Information Infinity

What can one do with access to all the world’s information? How could knowledge help farmers in rural Kenya? What if they could easily communicate with anyone else in the world?

Before I attempt to answer these questions, really think about them. This is a period in human history without precedent. Seriously take a moment and reflect on how the world has fundamentally changed in the last decade or two. There are certain patterns of development that repeat in developing countries, but never have the poorest and least developed had anything near good access to information.

The legends of the US bear with heroes as diverse as Ben Franklyn and Andrew Carnegie attributing much of their success to a unique access to information. In their case, they could visit libraries with a few hundred books in it. Now everyone who can save up $50 has access to a billion volume library. For about $50, a cell phone can be purchased with a camera and access to the internet. This is still expensive, but not impossibly so.

In 1700 BC the fastest communication was by horseback. In 1700AD the fastest communication was by horseback. From 1700AD to 2010AD, communication got about 10 million times faster. For a penny, I can send a message from anywhere in Kuria at the speed of light to anyone in the world.

But what does this all mean? Not too much yet. It means that we can coordinate a bit better with our Nuru staff and that you can inform people if you’re running late. The true power has yet to be realized. But it’s so hard to think in a way that’s never been thought before.

And that’s my job starting February 11. I am handing over Healthcare Program Manager to Janine Dzuba for two months while I step into the role of Research Program Manager. I am going to attempt to set up a system for communicating and collecting data. The primary thrust of this will be to distribute data collection tools to our leaders, that is, cell phones. We’ll have 50 people, some measuring fevers, rainfall, school attendance, savings rates, and agriculture yields. This will give us the ability to collect and organize pictures of farms at various stages, confirm the straightness of their columns, do remote diagnosis of medical conditions (“telemedicine”), and possibly even identity confirmation using Picasa.

I’ve written earlier on the Disease Intelligence Network (DIN), the concept that we could potentially respond rapidly to fluid data. Starting next month, I’m going to start work on the Poverty Intelligence Network (PIN). I want to get a good look at what’s going in Kuria, fast, slow and everything in between.

Nuru has a unique position when it comes to data. Most aid agencies aren’t so interested in data. Those that are care more about numbers and less about the accuracy of those numbers. Or at least they don’t seem to care as most of the data that is getting fed to them is at least partly bogus (a fact which they could find out if they really wanted to).

Researchers do care about good data. But they’re hindered because grants must be spent only on research and not on ending poverty. A Malaria epidemiologist can never really help a community directly (at least not as part of his day job). He’s helping humanity in general, but not that particular community. With a researcher strictly doing his job as a researcher and nothing more, the community is unlikely to offer any more than lukewarm support. The other challenge with research is that it’s extremely silo-ed. You have to specialize; you have to ask a single focused question.

Nuru is unique. The data, while critical, is not our end. The people are. The data serves the people, not vice versa. As such, we have incredible buy-in and support for our work. People will answer awkward survey questions they wouldn’t if we were just strangers.

We are also not constrained by the hyper-focus of science. We can collect data on all different program areas. Then we might see relationships we didn’t expect. Maybe malaria rate has something to do with maize yield. Or water source with savings rates. There are probably a thousand relationships which we may be able to see because we don’t have to start with one specific question.

All that to say I’m excited. There are a billion things which could be measured, but what matters? What’s helpful? What’s accurate? I’m still looking for ideas if you have any (the crazier the better).

I hope that I can begin to take advantage of the unimaginable potential of infinite information and limitless communication.

Travel

This week, I just arrived. Nothing has really happened yet, so I’ll just write about what did: a 49 hours and 52 minutes of planes, trains and automobiles, except without the trains. Which is the shortest amount of time it’s yet taken to get from my door in California to my door in Kenya. And, my dear reader, I pray your forgiveness, for I have just finished Tom Sawyer and I cannot but retain some nineteenth century vocabulary and Twain sarcasm in my voice. It may wear off by and by.

