Fieldtrip to Kenya, final edition

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Dear Friends,

Last time I wrote it was day 10 of my time in Kenya.  Today it is day 30 and my time here has come to an end.  Since I last wrote, my circumstances changed considerably and without warning.  While I knew I would be moving to a more remote location, I thought I would be able to use my phone as a modem for my computer such that I would still be connected to the Internet. However, when I arrived in Rongo, I learned that the cell signals were so weak that not only did I not have internet, but I often didn’t have the ability to make a phone call.  Electricity was also a bit of a luxury.  My colleague who lives there had not had electricity for one month.  When I arrived back in Kisumu with electricity and Internet for my last 5 days, I unfortunately had a health incident which landed me in the hospital.  I’m ok now, but it was not an ideal situation to write.  So please forgive the length of this newsletter and consider it installments for weeks 3 and 4.

Rongo is only a 3-hour drive from Kisumu, but a world apart.  This is a part of Kenya with an almost universal dependence upon farming.  75% of Kenyans make their living and provide the majority of their household food from smallholder farming, according to the World Bank and Kenya’s Ministry of Agriculture, however, when you are in Rongo that number shoots up to 100%.  It feels like one giant farm, which I loved.  But the Kenyan government seems to have forgotten this part of its country existed.  The extreme lack of infrastructure is shameful.  If you were in need of emergency medical care, you would die while trying to access it.  The leaders of this country have left the people of Rongo to fend for themselves.  If Kisumu’s farmers had problems with their roads flooding, the farmers of Rongo could be jealous of roads for which to become flooded.

Baptism by Rain

As we made our way to our final health clinic on my first day in Rongo, our driver Julius said, “This is more of a passage way than a road.  Don’t be alarmed, I know this vehicle can make it because we do it all the time.”  “It’s fine, I’m not afraid.”, attempting to sound aloof as I surveyed what looked something like a deep, dry riverbed with deeper crevasses and giant rock formations.  Thoughts of Joshua Tree came to mind.  Some of the rock formations were more like boulders.  Julius explained that each day when it rains, more and more of the soil is washed away and the Ministry of Transportation doesn’t provide any support to this area.  

As the sky turned black in the distance and the wind started to pick up, Julius and my colleague Bernard began calculating how much time it will take us to reach the clinic, do our quality control check on 9 random charts, talk with the research assistant and get back to the main road.  “Tammy, have you ever been stuck in a truck before?”  “Actually, I’ve been stuck in many worse places than a truck in the Kenyan countryside.  Do not worry about me.”  That was not entirely true, but I didn’t want to let on that I was getting a little uneasy.

When we arrived at the clinic and set up our quality control assembly line, Bernard with my computer and me with the charts, reading to him as he cross-checked, the wind started to howl underneath the tin corrugated roof that wasn’t quite flush with the cinder block walls.  Soon the glass and iron doors and windows were rattling like a Midwestern tornado was afoot.  Bernard sensed my fear and said, “Don’t worry, we will not have to pitch a tent here tonight.  This is going to pass.”  Next the rain started, first in heavy drops and then in sheets.  I looked at Julius’ face and realized I wasn’t the only one with the scent of fear, he asked, “How many charts do you have to complete?”  “We’re going as fast as we can.”  I replied.  And then the sheets of rain turned to something I’ve never seen before except maybe in the film, The Perfect Storm.  It was as if the air outside the clinic was being exchanged for water.  The air felt thick and heavy while a hi-fidelity symphony played of wind, lightning, and thunder.  Trees were bowing such that their tops were parallel to the ground.  I may have seen a few cows sail by.  And then almost as quickly as it started, it stopped.  What I learned over the course of my two weeks in Rongo, is that this storm visits every day like clockwork at roughly the same time.  What was most interesting was talking to the oldest farmers, whose families lived on their land for hundreds of years, talk about how this extreme weather did not exist in their childhoods or their ancestors.  It was like all the lectures I attended on climate change and global health in my non-communicable diseases class were coming to life.  These farmers were experiencing horrific weather conditions due to climate changed mostly caused by wealthy countries on the other side of the planet.  Us, we, Americans’ choices to ignore our impact on the environment is essentially making these already poor people, poorer.  Their yields have been falling without their changing their practices.  Try arguing with an 80-year old Kenyan farmer that climate change isn’t real.

