, 30 clinicians from 20 facilities around the district had been trained in HIV/AIDS testing, the clinic was constructed near the District Hospital, and the eight staff seconded to the program by the Ministry of Health had all undergone initial training in HIV/AIDS treatment, including both antiretroviral therapy and that for opportunistic infections. The clinicians saw their first patients on November 1, 2005. Eighteen months later, by May 2007, more than 800 patients had been enrolled, and the clinical staff had expanded to include a social worker, an outreach coordinator, and an agricultural program manager. Not only had the HIV/AIDS comprehensive treatment program grown to include, for example, weekly education sessions for patients and ward volunteers who provide peer-based support to inpatients at the district hospital, but DOW had also expanded into three distinct but complementary programs to improve health care in two districts.
There were dozens of people integrally involved in the starting up and expansion of DOW’s programs in western Kenya, both in Kenya and the United States. Indeed, there was an amazing rapport between offices, between teams, as multiple people worked together to, for example, secure funding for the future of the program; facilitate a working relationship with the Ministry of Health and other key stakeholders in the area; and, most importantly, get the word out in West Pokot District that HIV/AIDS testing is now conducted in over 20 facilities – and if you test positive, help is available.
It is this last activity that made my job, as the first Project Director for DOW’s HIV/AIDS program, so fulfilling – and, in some cases, frustrating or discouraging.
One of the very first days that Lucy Loboo, DOW’s social worker, began working with DOW, she and I visited a patient on ARVs who had already twice defaulted on her clinical appointments. According to the patient contact sheet we had, Maximilla lived in a town – not a village – in West Pokot. In reality, Maximilla lived in the hills above and beyond that town, about a 45 minute walk from the road. With guidance from neighbors, Lucy and I proceeded through the fields, across the river, up the hillside, slipping and sliding in our sandals hardly suitable for such field work; and just when Lucy finally decided that walking barefooted was more useful than her sandals, we rounded the final bend. Maximilla was inside the mud hut, a bone-thin rendition of her former self. Ever conscious of hosting guests, she struggled out of the hut with a wooden cane to meet us on a log outside. She couldn’t make it to the clinic, she said, because she couldn’t walk to the road. Can someone carry you, we asked? Yes, her brother usually carried her, but he had been away. Is there anyone else? Maybe her father, but he was old. Anyway, she said, no family members knew about her status, and she was anxious to keep it that way. When her father appeared at the hut moments later, just returning from the fields, Lucy spoke to him about Maximilla’s deteriorating health, never once mentioning the words HIV/AIDS. Though he never admitted how much he understood of her illness, he did acknowledge that she was very sick, and indeed needed to make it to the clinic.
In the end, Maximilla, her father, and her brother worked out a routine for who would carry her down to the road, and back up, for each appointment. In early 2007, I saw Maximilla in the clinic. Due to my own scheduling conflicts, I hadn’t seen her in many months. Actually, she saw me first. I hardly recognized her. She had gained enough weight to look not only healthy but radiant. My eyes lit up, and though she smiled shyly, her eyes sparkled with pride.
In addition to the many stories of patients who benefited from the HIV/AIDS care and support directly, there were other promising notes that resounded when, for example, a nurse in a rural health dispensary began to implement HIV/AIDS testing with such enthusiasm that community members readily accepted – and sought out – the rapid testing. Or, we were able to expand our semi-mobile testing sites to include the northern part of West Pokot (now North Pokot), a place so rural that no one thought would accept such an activity; and at our initial community mobilization session, 90 people were tested (two of whom were positive). Or, simply to watch the dedication and determination of the staff involved in making this program succeed: there were many long days, endless driving, and an incessant increase in case load and responsibilities, not to mention the unspoken requirement that everyone be flexible as we were all working out how to actually create this new program – and make it work. Over and over again, however, through listening to the profound discussions at the weekly staff meetings, through accompanying staff on field visits to patients, and through watching the weekly education sessions it was very clear that the staff involved in DOW’s programs became more, not less, devoted to their work as the months wore on.
Sometimes, of course, things didn’t proceed so smoothly. Sometimes, you would visit a government dispensary, and find that the nurse who had undergone a DOW-sponsored training in HIV testing had been AWOL for most of the last month; or sometimes the entire district’s stock of HIV test kits would run out for a few months because no one had remembered to place the order; or a patient was evicted with her child because her husband or her parents found out she was positive; or, maybe, sometimes, it just seemed like there was no way to address all the problems that were thrown in your face on a daily basis.
With all that said, what could possibly have lured me away from the best job in the world? Actually, I left for some of the same reasons that I took it in the first place. In the beginning, I knew I wanted to return to rural Africa to work to improve health care services. In the end, I knew I wanted to do the same thing – but, instead, being inspired by the very same clinicians who provided care and treatment to the more than 800 patients enrolled in the HIV/AIDS treatment program in West Pokot, in addition to program management, I want to provide care and treatment directly. I want to be a doctor. So, in the end, I left to attend medical school, starting with a one-year pre-medical curriculum. And, now, as I struggle through intensive chemistry classes, it’s Maximilla’s face, and those of all the other patients and community members we worked with, that inspire me to persevere.