My alarm clock started beeping and I my heart leaped with the anticipation of the tortuous few days ahead of me. I would have awoken on sunny Sunday in Temecula, California in my parents’ home, but it was before sunrise and so not very sunny. I did some last minute packing of things I had forgotten, and then got in the car, Dad driving and Mom asleep in the back. She was feeling bad, for she was ill, and so went to sleep in the back seat. Dad and I passed the time by discussing theology and science, two of our favorite subjects.

We travelled at or above the speed limit for the duration of the time, for there were few other unfortunate souls on the road pre-sunrise on a Sunday. And we were able to witness a miracle which comes but a few times a year, Southern California roadways which are uncongested and thereby functional.

After breakfasting at McDonalds (or rather in the car outside a McDonalds, as they had decided to keep guests out of the restaurant by having the air conditioning on), we arrived at the airport. I was dropped off and waited in the first of several lines. It passed slowly, and I had the good fortune of seeing my esteemed teammate Vivian Lu while in line. Time slowed, as it always seems to do while in a line, but I managed to make it through and check my bag. I waited in another line and went through that strange and loathsome ritual of undressing before a hurried line of travelers and dreary eyed TSA officials. Belt, shoes, pockets. *Beep* Watch.

I redressed an approached my first gate. I had the good fortune of avoiding the dreaded middle seat, and had the chance to view the beautiful Southwestern countryside for this first short leg. The unfortunate soul beside me was friendly but not so talkative. And though I do revel in conversing with strangers (at least early in my journey), I am aware that I am in the minority and so try to respect the square foot of privacy beside me.

Vivian and I arrived in Houston. The few hour flight was not so wearisome, and it seemed about morning, though what time the clocks said I cannot now remember. We waited for our next flight for a few hours in a crowd of people who had built up single-chair airport fiefdoms, strong with mental fortifications against interacting with their equally-well fortified neighbors.

We boarded this next flight and were presently en route to Paris. The passengers were a strange assortment of well-dressed Europeans, Texan-dressed Texans, and poorly-dressed us. We boarded the 777, and I retained my fortunate position near the window and Vivian had the

This next trip was quite a bit longer. Something like 10 if I remember. The plane took off, went through the clouds, and my view went from a monotony of white to a monotony of black.

I remembered the illness with which my mother was afflicted as it seemed to be the one which had decided to choose me as its next victim. A decongestant helped, but my misery began. My thirst and subsequent drinking transformed my nice window seat into prison cell, locked by two sleeping people beside me. I escaped when one or the other stood up to seek a similar relief.

I passed the time by listening to the Autobiography of Benjamin Franklyn. He was a rather interesting fellow, and it made the trip speed by, though my focus wanted towards the end for want of sleep, my burgeoning illness and my back pain (a long-time friend, who always accompanied me on such journeys).

And so we arrived in Paris. The funny thing about France is, firstly, that everybody speaks French. But by some sorcery, everyone was able to figure out that we were not in fact French, but Americans. But for spite, I think, they still started in French. I would ask if they spoke English, they would betray annoyance, and then continue in English. I was glad it wasn’t the French equivalent of “Why don’t you talk ‘Merican?”

On the plane, we had noted the pilots indication that the temperature outside was 17 degrees Fahrenheit. I, being from California, did not understand what this meant. It was surely colder than normal cold California weather of 60 degrees, but impossible for me to estimate. I think I supposed 50 degrees was right around as cold as things got, so steeled myself for that. I was dressed for California/Kenya weather, and so was equipped with a long-sleeve shirt and a pair of slacks. I figured I should steal a blanket from the airplane as it would probably find some use in the new cold land.

We wanted to find our next flight; the time was 12 hours away and the terminal about a thousand miles away by foot. Let the reader beware: Charles de Gaulle airport is very large. Everything was ready so we had about 8 hours to spend in Paris. So we walked outside.