Our farmer trainings over these two weeks took on a slightly different form than the trainings we did in Kisumu because this rain, this rain affects everything.  And the effort these HIV-positive farmers must make to reach the clinics to get their HIV medications is something to behold.  Much to my surprise, one day I learned that an additional challenge of one of our participants was the hippopotami who kept creeping over the river that separates this part of Kenya from Tanzania.  They were destroying her crops.  This too was a living example of human encroachment on the environment.  Hippos were not always a threat to farmers here.  However, due to human development encroaching on wildlife habitats, the wildlife seeks new areas to survive.  And now I had one more thing to be afraid of, a surprise attack by a hippopotamus while doing farm visits on the Tanzanian border.  With all the time I was spending worrying about getting malaria, I wasn’t sure where I would fit this new source of worry.

 

The Law of the Cow

While working on a multisectoral project like ours, that aims to address the upstream causes (malnutrition and poverty) of poor HIV outcomes, while creating a sustainable solution, it’s natural to want to understand as many cultural, social, political, economic, etc. systems and how those might affect poor health outcomes.  One day a group of my Kenyan colleagues, myself, and one of my UCSF colleagues were making the 3-hour drive from Rongo to Kisumu and we learned a male travel companion was going to spend his weekend helping his brother transport 5 cows, 10 goats, and a clutch of chickens to his brother’s fiancé’s parents’ home.  This opened a conversation where our Kenyan friends asked us two Americans what men had to give to a woman’s parents in the US in order to be able to marry.  We laughed and told them, “nothing”.  We explained that in the US, both males and females are supposed to be valued equally and are supposed to enter into marriage of their own free will, not as a transaction between the male suitor and the female’s parents.  Our Kenyan friends pressed us, “Not even cash?  What about the US dollars?  Those are as valuable as cows.  Doesn’t the man give the woman’s parents some cash then?”  We laughed some more.  Then we asked the others in the vehicle if they participated in this exchange of cows and livestock, they all answered in the affirmative.  Lillian who is from Uganda and married a Kenyan explained that her husband had to travel to Uganda to buy the cows and other livestock there because, “No respectable man would present those sickly, tiny Kenyan cows to Ugandan parents and expect the parents to give their daughter away.  It wouldn’t be fair.”  We also learned that in Uganda, after the cows and livestock are exchanged, all the sisters and cousins of the prospective bride’s family who are of similar age to her, must dress in identical clothes with their heads and faces covered.  The prospective bride does this along with her cousins and sisters.  Then they all kneel with their heads bowed and the future bridegroom enters the room and he has to identify his future bride, or else, he gets stuck with whomever he chooses.  We couldn’t believe this seemingly unfair ritual and expressed our shock.  Then Lilian told us that the couple makes a pact before this ritual; for the woman to use a certain nail polish or to make a hand signal so their union can be protected.  Then we got on the topic of domestic violence and what laws exist to protect a woman if she wants to get a divorce due to her husband beating her.  We learned that first the woman goes to her parents’ house and seeks refuge.  Then after a day or so of rest, she is told to go back to her husband because being beaten is just a fact of life.  If she returns to her husband’s house and the beating continues and she decides to leave her husband and seek a divorce using the laws that allow this process…she is out of luck if there was an exchange of cows.  Cows trump written laws.  It turns out, if a woman goes through the legal process to get a divorce and is granted one, her family and the family of her now ex-husband, will not recognize the legally binding papers, “Because her family has the cows.”  Instead, she will just live elsewhere but when she dies, she will be buried on her ex-husband’s property because of the cows.  “Otherwise her spirit would be unsettled if she were buried elsewhere and the living would run the risk of being terrorized by her spirit being in the wrong place.  Because her husband gave her parents the cows, she has to rest on his property.”  We asked Lilian, a seemingly modern woman who has a 10-year old daughter, “Are you going to make your daughter go through these rituals when she is old enough to marry?”  Lilian burst out laughing, “Hell no.  If my daughter marries and her husband beats her, she will come home.  And when that man comes to get her, I will beat him so badly that he’ll wish he never gave us a cow.  And I would never let her go back.”  So there is hope.  Maybe all of our efforts to level the playing field for women farmers is not in vain.

