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.

New Website

So our new website totally rocks. Our media team is incredible:

www.nuruinternational.org

I guess I'll actually have to start living up to those videos... :)

Please comment about what you think.

Disease Intelligence Network, Part II

A while ago I told you all about the concept of the Disease Intelligence Network. As a refresher, the elevator pitch is this: we plan to collect health data and make it useful to the health workers. We want to know who has a cough (and where they are) this week to prevent it in others next week.

Well, concept has become reality! At least a little bit.

The last four weeks, I’ve sent surveys with the health reps. It’s unfortunate for the data enterer (me) that there are only about three male Kurian names (Mwita, Maroa, Chacha). If you’re lucky, you get a “Christian” name mixed in there (e.g. Peter, George…because George was a very important character in the Bible). But last names work differently here. They’re not really last; they “other” names. Parents like to keep the memory of all their relatives alive in their children’s names; unfortunately their relatives were also called Mwita, Maroa and Chacha.
What has drastically improved the efficiency of data entry is printing an individual sheet with the farmers names ALREADY printed. The Health Rep from Gesiora Group is a lot better at finding Mr. Chacha Mwita of Gesiora Group than I am at discerning “Chacha Mwita” scrawled on paper and finding which of the 35 Chacha Mwitas I should put that data under. Also, they know who’s married to whom a lot better than I do (so if a wife answers a survey, I know which family it’s from).

That hurdle overcome, the next step is to input the data. With the lists pre-printed, I just need to Ctrl-F my way to victory. It took me about an hour to put in the data for most of the farmers. Not too shabby, but shabby nonetheless. A present work in progress is to figure out how to make that faster and not me. Computer literacy here is very poor and experiments computer trainings have been disappointing (it took one person new to computers an hour to input one of the seventy groups). Our most promising lead is to get the Health Reps to do it themselves.

“Wait!” you must be thinking, “But how are you going to get 70 laptops?” And I would say in reply, “Who needs laptops when cell phones do everything laptops can!” We’ve been talking with SMS:Frontline Medic, an organization that does great work in using cell phones for communicating with CHWs. People don’t know how to use computers at all, but almost everyone knows and/or is learning to use cell phones. And PS just so you know, the cell networks are amazing here. I can buy GPRS data for about $0.03 per MB. And I haven’t found a dead spot yet. Take that developed world!

So after a month of data, what do we see? It’s tough to say. I’m proposing to Stanford that we do this formally for 6 months and analyze it rigorously. But for now, I think I see certain patterns. For example, there was an area one week with a single case of diarrhea; the next week, there were dozens in that area. Did the one cause the others? We can’t know yet. (Technically with what I have proposed, we can’t ever actually determine causality; but who cares? Because we may be able to determine that there is a strong correlation between a particular case of diarrhea and cases in the weeks to follow).

DIN may allow for other cool things beyond just the common diseases. Unaltered, it can help track and stem outbreaks of serious diseases like Cholera. We can send and alert and mobilize our team to warn people in at-risk areas and to distribute water purification products. Another possible idea is linking it with our in-planning health insurance; we can identify certain situations like a Malaria outbreak and use insurance to actually help stem the spread of the disease, rather than just pay for its treatment. If we predict a big Malaria outbreak with DIN, we can drop the patient co-pays for malaria visits to zero for a week or two (and announce this by health reps); this would increase those taking anti-malarials and may actually prevent the outbreak. This would, in addition to helping people directly, save money for us, the insurer, contributing to Nuru’s sustainability.

The bottom line is this: rapidly moving disease can be tracked with a precision and resolution previously unheard of. I had the privilege of meeting someone from the provincial medical office yesterday. We chatted about Nuru’s programs and he was mildly interested; but when he saw our first map, he said, “This is Revolutionary.” I certainly hope it is; I hope that it will bring better health for these people.

Hand Washing

One of our initiatives is to set up hand washing stations. Without running water, it takes some amount of innovation to have a place to wash your hands. Our design is basic: a holey cup with a hook, soap tied by twine (covered by the top of a water bottle) and a small pot or bucket for holding water. You dip the cup in the pot, and then use the drizzling water to wash your hands.

The great thing about this is that people before don’t have much way to wash their hands. And in a place where toilet paper is not yet widely used, it’s especially, especially important for people to wash their hands.

Last month, we’ve been running a competition to see who could build the most stations. Last week, Nelly and I went around checking those who people said they had built. There were mixed results. Some of the stations were not in use. Some had been destroyed by children (by doing such things as using the twine-attached cup to swing from). There were also problems we had not anticipated. Who would have guessed that livestock love eating soap? The core problem in these places, in my opinion at least, was that people did not value the stations. Sure they liked washing their hands, but not enough to keep water in the basin or to replace the soap. Maybe this is because diarrhea is less of a problem (we’ll have the data on that soon). Maybe it has to do with different ways our health reps and field officers explained it. Behavior change is a tough thing, particularly teaching grown-ups a new and strange habit.

But not all the homes were like that. One of the families we visited had even innovated on our original design: they attached it to their dish rack (a box with chicken wire for drying dishes). This was a pre-existing, sturdy structure already valued by the family. Children could not destroy it without consequence. They used it regularly and were satisfied.

Another family told us with joy about their station. The mother showed it off, proudly telling about how her children actually helped maintain it and kept the water full. They would wash their hands even without being told. She told us that the months before, her family had really been affected by diarrhea. But since she had been washing her hands last month, her family hasn’t had any diarrhea. She was beaming!

It is certainly amazing how cheap improved health can be in Kenya. In the US, to improve health is extremely expensive. To reduce diarrhea in the US, we have to spend millions of dollars to make sure we screen every last spinach leaf, or do surgery on rare bowel disorders. But in Kenya, it only costs a foot of wire, a re-used water bottle and a few minutes of education. When you including the cost for me to be here, Nelly to administer the program, and the Field Officers to build the stations and teach (adjusting for the portion of our time here dedicated to the stations) the cost per station is just $5.

In the US we talk and talk about how we shouldn’t put a price on a human life; we debate forever about how this health plan or that insurance company is putting a dollar sign on a life. But the reality is that we already do that. For every dollar we, as a society, spend on US healthcare instead of on Kenyan healthcare, we are putting a dollar sign on Kenyan life. In the US, we spend more than 15% of our GDP on our own health and far less than 1% on all development (health projects being one small part of that). When we, as a society, pay for a $50,000 surgery we’re saying that’s more important to us than 1,000 families in the developing world having a place to wash their hands. We certainly shouldn’t dump money on the developing world stupidly (like we have been doing…I’ve seen it all over Kenya and healthcare especially) and I’m not suggesting we stop caring for our own sick. But we should spend more of our resources caring for the sick outside out own borders, and we should do it intelligently.