It’s difficult for me to describe what 17 degrees feels like to a Californian wearing a light shirt. Words like ‘soul-sucking’ and ‘*%*#’ come to mind, but fail to capture quite what it was like. Vivian had a two-layered jacket and graciously offered me the outer shell. This made deathly cold into I-want-to-die cold, and permitted the exploration of the city. Vivian adapted the Continental Airlines blanket into a scarf.

We took the train into town, and attempted to buy a day-use city subway pass. This simple task was quite difficult as the cold had significantly impaired my cognitive abilities. But we figured it out and retreated into the bowels of the subway where at least we wouldn’t die. For the next few hours, we explored the city, choosing an attraction, popping up from underground for just long enough to photograph it, and then retreating to the warmth of the subways again. In this manner, we were able to see Notre Dame, the Eiffel Tower and the Arc de Triumph.

The grandness of these three struck me. My mortality was always in my mind because the cold was constantly threatening it; the destinations each had an analogous effect: making me feel small and insignificant. Though constructed in very different ages, they all seemed to say: you’re small and unimportant. Notre Dame, because God is so great; the Arc, because the French military is so great (I was successful in suppressing any audible laughter); the Tower, because the Human Mind is so great. Anyways, with what remained of my vitality, Vivian and I travelled back to the airport; we had a few extra hours, but as night fell, death surely awaited us in any unheated place.

We went through the security ritual again, we boarded our last plane, and took off for Nairobi. Perhaps because He felt bad for the joke of the French weather He played on us, God smiled warmly on us in the plane. We had been upgraded to Business Class! It had been some time now since I had slept, and so I was looking forward to the reprieve. Unfortunately, my illness was intent upon making my remaining journey as miserable as possible. With malice, it pressurized my sinuses (which is a cruel trick in an airplane, I’ll have you know) and made my nose run like the Mississippi. By the end of the journey, my nostrils were so chapped they were almost bleeding. But I was able to get a few hours of sleep in the warm plane under a warm plane blanket, the horrors of the preceding afternoon drifting away.

I awoke a few hours before landing, my sinuses in open rebellion (but not so open as to be depressurized). We landed, got our visas in short order, and went to wait for our bags. We waited. No bags. And waited. No bags. And waited. No bags. We went to the window to file a claim for our bags, but a dozen passengers had given up hope before us and so were in line before us. Though it was five lines of information about us and our bags, the process took no less than twenty minutes per passenger. I had taken a decongestant which was presently affecting me adversely and not really doing much else. My patience grew short as the line didn’t. Finally, after what must have been about three weeks in line, we were served. My alacrity waning, I provided my information as best I could.

What follows may be lacking in accuracy because either for lack of sleep, the back pain, the sinus pain, the nostril pain, or the general malaise (or some combination thereof), I no longer maintained full consciousness. I would have loved to it if my affliction would have been so kind as to render me unconscious, for then I would have remembered none of the forthcoming torment. And I also would have loved it to just leave me alone. But alas, it knew exactly what I didn’t want, and gave it to me.

We met our fellow travelers who had arrived before us and together left the airport. We got in a car, and headed for the bus stage. Nairobi traffic is quite interesting and unlike most places. Some developing country traffic arrangements are quite chaotic, with little regard for lines or directions. But Nairobi seems to be a patchwork. In places, there is the utmost of order. And then sometimes it is customary for drivers to pass on the wrong side of the road simply because an opportunity presented itself. But we arrived at the bus stage after about an hour or two. That’s a guess, but what I do remember is a lot of not moving.

The bus stage is a unique place in that it is positive, tangible evidence to the Atheist that hell does indeed exist. It seems that all of the most worthless and unsavory characters have been sentenced to reside in what is literally a hot, steaming pit of filth. So, like Dante, we descended into it, but without the help of a guide so kind and helpful as Virgil. Seeing white faces brought a swarm of these tormented souls to our ‘assistance,’ desiring to ‘help’ us carry our bags for a ‘fair’ price. One swooped in for one of our bags, and I blocked and then proceeded, hoping that they’d go away if we ignored them. But unlike stray dogs and pimples, this did not work. They followed in train, and we ducked, pushed and swam through the throng.