Kenya’s Smallholder Farmers for the Environmental Win

In what seemed like a never ending state of realizations that Kenya’s government is doing everything wrong while the US has historically done things better, I found a deviation from this constant, even if the deviation involves utter neglect on the part of the Kenyan government.  Attention Kenyan Ministry of Agriculture: your smallholder farmers need your help!  Most Americans have no idea where their food comes from, nor do they care.  If animals are kept in crates their entire lives while fattened on grain and chemicals, Americans in large part could care less, as long as their grocery bills stay cheap.  If the land is over-tilled, showered with pesticides, and chemical fertilizers so they can buy cheap vegetables and sugar-sweetened everything, Americans in general, vote against the notion of changing this.  There is a battle going on in agriculture in the developing world, smallholder verses factory farming.  (I’m sad to say there is less of a battle happening in the US because Americans may be too far gone into their coma of cheap, processed food, happy to pretend their food supply isn’t affecting global warming, happy pay the price with their diabetes, cancers, obesity, heart attacks, and the like.)  In Kenya, nearly everyone knows exactly how and where their food is grown.  With 75% of Kenyans making their living and supplying the majority of their food from smallholder farming, this means their food supply, for the most part, respects the environment.  But their farming practices need improvement in order to diversify their diets and improve nutrition to meet the needs of a developing child’s brain, a breastfeeding mother, an HIV infected individual, or an elderly adult.  When the English colonized Kenya they used the land to farm corn and sugarcane because these crops can become commodities, while blueberries, spinach, beets, and broccoli cannot.  Now China is investing massive amounts of capital in sub-Saharan African agriculture that is profit and market-opportunity driven, not environmentally or health driven.  While there is no doubt, agriculture needs improvement in Kenya and all of sub-Saharan Africa, if the smallholder farmers can hang on to their respect for the environment while increasing their yields and diversifying their crops, the whole world will win.  Working side-by-side with smallholder farmers in Kenya gave me hope because projects like ours that are environmental and health centric are what the farmers want.  They appreciate the diversity of birds that populate their farms and understand that when the birds disappear, something is out of balance in their environment.  Essentially, I saw a greater respect for the environment in the poorest people I’ve ever worked with, than I see in my own fellow Americans, the richest in the world.

Endnotes

As I finish writing this newsletter, I am enjoying France, reuniting with Brent, who has also been traveling while I was in Kenya.  We will also be visiting my friend Stephanie, whom I met in graduate school in the late 90’s when we were studying Animal Science with Dr. Matt Wheeler at the University of Illinois.  I’m encouraged by Dr. Wheeler’s work because he is still advancing the field of food production while decreasing the carbon footprint of animal agriculture and applying it to the developing world.  This is one of the ways I realize my past and present fit so naturally together; recycling my former graduate education with my current.

Being away from Kenya and not yet back to San Francisco, is providing a reflecting pool to digest and process the many lessons learned, problems left unsolved and how it all fits into the world at large.  In Friday’s New York Times, there is a great opinion piece by former Secretary of State Colin Powell titled “Leadership isn’t free”.  If you get a chance, please read it online, https://www.nytimes.com/2017/05/24/opinion/colin-powell-trump-budget-state-department.html?_r=0.  He outlines why the 1% of our GDP that we have historically spent on foreign aid, for programs like the one in which I’m working, is a necessary component of world peace and economic prosperity for Americans. 

At our best, being a great nation has always meant a commitment to building a better, safer world — not just for ourselves, but for our children and grandchildren. This has meant leading the world in advancing the cause of peace, responding when disease and disaster strike, lifting millions out of poverty and inspiring those yearning for freedom.”  General Powell goes on to say that decreasing the US budget for foreign aid “…would be internationally irresponsible, distressing our friends, encouraging our enemies and undermining our own economic and national security interests.”

Listening to my Kenyan friends tell me that it gave them hope, to have an American graduate student teaching them how to be better farmers and healthier people, and seeing it in their eyes, reminded me of the book, The Power of One by Bryce Courtenay, a true story set in South Africa about the power in each of us, published the year I graduated from high school and given as a gift by my mom.  Each of these Kenyans has the power to change the world and I can only give thanks that I had the opportunity to be a tiny part of

it. 

In peace and hope, Tammy

 

Fieldtrip to Kenya, part two

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May 6th, 2017

Greetings from Kenya!  I realize I’m a bit late with my “weekly” newsletter.  What I didn’t realize until Monday of this past week, is that I have very little free time.  I am working in the field or in the HIV clinics from 8-5 and in the evenings I have calls every night with my faculty mentors at UCSF, the co-principal investigators for this study, as well as with my co-author for the paper we are writing, and with the collective UCSF-Kenya team.  So when I am not working, I am writing or on the phone, and I can thankfully say, I am having the time of my life.  I now find myself with my first moment to reflect on the past 10 days.