Laboratory

These last few months, we’ve been working hard at Nyametaburo Health Center. The way medicine is practice here has really struck me. As an example: a friend had a persistent cough. I took the history and physical and narrowed down to a few possibilities. In medical school, that’s when you get the next round of test results. But there’s not a single X-ray machine in our district. She had to spend half a day going to the nearest hospital and waiting in line to get a sputum test. Then another half day to go back and get the results and yet another half day to visit her doctor who works in another hospital. Thankfully the result was negative. Finally. But what about people who don’t have the resources to spend a day and a half (plus travel expenses) to get a TB test?

The old answer was that they didn’t. They’d just cough and cough and cough, infecting family and friends until they couldn’t work anymore, and only then would they go to a hospital. We thought this state of affairs was bad. So Nuru decided to continue the upgrade of Nyametaburo Health Center (NHC): adding a laboratory.

The first step was finding a lab tech. Fortunately for us, there happens to be an abundance of them. There are far more trained than there are jobs available in Kenya, so those who can leave, and those who can’t, stay and get paid less than they ‘should’ be worth. And by ‘should’ I mean the amount someone of equivalent schooling would be paid. In order to do all that we wanted, we needed not only a lab technician (2 year program), we needed a lab technologist (4 year program). We put out a request and ended up interviewing a highly qualified candidate who was willing to start work immediately. The candidate, Alice, was being interviewed by the 8-member board. The problem was that she asked to be paid what she was technically worth: 25,000/= per month (~$330/month). That was way too high for our facility which, on a good month, might bring in half that amount in cost-share payments. But then, in a tag-team barter that will go down in history, the board haggled the price down to 14,000/= per month.

So we hired her and with her, we came up with a list of reagents and equipment she needed. We began renovation of the lab, which included a solid, tiled countertop (important for sanitizing and cleaning spilled reagents) and a sink for hand washing. She doing what she could immediately, and we had a line out the door for her services. She did an incredible job in pulling from the resources she already had and asking for those she lacked. And, it seems, adding additional services is a great way to attract customers and bring in more money for the facility that is hurting financially.

One of the first things she did was turning NHC into a “Voulntary Counselling and Testing” (VCT) center. Standalone VCTs are one moderately effective way of going about getting people to know their HIV status. But with the stigma associated with HIV, there have been problems with people voluntarily walking through the door for fear of being associated with the disease. One of the recommendations now is a strategy called “Provider Initiated Counseling and Testing” (PICT); it addresses the stigma (there are plenty of non-stigmatized reasons for going to a health center) and makes testing convenient (“I know you’re here for malaria, but why don’t you get tested for HIV while you’re here at no charge?”). So we are beginning to transition toward the latter strategy.

Now we can test for the famous developing world diseases: HIV, TB, and Malaria. And also the forgotten developing world disease (diahrrhea) by fecal test (ewww!).

Why should anyone care about testing? Well firstly because it helps patients. Knowing your HIV status, for example, will put you on track for managing the disease rather than just dying of it. With a lab test, you can tell which cases are Malaria and which are not and then treat appropriately. In some diseases (worms, for example), doing a test will help design the treatment regimen.

Beyond the individual patients, there’s a larger issue of global responsibility. Understand that microorganisms are like the Borg in Star Trek: they adapt. Roughly speaking, the more you use a drug, the less effective it is. It’s like you only have a certain number of doses; you don’t want waste them on those who don’t have malaria. The idea of resistant bugs becomes even scarier when you think about the fact that antibiotic discovery is slowing down despite the huge amounts of spending.

So not only is Nuru fighting for the poor in Nyametaburo, but we are also doing our part to conserve the drugs for those who truly need them worldwide.

Adventures in Capitalism

Nuru’s all about sustainability. We want our programs to be self-funding as soon as possible. And there are few things more sustainable than profitable business models. One of the best ideas out there on this is the Living Goods model. The idea is basically to use Community Health Promoters (CHP’s, not to be confused with CHWs; everyone wants to brand their health workers) to sell health-promoting goods at a small profit. That profit is the incentive to keep them working. Because research has shown that if you don’t pay people, they don’t work for you forever (seriously, people had to research that).

So four weeks ago, we distributed 200 bars of soap to 50 Nuru health reps. The health reps are organized into teams under 7 field officers. And because a bit of friendly competition makes people do amazing things, we told them that there’d be a prize for the team that sold the most soap. And just like that, the soap sold like hotcakes! We were sold out in a matter of days, selling at 15/=. The Field Officers complained; more of their members wanted soap and couldn’t get it. So I asked them to write a proposal. They did, and I funded it. This was originally supposed to be a proof-of-concept exercise: giving inventory and getting roughly enough money back to pay for the inventory. But we couldn’t let that kind of demand go to waste, so we bought an additional 400 bars and upped the price to 20/=. If this sold, we would actually be profiting (we bought the soaps originally at 16/=). And they did sell. We’re expecting a profit of about 1000/=.

Sounds great, right? All but one thing: the health reps are friends with all their customers. And friends don’t always have the money to pay for things like soap. But if they say they’re good for it, they’re good for it, right? Well not quite. We made it crystal clear to the Field Officers that they were responsible for returning the soaps or the money for the soaps; these were not gifts. And so some of the Field Officers came to collect money from their health reps who, because of their generously, had given the soap out on credit. The Field Officers told them it was their responsibility to pay for the soap and so they did; those who extended the credit paid from their own money. We debriefed today and we asked about what they’d do differently. “We won’t give them the product until they give us the money.” And they didn’t even need me to lecture them on following our instructions better. By holding 7 people responsible, they hold those below them responsible. Isn’t responsibility amazing?

But why did people buy our soap? Were our never-sold-anything-before farmers that good at selling? Or was this, like the discount flyers, something novel. What’s so novel about that? Well apparently nobody has thought of it yet. The door-to-door salesman is a fresh idea here. People in the villages don’t go into town often. And certainly not often enough to buy soap. But they would use soap if they had it, and would buy it if it were available. And now it is available.

What next? The reps are doing market research this week to find out about products, prices and volumes. And I’m looking for wholesalers to get our prices down lower. We hope that in a few months, we’ll promote the better ones to a paid position (possibly full-fledged government CHW’s). They’ll have other responsibilities beyond the selling, but this could be the mechanism by which they could fund themselves.

Disease Intelligence Network

[Some of these posts will include topics that I'm working on. For such topics, I'd really like feedback. Now I know you don't think you have anything to contribute, but that's a lie. I want these to be understandable by everyone, both in vocabulary and concepts. So if there's something you don't understand please point it out. I have no other way to gauge how crazy my writing is becoming. So with that introduction, here is my first Blogged program idea.]