We made it onto the waiting bus where at least the conductor kept most of them out. We then had to wait in the pit in the bus until it got full. We were about the third on the bus, which had a capacity of fifty. It was a large bus, like Greyhounds back home, but without any of the luxuries and moved to an equatorial latitude. I had the unfortunate need now to use the toilet. There was a ‘rehabilitated public toilet’ a few hundred meters from the bus. What it had looked like before the rehabilitation is impossible even to imagine. I was charged 10 shillings to urinate surrounded by filth indoors; I suppose I could have saved the 10 shillings and urinated surrounded by filth outdoors. I returned to the bus, somewhat relieved.

So we had some time to wait. I, now fully in torment from illness, hotness and pain, sat on the aisle seat doing everything in my power to hold on to hope and lose consciousness. But while hope fled, consciousness remained as every ten minutes a person would not walk sideways down the aisle and give me I solid bump with their hip and promptly not apologize. I say every ten minutes, but it wasn’t that; for even the luxury of regular bumps eluded me and I was bumped, it seemed, whenever it was that I was about to escape into sleep.

After about three or four eternities, the bus began moving. I have a vague recollection of this being, in clock-terms about two hours. We started moving at about noon, and thanks to the very mercy of the Almighty, didn’t stop until we arrived. All I remember of these next hours was misery. I was able to slip away for a few moments, but it was probably just to add to my misery in re-realizing again and again that I was and would long be in agony.

Finally, we arrived. We walked about half a kilometer to home, carrying our bags, relieved to be off the hellish bus. As we met friends along the road, all were greeted warmly but me; when people greeted me, they seemed somehow frightened. Which, if I looked one tenth as bad as I felt, would be the appropriate reaction. But we finally, finally got home.

49 hours, 52 minutes, 48 seconds. A new record.

Human Rights and Sustainability

The other night, a man came to the health center. The only nurse, Stephen Sangara, works eight hours per day and then sleeps on the premises. But he’s on call 24 hours a day, every day. The man awoke him, shouting in the night. Mr. Sangara came to the gate and opened it. The man is standing there with his son who has a bean stuck in his nose.

Immediately to the patient’s right is a wall-sized painting of his rights. Though he can’t read them (because they’re in English; MOH loves looking Westernized), he fully understands them.

Mr. Sangara opened his office and asked the man for payment (40/=, ~$0.50). The man said he had nothing, but he’d get it later (which he never did). In the exchange, he was rude to Mr. Sangara partly because he had to wait for him to wake up. And according to the Rights Mural, he has the ”Right to timely services” and the “Right to Optimum Care by qualified health Care providers .” His rights are clear, are extensively listed, customer obligations notably omit payment. He was annoyed in being asked to pay; paying for medical service is not mentioned as a customer obligation.

For reasons that are beyond the scope of this blog, the Ministry of Health (MOH) cannot reliably keep its health facility operating optimally. There is never enough staff, so wait times are very long in most MOH clinics. The supply of medical personnel comes from Nairobi and is doled out according to need. And the need is always too great.

Medication resupply shipments come in with random supplies at random intervals. They’re supposed to come every three months, but sometimes it’s five months between shipments. They’re supposed to be filled with medicines based on patient loads, but it seems quite random (we have about 40,000 condoms and almost no antibiotics).
So health facilities have two options. The first option is to violate customer rights #1 and #2, the right to “Optimum service” by not providing the drugs patients need and the right to “Timely service” by not having sufficient staff. This is what most clinics are forced to do. The other option is to add a customer obligation: the obligation to “Share in the cost of treatment.”

Those who chose the second option begin acting like private clinics. They buy medications from local pharmacists (which are always in stock) and sell them at a premium. The premium then goes to hire casuals, nurse assistants and clerks to help with patient management.

