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!

This is bat country

Day 2. This is Bat Country.

There's a lot of talk about the best ways to improve health in a developing country. In the US, I thought long and hard about different methods of distributing healthcare resources, streamlining supply chains, and improving provider performance. But it's actually turning out to be a lot easier than I thought (at least at first!). Or at least hard in a different way.

Last week in an email entitled "this is so random but needed..." I was informed by the present healthcare program manager (Janine) of a bat infestation at the health center. I envisioned a few friendly bats (in my imagination they were cute and animated) peacefully residing in the rafters. Today, my assumptions were engulfed in a big fat mound of bad guano.

I was talking to Aerie, the Nuru small business manager, who was helping to keep inventory. He told me, "Some of the medicines are spoiled."

"You mean, 'expired,'" I corrected, flaunting my vast medical knowledge of proper pharmacological terminology.

"No, I mean spoiled. There's bats and rat feces all over them. There's expired meds, too."

Those little guys pooped all over the entire center (5 rooms). Not just a light layer, peppered on top. Literal mounds. The picture attached was taken in the pharmacy.


Improving healthcare is not that hard. The first step for me was not talking about innovative ways to improve performance through appropriate incentive schemes. The first step is making sure that there's not feces in the health center. But as I implied earlier, that presents its own set of challenges that I had not come prepared for: how not to get feces all over you while cleaning.

The center is getting remodeled and cleaned, so we have to get rid of the bats. How? Well, you'll have to wait to find out. The job is not yet done. There will certainly be a story tomorrow.

P.S. Gold Star to the first person to correctly identify the source of the title of this entry without Googleing it.
P.P.S. Facebook photo uploads are coming (probably Sunday). I do have more pictures than of bat guano.

Day One

It is 9:00pm in Kuria, Kenya. I have just finished my first day here [Edit: A power outage last night made it so that this was posted a day late].

Yesterday and the day before and the day before the day before were a kaleidoscope of tires and tickets, wings and waiting. 51 hours, 23 minutes and 43 seconds to be exact, door to door. Which, for people whose backs do not like extended periods of sitting, was quite uncomfortable. But if you think about it, is a pretty incredibly short time. Getting to a remote village on the opposite side of the world is no small matter.

But after a long and restorative sleep (my first under a mosquito net (or if you're an insider, an Insecticide Treated Net, an ITN), it has begun. I spent the morning with Jake, a farm boy turned Marine who has decided now to spend his life in the service of the poor. We walked accros the district, from one end to the other, looking at the corn that Nuru had helped to bring to pass. It's staggering to compare: Nuru corn is ~7-8 feet while non-Nuru farmers barely come up to my waist. The words from "Oklahoma!" are perfectly appropriate:

The corn is as high as an elephant's eye
And it looks like it's climbing right up to the sky

Oh what a beautiful morning
Oh what a beautiful day
I've got a beautiful feeling
Everything's going my way

Following that, Chris (Water and Sanitation leader) took me on a pikipiki (motorcycle) around in a circle around the town. I got to sit in on one of his meetings (wherein I was hit hard by a bout of jet lag and just about lost consciousness).

The beauty of this land is difficult to describe. Hills roll, covered with yellow and green corn stalks. Those few pieces of land which remain uncultivated host a wide variety of strange and wonderful trees and plants. The road was an orange cut through the green, worn and twisted from the heavy traffic on a dirt road.

The only thing that was more inspiring about the land was the people who till it. The Kurians are an incredible people. I have seen variances in how friendly people are on the street. But there was not a person we passed in the street who did not warmly and sincerely greet us. I met most of the Community Development Committee, the full-time Nuru staff in Kenya. These, too, were incredible people: hardworking and ambitious for those they serve. Perhaps most entertaining was cries of "muzungu" coming from elated children who rarely see white people.

To top off a wonderful day, there was a thunderstorm right as we got home. This had the benefit of being awesome, but the disadvantage of making the power go out.

Overall, I have done my best to learn the geography, people and language. For example, I learned that to say "hello" in Kikurian: "mbuya" which is pronounced almost exactly like "boo-yah" as we say in English slang. Unfortunately, I have been largely unsuccessful in becoming a master of Nuru, Kuria and Kurians in a day. Perhaps tomorrow will yield better results.