One of the problems in healthcare is that it is slow. If we ever want to find something out, we commission a study which takes a year or so. If we want to change something, it's like turning an aircraft carrier (which, I've been told, is difficult). In the US, it's a system which is quite disconnected and has little incentive to be fast or dynamic (but that's a whole different discussion). But, in starting from a very basic system, is there a way to speed things up?

The first thing that needs speeding is disease information. Collection has been so slow up to now, that only strategic information could be used. How many million people are infected with HIV? Is hypertension on the rise this decade? And when I say strategic, it's like counting the number of men in your army compared to your enemy's. Keeping to the military analogy, tactical is talking about things like how to defend a particular hill; we do no generally use tactical information in modern healthcare.

But in Kenya, disease moves much too fast. Three of the top culprits here are Respiratory Tract Infections, Malaria, and diarrhea. These three conditions don't even last a week (if you're lucky), so no existing system is nearly fast enough. What do we do?

Well it's actually quite easy (if you're Nuru). We ask people about the sickness in their family that week. And since they meet once per week anyways in their Nuru groups, it won't be that hard. And once we have this information, we can begin to do things like targeted interventions with our Nuru Healthcare Representatives (who we hope will become Community Health Workers; more on the details of this later).

Say there is a diarrhea outbreak. Say 10 people in Area A get diarrhea on Monday and Tuesday. On Wednesday, they would then report to the Health Rep during their Nuru meeting. So on Wednesday afternoon, we can equip the Health Reps with anti-diarrheal drugs to take to Area A on Thursday, and with soap to get to Area B next door to prevent diarrhea from spreading there. And it could be the same story with Malaria and respiratory infections.

Today it's diarrhea, but it could ultimately include many more things. To make it fast and efficient, we may make it phone-based (we have internet phones out here) and use online servers to process the data (i.e. a farmer could send a text message to find out what his Malaria risk was that week). We're planning to get GPS on all our farmers, so we could produce a map of our results, helping us to predict outbreaks. We've considered doing regular weighings which could help identify malnutrition, HIV, and TB. We could integrate screenings for other common diseases as well. We've even considered expanding the Disease Intelligence Network to the Poverty Intelligence Network and including all the information we have (farming yields, pests and weed growth, etc), making it a useful set of data for all programs.

The most important part of the Disease Intelligence Network is this: Information->Response. This is what we care about. There are about a million applications to this basic idea, but the unique thing about this is that we have connected information directly with a response, and both are fast enough to make a difference; the thing that makes DIN special is that it is tactical. And, God willing, tactical will mean lives saved.

My Dinner with Charles

Two weeks ago, I was invited to dinner at the home of one of my field officers, Charles Magige. Charles is one of my best officers. He works hard and he's always on time (a very rare and treasured attribute here). Though he never finished secondary school, he has learned leadership quickly.

We had a meeting with our health reps where we talked about several of the initiatives we've got running. It was a good meeting. We debriefed and talked about how the meeting went. Then Nelly, Pius (another rock-star field officer), Charles and I walked to his home. That is 'nyumbani' because he has enough land to have a farm, not 'numba' which is a house without land (like what most Americans live in). I have been told that it is a part of Kenyan manliness to own land; you are not a man unless you own land.

We walked past fields of sprouting maize. Most of it near Charles' is Nuru maize. It's easy to see by the clean rows, clear of weeds compared to the random scattering that happens normally.

We approached his shamba (farm) and I saw his house. It was typical Kurian home. There were two mud-walled, tin-roofed western-inspired homes and two round huts with thatched roofs. These buildings made up three sides of a center dirt courtyard. The fourth side was a wall of wood: planks and sticks nailed together.

I entered and greeted his second wife and his children. Polygamy is condoned here, but divorce isn't. His first wife had left him after stealing his life savings (120,000 KES; ~$1,500. A farmer on one acre can earn about 40,000 KES per year). So he couldn't live life alone, and couldn't divorce her, so he took a 'second' wife.

We waited in his living room (the western tin-roofed building) and the three others talked in Swahili. Every once in a while I caught something or had something translated. The conversation was mostly on farming matters. The recent shortage of good grazing land, ways to fight witchweed, stories about planting tobacco. Charles came in and served us sodas, a very valuable luxury (sodas cost about 45 KES; the four that he served were about equal to a day's wages).

Then Charles' wife came in. She carried a platter about the size of a large pizza tin (mmmm...pizza...), but instead of pizza, it carried a pile of sticky rice six inches high. Following that was a plate of something deep yellow and irregularly shaped. I later found out after tasting it that it was 'local eggs', which are far tastier though smaller than eggs in the US. There was also beef in a bit of stew that tasted wonderfully. And if that wasn't enough for the four of us, there was chai (which is just Kenyan tea with lots of milk and sugar). When the food came, the conversation stopped.

This was my first meal at someone's home, so I paid very close attention to the others. Eating in a foreign culture is always a tricky business. Did they slurp the tea, or drink it quietly? Slurped it; I began slurping. How did they sit? Hunch over; hold the bowl. How did they use their spoons? Is that lip smacking I hear? Then commence lip smacking!

Oh no! I ate too fast and finished my first plate slighty before the others. That meant more food. "Nimesheba" (I am satisfied) only slightly reduced the amount I was compelled to take for seconds. And then, when I couldn't eat any more, 'sweet bananas' were brought out. The banans here are a breed that is about six inches long, and sweeter and smoother than US bananas. I asked Nelly, "How do you say I'm very full!" "Nimesheba sana!" I cried, but to no avail. More bananas. More chai. Still soda to finish! Ay!

We finally finished and set our bowls down. I was full. I neither waste words nor fill easily, so when I way I was full, I mean it. I have no way to estimate how big a sacrifice this was to honor me, his guest, but that was a luxurious meal even by my standards. We stood up to leave, and Charles said "Wait! We must pray!" He gathered all his family in the living room, and Pius prayed for a good few minutes. We greeted everyone and I began to walk home.

Charles wanted to walk with me. The walk took about 45 minutes through a beautiful countryside. I was walking slow (i.e. a normal American pace) and he asked, “Are you tired?”

“No, but I am just having trouble carrying all this food up the hill!” I said, pointing to my distended belly.
“What food?” he asked.
I replied, “All the rice you just fed me.”
He looked confused, “Rice is not food.”
I looked confused, “What is food? What am I full of? Isn’t that food?”
“No,” he replied, in a tone as if he were explaining something very simple, “Food is ugali, not rice.”
Ugali is a paste made from maize that is the local staple. We had always known that “A meal’s not a meal without it!” But they meant that literally!