But when they sell drugs, people are angry. Even one of our good-hearted entrepreneurial boda drivers felt cheated when he was charged for medicines beyond the flat (subsidized) government rate. He went on and on about how they were very “funny” [devious] people at the hospital. The very people who used a bit of business sense to provide better treatment to their patients are perceived by the community as cheaters. Because, after all, people have a right to optimum service. And you shouldn’t have to pay for rights.

Maybe free healthcare for all should be the goal. We (theoretically…maybe…I hope) can afford it in the West. But Kenya’s not there yet, even counting foreign aid. So in the meantime, most government clinics have chosen to do their best to provide decent service to as many as they can, bearing the scorn of those who feel their rights have been violated.

Nuru aspires to sustainability. That means that we want our programs to be running full-steam without extra Western money within 5 years. And the “Healthcare is a right” worldview makes sustainability extremely difficult in the absence of a reliable well-funded government system. Every price increase, every user fee, every shilling asked for at a clinic is a perceived violation of rights.
People here have been told all their lives that healthcare is and should be a handout. Nuru’s No-Handouts ambition is confronting that view head-on. Our next major step is figuring out a mechanism for doing that. Do we increase fees at the clinics? Do we try to offer private options? Can a health plan or insurance plan be a financing mechanism? The real question is: do people value healthcare as something valuable enough to be paid for? Or are they satisfied in accepting whatever the government can hand out? And, an even harder question, if they see it as valuable for themselves, would they be willing to contribute so that the less fortunate can have it?

Is there a fundamental human right to healthcare? Let’s leave that to the philosophers (or me on my personal non-Nuru affiliated blog). But from the perspective from one on the ground, the idea that healthcare is a right has proved to be a significant obstacle to actually providing it.

Health Center Update

When I arrived in Kenya, Nyametaburo Health Center (NHC) was in a sorry state. Janine, my predecessor, did an excellent job of identifying needs at the center. And believe me, even listing the problems was quite a task. Counting down, I’ll describe the top three problems at NHC and what we’ve done.

Problem 3:
Lab services are far away and take a long time. For full lab services (to test for TB, for example), patients had to go to Isibania Sub District Hospital. For some in our area, that would be a two-hour walk (average would probably be about an hour). And once they got there, it would probably take an hour at least (probably several) to see the laboratory technician. Once seeing him, you’d then have to wait for the test to be performed. All in all, the experience would take you all day if you decided to do it. Most people don’t. And so their conditions remain undiagnosed. With Malaria, this isn’t a huge problem (except, of course for the development of drug-resistant Malaria), but it is a real big problem for diseases like TB and HIV which are quite contagious.

Solution 3:
We have constructed and outfit a laboratory. We’ve hired a laboratory technologist who is very proficient and very ready to work. Now NHC is able to test for HIV, TB, Malaria, intestinal worms and Typhoid, to name a few. “Great!” you may say, “Having HIV testing abilities does no good if stigma prevents people from being tested.” Which is true. But, whether it is the warm and friendly staff of NHC or the HIV training we recently did, there have been nearly 100 people from the community who have been tested since the lab opened in September. [With an adult population of ~2000, we’d get them all tested in about two years at that rate; however, we hope to accelerate it]

Problem 2:
KEMSA (the Kenya Medical Supply Agency… I don’t know what happened to the ‘E’) is supposed to keep the Health Center supplied with drugs. There are quarterly shipments of medications which are adjusted based on the level of the facility and the patient loads. And by ‘quarterly’ I mean that I got here in July and the only shipment yet received was at the end of October. And when I say ‘adjusted’, I mean that they give facilities whatever they happen to have in stock, whatever is trendy amongst international donors and whatever is about to expire. Also the District has not managed to fill the form to upgrade us to a Health Center in KEMSA’s registers since August 2008 (sic). So in our latest shipment, we got roughly 3.4 million condoms (we distribute precisely zero per month…), lots of otherwise expensive Malaria meds (thank you, Global Fund) and almost no antibiotics. Even though respiratory tract infections account for more lost life than Malaria, it’s not as sexy, so no money goes to it. Even though $0.50 of amoxicillin could potentially save more life by curing pneumonia than $5.00 of Artemether-Lumefantrine could by curing Malaria, we have plenty of the expensive stuff and none of the other. Also, KEMSA never supplies certain injections which could considerably improve patients’ conditions.

Solution 2:
Nuru has established a Pharmacy Reserve for the NHC pharmacy, guaranteeing that, no matter what KEMSA provides or fails to provide, patients who come for treatment don’t have to be told to go to the private pharmacist 6 kilometers away. As the financial situation of NHC continues to improve, this subsidy can be reduced until NHC does not have to depend on KEMSA or Nuru.

Problem 1:
There were no patients. NHC only had a handful of patients per day. There was no delivery couch; a broken exam bench was all that they had and no amenities (think uncomfortable doctor’s table, but with the padding falling apart).
The present In-Charge was pushed into his “temporary” position at NHC, undesirably out and away from the town. After a month, he discovered that there would be no backup and he could not re-transfer. He was bored because there were no patients, and was frequently absent. Also he lived in town so was not available for emergencies.
What was very troublingly for us who aspire to sustainability, the revenues of the center were quite low. NHC (as most government facilities) charges a flat rate per patient, so keeping that the same, this part of it was directly dependent on patient load. Additionally, very few were coming to deliver at NHC. A preference for home birth is a significant challenge with a lack of trained midwives.

Solution 1:
We improved the facility by buying a delivery couch for the maternity ward and renovating the staff house to make it livable. Through a combination of efforts, we have marketed the heck out of NHC. We’ve pushed it with our health reps (we even had a “sale” with coupons; the rep who referred the most patients got a prize). We pushed it with Traditional Birth Attendants (following after other innovative local dispensaries, we paid them $2 for delivery referrals and charged women $2.50 for deliveries). And most of all, we encouraged and supported the staff to get quality of treatment high and keep it there (see solutions 2 and 3). Word of mouth is the best advertisement.

What happened? It worked. A total of 1000 outpatient services delivered in the month of July, and 1700 by October and rising. The number of monthly births at the facility has doubled since July (7 per month). And along with the patients, revenues have dramatically increased. Mr. Sangara moved into the staff house and has been seeing patients at night. Other staff keep it running on weekends. And with all this new activity, with the ability to practice proper medicine (with a lab and reliable drug supply), Mr. Sangara has been around a lot more frequently than before.

So all in all, things are improving. I cannot, either as a scientist or Nuru employee, toot my own horn too much. As a scientist, I can say that correlation is not causation; as a Nuru employee, I believe that it is the work of the people here which is the biggest effect. Mr. Sangara (the In Charge) and Ms. Alice (the Lab Tech) have been the foundation of the service improvements at NHC; Nuru has empowered them with the tools they need to work. And work they have! And perhaps most of all, Nelly Andega, my Nuru counterpart, has been fundamental in carrying out all of these many things with a competence and coolness of demeanor that I love.

[Bonus anecdote: Nelly was In the process of delivering cement for construction and sent me the following text: “Hello. The vehicle is on fire.” Upon calling, Nelly was completely calm. I asked, “Do you need help?” She said, “No. I am just helping the driver of the vehicle put it out. I was just calling to inform you.” She successfully extinguished the vehicle fire and then successfully deliver the bags of cement]

The End - Jake's Story

Nuru Media just put out a video about how Jake got into this work and discusses the connection between terrorism and poverty. It's a really powerful story and makes me proud to be able to work with him. I would encourage all you, my dear readers, to watch it and respond.

http://www.nuruinternational.org/takeaction/theend.html

P.S. The music was done by Tyler Bates, the guy who did the music for "300".