As I was nearing home (nyumba), Charles told me, "I was very feared today." "Why Charles?" I asked. He replied, "I had never controlled a meeting before."

It never occurred to me. I've been in some sort of leadership position for about as long as I can remember. But this 38 year old man had never had the chance to lead before today.

"You did a very good job! Kazi Nzuri!" I assured him and pondered that the rest of the way home.

Part Time Economy

Figuring out the economics here is hard. I'm used to the US where people work for money, and there's no time left in a day. Here it's completely different. Farm work seems to take half a day. The other half of the day is free. And that's during planting season. The work gets even lighter between planting and harvesting. Workload is cyclical. If workload is cyclical, income comes in spikes. Two big ones per year. Once in the summer and once in the winter. I imagine that means money is more valuable right before harvest, but only having been here when money is cheap, I haven’t observed this trend.

But what does one do with half the day free? Here you'd think that an ambitious person would just get a part-time job. Except that there are no part time jobs. There's no McDonalds to work at. No paper routes. No secretarial work. So people spend it largely with other people and doing things around the town.

The concept of the hour, I am finding, is somewhat foreign. Certainly people know what an hour is, but it's not how they think. I asked my Field Officers today how many hours this week they worked on Nuru stuff. The literally had no idea; they couldn't even guess. It was two or three afternoons and a morning. How many hours was that? They couldn’t even estimate.

People work for free. Many people. I met a university grad in a rural village last week (which is very highly educated here; there might be 5 in our entire location). He was working in the lab at the health facility, not getting paid. Actually, he was subsidizing the cost of the tests to keep his skills sharp. There are many like him. There are teachers who work as 'casuals' in the schools who (sometimes) get paid $26 per month. But, being an agrarian society, they all have farms and so long as they do their farm work in the morning (4-8am), they don't really need to get paid. The chance at a better job is good enough, it seems, to keep them somewhat motivated, at least for a while.

The value of money isn't quite clear to me yet. The things people spend money on and the things they don't perfectly line up. Two dollars is about the cost of a day's labor. It can also buy you two full lunches at a restaurant, four Coca Colas, a motorcycle taxi from Kehancha (~15 miles) or ten days' calories in flour. In the US, it would take closer to $50 to hire someone for a day (legally). With that you could buy 5 lunches, 50 Coca Colas, a car taxi about the same distance, and with frugal home cooking, about 5 days of food.

We gave out discount coupons to try to build the patient base at the local health center (it's an internal competition for my field officers, each of whom were given 80 flyers with their name printed on them; the one who refers the most patients wins). The normal price is about $0.50 for a clinic visit and we were discounting it $0.25. A woman came in today with a deep gash in her leg. I was shadowing the in-charge. "When did it happen?" I asked. He asked in Swahili. "Ten days ago." It was quite infected. Why did she decide today? I'm sure it was partly the increasing pain. But she proudly held the discount flyer. She'd deal with a festering leg wound if fixing it cost $0.50, but it just wasn't worth dealing with it if $0.25 could fix it.
But even if one took this to be the value of money, it’s varies wildly person to person. Roughly half of our patients didn’t walk today; they took the motorcycle taxis. I'd crudely estimate that a quarter of them pay more in transport than they do in clinic fees.
That woman wasn't the only one. There were 25 patients today, the first day of the promotion (the 'sale' lasts two weeks); last week we didn't even have that many. Is that $0.25 price really such a barrier? Or is the perception of a discount that powerful? Are some people really paying $0.50 in transport to save $0.25 in medical fees? These questions and more are being actively pondered by your favorite Nuru FT3 Healthcare Program Manager.

Leadership

There are many things we take for granted. The thing I realized today is that we take opportunities for leadership and advancement totally for granted. In the US, almost every single job has some way to advance. If there's no advancement in the job, then it's seen as a stepping stone to some other job. But as an impoverished farmer, there is no advancement. Either for you or your family. You really need to go to extreme measures even to get your kids out of poverty. One of our CDC members is saving 90% of he and his wife's combined income to send their kids to university. Other than that, there's not much hope. You could be a farmer. And, well, you could be a farmer who gets a bit of money on the side.

We thinking about going from 700 farmers to 2500 farmers by the end of next year, more than a threefold increase. We are creating jobs, but more, we're creating career tracks. There is a clear path from representative to field officer to field manager to district manager. Like any career, not everyone makes it. But some do. And because some do, there is hope. Real, tangible hope. As in "Be light. Be hope. Be Nuru." We are blasting a path through the mountains of poverty.

Beyond simply creating jobs and career tracks, Nuru is building leaders. Nuru has a radically high view of the poor. They're not lesser people. Really. We really believe that. They're actually equal to Americans in value and potential ability. They could be powerful leaders given the opportunity and a bit of training. For reals.

Already we've recruited a nine-member Community Development Committee who are leading our five program areas. Under them are about thirty field officers. Under the health and WatSan (water and sanitation) field officers are about 70 representatives.

All these people used to be poor people. Most of them were farmers earning what they could. My Field Manager, Nelly, was a fully trained nurse working for no pay at the health center. They were poor. But we Nuru told them they were leaders and began training them as such. And not just leaders, but servant-leaders. And guess what? They've become leaders. Fully-fledged, real life leaders. And another thing: they're now inspiring the people under them to be as they are.

I admit that I used to think that poor people were poor because they couldn't think like leaders. In my elitism (and when I read Plato), I am tempted to believe that this is only a result of nature. But that is a lie. The reason Nelly was not a powerful community leader last year was because there was neither leadership opportunity nor example. For our field manager,s it was an issue of circumstance, not natural ability. The team before us did an incredible job of finding those in whom the ember of humble leadership resided, but it would never have produced a flame if it remained buried in the clay of Kuria. Nuru has been able to fan it, fuel it, and now, even to spread it. In spite of their lives of extreme poverty, our people have become powerful leaders in their community and have begun to teach others as well.

Are leaders born? Or are they made? I say both. A seed of leadership needs to be present, but that seed must be planted in a soil which allows for growth, and watered with training, mentorship and experience. And like a great tree leaders grow. In due time, they will yield sweet fruits which can themselves be planted.

Perhaps the answer to the desert of poverty is not to shower it with more aid, or clear it of the rocks of bureaucracy, or limit the runoff of corruption. Clearly all these are good things. But maybe the key to turning the desert into a paradise is cultivating leaders like trees; tiling the soil, fertilizing it, and then planting good leaders from native seed. Then carefully watering, not the vast and burning sands, but the soil around these tender plants. And after a few are established, no further gardening will be needed. The water from the rains will be retained, and the roots as they go deeper will draw up water from below; the shade of these trees will provide a pleasant refuge for others who would grow up. An oasis in the desert will form, and then continue to grow until there is no desert left.