Help me address malnutrition

I'm reading and thinking about severe malnutrition interventions. WHO says RUTF (home-made power-bar paste) is the way to go; about $45 and 8 weeks to treat a kid (which much cheaper than the hospital route but not quite affordable to the poorest of the extreme poor). A tape measure can be used to identify kids (mid upper arm circumference < 110mm =" malnourished).">

Comment/message/email me with ideas on how to find and treat kids with malnutrition, especially ideas that fit with Nuru's aim to do things sustainably. Sure I can screen kids and feed them this stuff while I'm here, but who will do it/pay for it when I leave?

Mobile Clinic

It is 12:00PM on Thursday. I have been called, right before I am going to eat. The vaccines are not approved by the Ministry of Health (MOH). Even though they were approved the day before, they are now unapproved, which means I have to drive an hour by motorcycle on a very dusty road to resolve the issue.

It is 1:30PM. I am sitting in a meeting room with MOH officials. My failures to navigate the bureaucracy along with the cited reasons for un-approving the vaccines is a tale too long and tedious to retell. An hour passes in one of the most soul-crushing meetings I have ever had. The vaccines are finally re-approved on the condition that Nuru pay for the a nurse from the nearby hospital.

It is 2:30PM. I get back on my bike, and drive the long road home, hungry and tired.

It is 7:30AM on Friday. The day has finally arrived. Everything is arranged, or arranged as well as it could be. My people should be arriving to prepare. The kids should start arriving at 8. And by kids, I mean all of them. We arranged for each and every school kid in the sub-location to take a couple hours off to walk over to the Keborui school to learn about hygiene and get de-wormed. We also invited mothers to come get their children immunized starting at 8.

It is 8:00AM. Most of my officers have not arrived. The medical staff has not arrived. And (fortunately) the kids have not arrived. We’ve made great strides in timeliness here, but we’re not yet as anal about time as Americans; it’s a good thing everyone is a bit late. Everyone except for the mothers. They arrive exactly on time, ready to have their kids vaccinated. So we have to apologize and ask them to wait. The Nuru Water and Sanitation (WatSan) team is arriving, ready to teach many many children.

It is 8:30AM. The first set of kids arrives. About a hundred of them, walking together in uniform with impressive discipline. The WatSan guys are on it and escort the kids over to the field. Two health Field Officers and another Nuru worker aid in giving out the Albendazole tabs, one per child. And the lessons begin. The nurse has still not arrived.

9:30AM the nursing staff arrives. Vivian and Chelsea, my muzungu (white) teammates, meet her as I am on the other side of the campus. I walk back towards the classrooms. Chelsea and Vivian approach me, poorly-suppressed rage in their voices.

“The nurse is here.” Chelsea says.
“And she has news.” Vivian adds.
“She has news, David,” Chelsea emphasizes.

What news? What could news could there be but bad news?

“I was called this morning,” the nurse begins, “and the MOH says that the vaccines are not approved to come here.”

Interesting. I had made a bureaucratic blunder the previous week, and such blunders are not forgiven easily. Why had I not been told to my face 18 hours before? Why weren’t we given time to inform people that there would be no vaccines?

“Alright,” I say, calmly.
Chelsea and Vivian are astounded at my calmness.

Getting the vaccines pulled is interesting indeed, but not surprising. It is so not-surprising, that I had planned on it. We are 3km from the hospital, and I had hired a taxi for the morning to transport people there and back just in case there was a need. And now there is need.

I tell the mothers the situation, apologize, and sent them with Isaac to the hospital to have their children vaccinated.

It is 10:00AM. The day is in full gear. The children from the other schools are cycling in better than we could have hoped. The WatSan team is doing an excellent job of managing the crowds and getting them educated. The Healthcare team is effectively dispensing the de-worming meds. Everything is going according to plan. We have taken 30 children to the hospital for immunizations, many of them who were “defaulters” who had been off their vaccination schedule.

It is 4:00PM. The day is done. All the kids from four schools have been de-wormed and educated. We had gone through 2000 tabs of our de-worming medications. 2000 kids. We have transported every mother who showed up for vaccination. 80 children. The day is done.