The Great War

[I'm departing this week from program updates. Partly because there is not one narrative which stands out as in previous weeks and partly that program updates will soon be housed somewhere else.]

Over dinner, I realized that I am incredibly blessed. I'm 24 years old and I've been given the commission to improve healthcare in a community. Not with any pre-concieved list of tasks I've got to carry out. And I don't even have to pay to do it. In fact, thousands of dollars are available for me to direct.

My boss is an awesome guy who is incredibly capable and, on top of that, humble. I mean, who else's boss cleans their toilet? In addition to him, I get to live and work with two other people who are able to help nurture new ideas and, on top of it all, cook really well. And all I have to do is be constructive about their ideas and do the dishes.

I feel like I'm riding the wave (if I surfed). God put me in "such a time as this" where I could apply for such a job. Nuru was in a place where it would hire someone like me.

I like Jake's phrase/Dad's phrase (must be a Marine thing): we are the tip of the spear. It's true in a lot of ways. Nuru is out in front of other organizations in figuring out how to eliminate extreme poverty. We, the Foundation Team, are at the tip of Nuru. All else is support for our success, helping us to be healthy, well-funded, well-staffed.. It is sobering to realize the gravity of our positions. If we fail, if the spear point is dull, then Nuru will fail. And if Nuru fails, it's a significant setback to this fight.

And if we succeed, if we are sharp, and the shaft behind us is strong, then this spear will pierce the heart of Poverty. And we will have been blessed with participating in the greatest War of our generation.

Let us not be like our great grandparents who fought one World War but planted the seeds of another which their children would reap. Let us end it well with justice and mercy as our weapons.

When we are older, when our bones ache from years of riding on dirt roads and when our skin is aged and weathered, our grandchildren will ask us, "Did you really see extreme poverty? What was it like? And did you really fight in the Great War? Did you really beat it?"

And I pray that on that day, I will be able to say, "Yes I fought in that War and I fought as hard as I could. But I only played my part. It wouldn't have been won without many others on the front lines like me playing their parts, and many more back at home supporting us playing theirs. Yes. Together we fought and together we won that War."

Pride Goeth Before Destruction – Part III of III

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The second load arrived, and I was ready to go. The unloaders began to offload the truck, somewhat slower as we had lost Jake to another site by this point. We also had lost some of the movers. It was me and two others. Many of the farmers had arrived at this point (probably with idlers mixed in), somewhat impatiently awaiting their seed and fertilizer. The two others movers carried the first bag together. I walked up to the pile of fertilizer, and there was no one to help. I looked around at the faces, and there was a bit of incredulity; I assumed this was disbelief in my capacity to do manual labor. Maybe I was wrong.

Up to that point, the majority of my motivation was good and clean and pure. But then the crystal spring of goodness was tainted. The weed of pride broke through, cracking the straight and narrow road of humble service. My desire to express manliness by diligence and exertion mutated into a dark pride in that which would have been virtue but for pride. I wanted to prove that I was a man who was strong, rather than a man who was humble. I wanted those who stood by to believe that I was strong, not that I was their servant. So, with my spirit puffed up within me, I squatted down and lifted the bag of fertilizer. I single-handedly carried it to the pile, arrogant in the strength which let me do the work of two men.

The other two (clearly not aware of the feat which had just been accomplished) continued working as if nothing had happened. So I went back to the pile, squatted down and lifted. Only this time, there was a deep pain in my lower back. Not a sharp pain, but diffuse throughout it. I set the fertilizer down and walked aside, holding my back. I decided to take a break, and the two others finished stacking the fertilizer. As I stood, the pain rose and my mobility fell. I got stiff if I stayed sitting or standing too long. It was a pain similar to what I had known many years before, my old back injury that I though was behind me. But it was somehow unique; I had not remembered the inflammation of my back muscles.

I took it easy the rest of the day, and suffered through the humility of sympathy. Sympathy is good for things that are accidents, but this was due prideful foolishness and I deserved nothing but contempt. I was able to walk, and in fact walking felt quite good; it kept my back stretched out. I expected other modes of transportation would be excruciating. So after the day was through, I walked home.

The walk was about an hour and a half. I needed the time; I had a lot to speak with God about. We hadn't spoken for a while; after all I was so busy. And I hadn't been reading my Bible, either.

I was quite concerned and I told God as much. I didn't know how bad the injury was. If it was degenerative, I wouldn't be able to stay in Kenya. Those who depended on me would be let down both my team and the people for whom I am here. My pride might sabotage even more than my own work. After half an hour of such reflections, I repented of my sin. As I walked along the way, the arms of God wrapped around me and He forgave me. A tear came to my eye as I beheld God's light shine down before me:

“The people that walked in darkness have seen a great light: they that dwell in the land of the shadow of death, upon them hath the light shined.” - Isa 9:2

I continued my painful and (I think) therapeutic walk. Last week, I had started reading the book of Job with no reason other than it felt right. I reflected on what I had read: “the LORD gave, and the LORD hath taken away; blessed be the name of the LORD” (Job 1:21). Either here or in the US, in failure or in success, with pain or free from it, God is in control. And He loves me. Even in the face of my foolish pride. I begged Him to let me stay and continue my work.

I got home. I apologized to Jake. He rejected my need to apologize and told me it was fine. We shook hands. That handshake communicated more than words ever could have: I was forgiven. We were reconciled.

I slept and woke. And I was slightly better. After stretching, I was able to walk at a normal pace. And it hurt slightly less than the day before. I was able to sit and work for most of the day. Praise be to God! Though I must bear weeks or months of pain, the complete failure which I feared will, God willing, be averted! He has heard my prayer and answered the cry of my heart!


As a closing thought, I really wish I would have listened to Merlin (Howard Pyle's Merlin, at least).
Something he taught Arthur was that not all men are free to pursue honor; moreover honor is not even the highest ambition. Arthur, upon finding out that the sheath of Excalibur made him invulnerable, refused to use it because it took the honor out of his fighting. Merlin told him that he must because he was no longer a knight errant whose only aim was to heap up honor for himself. Merlin told Arthur that he was king, and he was now a servant of the people; the good that he could do in a long life of service was far more important than the personal honor that he would lose for himself. He consented to sacrifice personal honor for humble service. I should have done the same.

Pride Goeth Before Destruction – Part II of III

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The truck had arrived. It was go time!

We were issuing to the farmers one bag of CAN, one bag of DAP and 10kg of seed (or double that for some of the larger land-owners). And by 'bag,' I mean 50kg BAG of fertilizer (for those of you who are twenty-first century Americans or seventeenth-century Englishmen, that's 110lbs). Jake and another Nuru-ite were on top of the truck, tossing the fertilizer into a pile below.

For those of you who don't know, Jake is strong. I knew that (people who were in the Marines are, as I have found, in general, stronger than those who were not in the Marines). But knowing a piece of information is a very different thing from seeing the man fling 110 pounds around like it was...was...was … something very, very light that would ordinarily be easily flung. [Note to self: if I ever get the time, I shall have to pontificate on the Philosophical differences between intellectual knowledge and experiential knowledge such as this].

Anyways, I was part of the moving team. I was so eager for the first bag, I just dragged it into place; from on top of the truck, Jake said it'd be faster with two people, and I found out he was correct. The field officers and I took the flung bags, two people per bag, and piled them in a line, awaiting the farmers. It was hard work. Really hard work. And I loved it!

I never get to exert my body in the service of others; this was perhaps the most meaningful menial labor I have ever done. In Boy Scouts, we did 'service projects,' but rarely for needy people. It was a superb thing to do when you're twelve. But now I was a grown up and I was actually helping someone provide food for their family (albeit in a small and exchangeable role; that is to say, anyone could have done what I was doing).

As further background, I've long believed physical strength to be a part of manliness, and one that I am rarely able to express. Both because of modern society and because of my position in it, only rarely have I felt the triumph of conquering a mountain or (rarer still) overcoming an opponent in a sport. The unique fulfillment of a hard day of physical work is for me is uniquely fulfilling and far too uncommon an occurrence.

I worked at double speed, making sure to push myself to the limit to not miss out on any of the labor. The field officers, accustomed to hard work, knew that it wasn't going anywhere. But I was greedy for it. The idlers, eager to get overpaid for work, were circling like vultures. The rapidity of our work also did much to communicate, “We don't need you,” to those who could potentially extort money or cause trouble. The first truck was unloaded of about ten thousand pounds of fertilizer in around fifteen minutes. Go team!

Then we had to wait. The seed and remaining fertilizer would have to come in a second load. It was a hot day, but we had shade, and in this we waited and conversed.

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Pride Goeth Before Destruction – Part I of III

Another amazing week has come and gone. The only thing this week had in common with my past weeks here is that it was different from every other week. Most of this week was planning. We planned and planned and planned. Five year plans. Five year budget. One year roll out plan. One year budget. Season work plan. Whew. Roughly 1.34 gazillion Excel cells were filled with important and detailed plans about what healthcare here will look like the next four years. These were all submitted to the boss about an hour ago. We were then called into his office/bedroom to explain ourselves (living together really blurs the lines between work life and personal life). To my surprise, he was impressed. Though I do not believe him, he too claims to be an Excel nerd (what he means by the term is that he is proficient in Excel; I mean that I enjoy playing with formulas and colored boxes). At least he appreciated the nice job I did with the borders of various widths. And I suppose the vision Janine and I set to heal the people of Kuria.

That was Monday, Tuesday, Wednesday, Friday and Saturday's work. But what about Thursday? What happened on Thursday? Sit right back and you'll hear a tale, a tale of a fateful trip, that started on a … well that's about as much of the song as is relevant. The tale I will tell is a tale of great drama and tragedy. Thursday, August 6, 2009 will be a day that will live in infamy.

So Thursday was Input Issue Day; the day that some absurd number of pounds of fertilizer and seed were to be loaned out to our 680 (I think) Nuru Farmers (at least those who paid back the last loan; with a 400% increase in yield, you should be able to pay back your loans). Jake had an elaborate logistical plan for the distribution in place. For once, all I had to do was show up. I can't remember the last time complicated logistics happened near me without me. So I was supposed to be at Gukipimo, a border town that, because of weak border enforcement with Tanzaniza, is where all the trucks go to transport grain into hungry Kenya.

Gukipimo is a bit of a tough place, where all the non-farming young men go to hire themselves out as loaders and unloaders. They do this as long as their strength lasts, getting overpaid during harvest season by grain transporters who, especially during the present famine, are making a killing. These men are called 'idlers' by the farmers, probably because their high pay rate allows them to sit around for a vast majority of their lives. As it is said, idle hands are the devils playthings; the men amuse themselves by alcohol and ruckus (and vice-versa).

Nevertheless, Gukipimo was near where many of our farmers lived, so Jake had decided to set it up as an input issue site. Janine and I arrived there ultimately at 9:00am. The entire logistical operation would be handled by a single medium-sized truck. It arrived, with Jake and a few other of our officers riding along, the back of the truck filled with fertilizer and seed.

The adventure was about to begin!

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Meeting

Back of a dirt bike. Dusty road. Bumps. One hour. Sore back. Aching knees.

Nelly, Janine, Phillip (the leader of the Kenyan Nuru team; AKA “Chairman”) and myself each with a separate hired boda. On the way, I saw a rope tied to a tree get pulled tight, blocking the road. The tightener was an un-uniformed man, whose friend came down to the road demanding twenty shillings of each of the drivers. My boda was in the lead, and my driver reached for money. Before he could get it, the other three pulled up beside us. I don't know quite what it is about motorcycles, but though the eight of us were on our way to a business meeting, we looked imposing. Imposing or not, all the drivers paid. My suspicion of the 'tollbooth' was not assuaged by the receipt that was given in exchange for the money. To my great surprise, when we approached a second rope-puller, the receipt satisfied him and nothing further was paid.

That is how to get from Isibania to Kehancha. That is the way to the division headquarters for the Ministry of Health (MOH). About 200,000 people are served by the Kehancha division; all administrative work at any government facility in the district must go through them. And so must we. Our fate lies in Kehancha.

Nelly was recently elected Board Chairwoman of the board governing the Nyametaburo Health Center. The previous board was ineffective at best; at worst... let's just say we're still looking for twenty-five thousand shillings. The Chiefs (appointed Kenyan executive leaders of our location) seem sincere in their desire to improve the community so were more than happy to aid in changing the board upon finding out its condition. But they can't change signatories; we need the MOH for that. The facility also lacked many of the forms and plans that a facility need to operate efficiently.

We drove up to the Kehancha hospital compound, a well manicured facility surrounded by gates and barbed wire. Unlike US hospitals which like to build up, this was laid out almost like a resort. There were a dozen buildings separated by grass and pathways, all shaded by tall trees. It really was a lot more pleasant an atmosphere than what is brought to my mind by the word “hospital.”

As we approached the guard, the gates were immediately opened for us and our posse entered. We dismounted and were instantly greeted by the secretary of Dr. Bongo, the MOH leader of the division. She escorted us to Dr. Bongo's office and we filed into what would soon become a cramped meeting room. To my chagrin, the chairs were solid, hard wood, all in right angles to the ground; the complaints that would be filed by my back, already aggrieved by the hour ride, promised to inflate the length of an already long meeting.

The meeting was primarily with the well-seasoned and eloquent bureaucrat Dr. Bongo. He was very good friends with Philip, which bought us a few rapport points from the beginning. To answer all our questions and to question us properly, Dr. Bongo brought in his key staff members: the division pharmacist, the record keeper, the chief nurse and the administrative person. And for the course of the next three hours, we discussed how a new board of directors would properly be set up, monies promised by WHO and IMF, how to order equipment, and the role of NGO's in Kenyan Healthcare.

The power dynamics were quite interesting. Dr. Bongo many times, to our delight, addressed Nelly many times rather than Janine or myself. Nuru's plan is to be out in five years, so empowerment of local leaders is essential; his mild snub of us Americans is precisely what we want. We have usually had the problem of the Kenyan being snubbed in favor of the muzungu. Fortunately, Dr. Bongo wants exactly what we do: no external influence. I think he just wants it sooner than we do.

After the official meeting, Janine and I started our scavenger hunt. All the papers we needed were on the premises...somewhere...we hoped. I first went with Mr. Atemba, the record-keeper. I followed him to his office, catching the faint but now-very-familiar smell of bat guano wafting from a roof space nearby. It seems that Nyametaburo is not the only place with bat problems.

I entered Mr. Atemba's office, passing bundled stacks upon stacks of papers (we discovered in the meeting that records are government property; to destroy government property for any reason is a crime). I sought what Dr. Bongo described as the “Bibles” of the MOH in Kehancha; three operating plans relevant to our division. Mr. Atemba sat down at what looked to be a five-year-old Dell. He valiantly searched and eventually found the documents (and along the way was gracious enough to give me whatever government documents I thought looked interesting while peering over his shoulder). Success! But how did Janine do?

It turned out that all the things on her scavenger hunt they didn't have. And the reason they didn't have them was that they didn't exist. Like a six-year-old's Christmas list, our list was a just a little bit optimistic. But some of our biggest disappointments were things like procedures for a facility board of directors and operating procedures for running a health center. Actually after more searching (i.e. asking the records person who referred me to the administrative person who referred me to the secretary who dug through a 12” pile of random papers to find a poorly-copied circular letter sent from Nairobi) we found the guidelines for running a board. They were theoretically also sent to Nyametaburo. Lacking a second copy or a copy machine on the premises, I used my trusty camera.

After all this, we regrouped and we loaded up into a Toyota hatchback and headed home (and by “we” I mean ten people).

With such difficulty in obtaining these documents, I doubt that all the hard work that was put into the reports will trickle down to other health facilities with less tenacity. The planning and production of some of these documents is very good, much better than I expected. But the implementation of those plans suffers for poor communication channels. Or perhaps they suffer from poor written communication channels. I suppose this is to be expected with so few computers available. The verbal communication is quite robust; meetings with those in charge of facilities are common. I suppose conversations with those enforcing the rules would suffice. But me, I'm a litigious American and I want papers.

In reflecting on the day, I really think Nuru and the MOH want the same thing, but we see it coming about in different ways. The government is rightfully wary of foreigners coming in and taking over. Western NGOs have a bad track record. And, I think, we are rightfully wary of the government not being effective. African Governments have a bad track record. And now we must work together.

By the end of the day, we learned much about the MOH and how Nyametaburo should proceed. All in all, it was very successful. Nelly was introduced as the Board Chairwoman, the papers which the facility needed were collected, and we made new friends. We learned that MOH is wary of us, but not at all hesitant to work with us.

Our explicit goals are the same: to improve the health of the people in our area. There is no fundamental reason why we cannot work together. But we must dance the dance. Give and take, push and pull. And try not to step on each others' toes.

I was all by myself

Through Wednesday, I was with Janine, the outgoing Healthcare program manager. Janine has been doing an excellent job of showing me the ropes, making introductions and helping with the transition. She negotiated our transportation, made plans with Nelly and chose the places to eat lunch. It has been something of a humbling experience; not knowing even how or where to relieve oneself.

But by Thursday, Janine figured there was at least greater than a 50% chance of my being able to return alive. And so she announced to me that she would not be coming with me. A transient pang of fear shot through me; I would not know what to do! I had become lazy, relying on the experience of another to figure things out. Being able to rely on others for this sort of information has been a singular experience for me. My previous work in Mexico afforded me no guide but Reality the Merciless.

On Thursday, I was thrust out of the nest, and I had to flap my wings or splatter (i.e. get so lost that sympathetic Kurians, seeing a crazy white man wandering about, would lead me back to where the other muzugus were staying). I would have to again rely on my wits to survive, which, I found, had dulled considerably since their last use.

Another unique feature of my situation was the continuing issue with language. I have said that “I don't speak Spanish.” But that was hyperbole. I meant that “I only speak a little Spanish, maybe a few hundred words.” But it's literally true that, “I don't speak Swahili.” I can't even say “I don't speak Swahili” in Swahili! This added to the trepidation with which I would go out that first day.

I was supposed to meet Nelly at the “stores of Taragwiti,” a village to the north of the district about four kilometers away. Ibraim, my boda driver, arrived on time (a “boda” is a motorcycle taxi, usually in various levels of disrepair). I hopped on, told him where to go in English (a language which he, Thank God, is fluent in), and we headed off. I had been to Taragwiti once, so had a rough idea where to go; fortunately, so did Ibraim.

We drive through the city (if it can be thus termed) of Isibania, and drove a good distance. Then we arrived at Taragwiti. But Ibraim didn't stop. He kept driving. A momentary panic was stilled by my ever-sharpening wits which reminding me, “You don't have any flipping idea where the stores of Taragwiti are, do you? Trust him.” My wits were nearly outmatched by my yellow belly which cried, “OMG OMG WHERE AM I?!/??[sic] OMG.”

It turned out my wits were right this time (they usually are). We arrived and Nelly was there to greet me. I would find out later that Ibraim lived very near the shops. I met Steven, one of the seven Field Officers (FO) who report directly to Nelly [According to the present organization, each FO has 6-10 Healthcare Representatives (HRs) reporting to them, and each HR has 9 other Nuru members they are responsible for].

I worked with Nelly as I had the days before on a malnutrition screening. I asked questions in English and she translated into Swahili (which, I am discovering, is a sandbox with many nuggets of English left behind by mischievous creatures like myself). After the first interview, I had an idea. She seemed to be tracking, so I gave the clipboard to her. And without skipping a beat, she continued the survey while I helped Steven do the weighing of the children. I had modified the form I had printed for myself and had my own private (so I thought) system of adding additional notes. She had been paying enough attention to me the previous days to figure it out without instruction. Amazing! The day proceeded like this and we got a great amount of data with the muzungu middle man cut out.

Sitting there with nothing to do but listen to the Swahili, I began to realize the power of the Nuru model for disease surveillance and, God willing, disease intelligence. Instead of simply collecting data and responding in a slow, top-down fashion, intelligence is information that can be acted upon, and that right quick! Imagine being able to have weekly Malaria reports, identifying hotspots. It would be possible to pick up outbreaks of diarrhea or epidemics of tuberculosis. And then have the manpower to do something about it! And the best part was that she was taking the first step right in front of my eyes!

After a few more minor adventures (scheming with Nelly, a debate with laborers working on the health center, a popped tire and a tipped boda) and a dozen more kids, I was back at home. Home sweet home. And I was greeted by Janine, who seemed not even a bit surprised that I had managed to return alive.

War

They are waiting for me. My enemies. Hundreds of them. Fortifying their stronghold with pile upon pile of filth. And I must destroy them.

Bats. They seized the space above the ceiling panel in the Nyamataburu Health Center some time ago, pushing out bird and bee alike in a ruthless conquest.

The war began on Friday. My sister in arms, Janine Dzuba, cleared the battlefield with me. We moved out everything in the four main rooms which make up the majority of the Health Center, carrying medical supplies of varying levels of contamination to another room. We asked the men who had been working on the center to leave; we would subject no one to the deed which had to be done that day.

I was asked a week ago to find something to get rid of bats. In searching, I thought of foggers, but I could only find ones that targeted insects. I remembered that insecticides were usually neurotoxins. And then I realized: bats are mammals. Humans are mammals (just like ninjas). A nerve gas strong enough to kill a bat probably could kill a human; I wouldn't be able to find it at the Home Depot. But maybe (just maybe) concentrated insecticide might be able to kill a bat. Or many bats, God willing. I bought three canisters of insect-killing gas.

Armed with these canisters, I entered the center. The bats' lair had three entrances: one foot square movable panels. The far end of the center was the pharmacy was the room in which their forces seemed most heavily concentrated. They had been secure for many a year and would not suspect that anyone would have the boldness to raise his hand against them. Their hubris gave us the element of surprise. We would hit them where they were most vulnerable first. If we could only shoot once, we wanted to make it as damaging to them as could be.

I entered the pharmacy, armored only by a handkerchief over my mouth. I know not the ways of bats, nor their valor in battle. I do know that they sometimes wield a terrible weapon in their saliva, Rabies. So they were not to be underestimated. We closed all the windows and doors (save for one out of which we might escape in case of a counterattack). I pulled up a ladder the workers had used, setting it beneath the hole ten feet above us. We could hear the multitude of bats above us chirping, ignorant of what would come.

I had never listened to the chirp of a bat before. It is a very eerie thing, being a very high-pitched sound. It is usually not very loud, but is certainly very distinct. For those of you who know me well, you know that I have superhuman hearing (I mean that literally. The “limit of human hearing” is 20,000Hz. In a Physics lab, we recorded the limit of my hearing at 24,000Hz). I suspect that my experience of it was even more unique.

In the pharmacy, I began to use the pole to move the first panel. The light entered, and the alert was raised. They began to chirp louder. I carefully climbed up the ladder carrying one of the canisters, Janine at the open doorway photographed. The rickety ladder wobbled as I climbed. As my head approached the void, the I could hear their voices louder. I reached up with my left hand inside the cave, grabbing a rafter for support. With my right hand, I set the canister in place. And I pressed the button.




Gas began to shoot up. Straight up. It shot out of the can loudly, directly at where the bats were roosting. Their ire was aroused and their previous song overwhelmed as by a a tsunami of chrips, full of rage and surprise. But they did not move! They neither attempted escape nor attack! Their anger startled me, but I maintained my balance on the ladder. I climbed down and reached for the pole. The gas needed to be as concentrated as possible, so I needed to replace the panel.

I pushed on it. Once. Twice. Three times. But it would not move! It's weight was on the wrong side of the rafter! The bats continued their screaming, and I continued in vain to replace the panel. Then I struck it hard, and it fell into a place where it could be moved. It was closed! We exited out the pharmacy door and closed it behind us.


We moved quickly to the second and third ceiling entrances, doing the same thing. We exited to the hallway, and could hear them and their loud cries. We left them, waiting for the deadly gas to do its work before they would leave for the night.

But we were not sure if the gas would be strong enough to kill them. We guessed that it would not, even given the perfect execution in placement. We had to have a backup plan. If the gas did not kill them, they would need to be scared away. We would beat on the tin roof; this would surely drive them out until the ceiling panels were taken down, exposing their filthy home to the purifying light of day and making it unsuitable for creatures of the night.

We returned early the next morning and we entered the center. There was not a sound. Either they were all dead or they were preparing an ambush. We opened the panels and let the dens air out of what poison remained. We opened up the windows and doors on the front side of the building, and closed all of them on the back. Then we prepared for the final battle. This time we armored ourselves with thick clothing over all our bodies. A jacket hood, glasses and a handkerchief provided almost complete cover for my face, albeit somewhat thin.



I tied two belts together, and went to the back side of the building, prepared for an attack to be launched out of the small, invisible holes through which they originally invaded. I swung the belt like a whip, and the heavy buckle beat against the tin roof. The roof resounded loudly. But there was no movement. No other sound. I walked down the whole building, beating on the roof without hearing anything from the bats.

They might be desperate and waiting to see my face before they vented their hatred for my race and my person. Or perhaps the nerve gas had driven them mad. Most probably there were heaps of bat corpses in the ceiling. In any case, my job was not done until this was answered. I had to see for myself. Janine taped towels to my hands for further protection and put a headlamp on my head. I girded myself to stick my head into what once was (and hopefully was no more) their stronghold. I climbed the ladder. I reached up with a toweled hand into the abyss, grabbing a rafter. I took a deep breath, and stood on the final rung of the ladder, my head reaching into the darkness.


What I saw amazed me.


I did not see anything. No sign of bat or bat corpse. Nothing. They were gone. Just gone. I checked the second hole. Gone. The third hole. Gone. The bats had left and had not returned. I removed my toweled gloves and took a picture to document the miracle that had occurred. It was a victory beyond all we could have imagined.

Janine had been praying about this, as had many people. I had prayed for the destruction of these creatures, good in their form and capacity but now corrupted and perverted as much of Creation had been. But God did not answer my prayer. He granted us more than we ever asked or imagined. The best I had hoped for would have itself been a problem: hundreds of bat corpses that needed to be disposed of. But He granted something even better: A voluntary departure, granting the heart of our prayer while sparing His creatures. Praise God, for He has done a mighty work!