My first full week in Kenya has been a combination of learning experiences among the three sectors involved in our study: finance, agriculture, and HIV health.  I was able to meet all 34 Kenyan research associates for our study, Shamba Maisha.  Shamba Maisha means “farm life” in Swahili.  I’m in awe of the work my new colleagues conduct each day.  Because the participants in our study must meet the study criteria for 12 months, these research associates do whatever it takes, within the study protocols, to keep the participants enrolled.  This is not easy because the participant requirements are as follows:

1.       Attend clinic appointments for HIV care so that adherence to antiretroviral therapy (drugs that when taken properly can reduce a person’s HIV viral load to non-detectable and non-transmissible) can be assessed.

2.       Show up to clinic appointments with MEMS cup, the pill bottle used to remotely track by computer, the participant’s opening and closing of the bottle to take their medications.

3.       Comply with getting blood drawn to measure HIV viral load and other markers we use to determine health.

4.       Produce down payment for loan to purchase irrigation pump and other farm implements.

5.       Make monthly loan payments.

6.       Attend financial training sessions.

7.       Attend agricultural training sessions, both theory and practical trainings.

8.       Plant seeds, cultivate crops, harvest, and bring to market excess crops not used for home consumption.

9.       Attend agricultural group meetings to discuss successful methods, help members who are struggling, and determine voluntary group savings and investments.

10.   Track income from crop sales as a result of Shamba Maisha.

11.   Participate in interviews with research staff to assess progress in each component of the study.

12.   If the participant has a child enrolled in the pediatric arm of the study, they must also attend additional clinic visits with the child to measure their health, nutritional and cognitive status.

13.   Participate in home visits by research staff.

I’ve also had the privilege of meeting 10 of our 700 participants and their beautiful children.  These are the people from which inspirational literary masterpieces can be written.  Against all odds, they have found themselves in partnership with our study, finding a way forward that was previously beyond their reach.  To be eligible for enrollment, each person must be HIV positive and meet the definition of suffering from food insecurity, as well as have access to water, the ability to farm on a certain size plot of land, and make the down payment for the irrigation pump required.  And to stay in the study they must meet all the requirements above.  Each participant is unique, obviously, with their own set of legitimate, competing demands for survival that sometimes get in the way of the study requirements.  In these cases, I’ve witnessed the most elegant execution of scientific research combined with humanity and social work by our team.    

Learning to Trust

There are no guarantees in this part of Kenya.  Things seem to be in a constant state of flux due to lack of infrastructure.  When the roads are flooded and people can’t get in or out of their villages, it is not news.  Nobody is declaring a state of emergency; no government agencies provide relief.  When I notice myself panic while our meticulous weekly plan dissolves due to the floods, I notice my Kenyan counterparts trust they will find a way forward.  They shift our schedule of home visits with our study participants and then a domino effect occurs where the schedule for the next week is rewritten all keeping within the timelines of the protocols.  None of this phases anyone here.  They work together taking on each other’s tasks if needed and being oh-so-creative.  Except some of our participants don’t have cell phones and so the process of getting in touch with them to confirm schedule changes could involve tracking them down before dawn at the beach where they also launch their small fishing boat each morning.  But also making sure we are discreet because we can’t let the beach chairman know that the participant is involved in an HIV study.  And anyway, why would two women be waiting for a fisherman at 4am?  The research assistants just roll their eyes and laugh at what this task can do to their reputation.  They care more about keeping the participants enrolled. This is true, this happened last week.  But mostly, my days have started like this:

Honking horns blaring against the dusty, crowded streets of Kisumu, where riding in a tuktuk feels something like being in a live video game where the tuktuk has to avoid hundreds of pedestrians, cows, goats, bicycles, vans and other tuktuks while the goal is for everyone to move at once in the same direction without yielding.  There are no traffic signals and I imagine if there were, they would be ignored.  When we arrive at Lumumba Hospital unscathed and without hitting anyone, I feel a sense of relief wash over me.  This is how most of my workdays begin.  I’m in awe of the navigation skills my driver and the collective maneuvering of space, so that nobody or no animal is harmed.  It makes me think that air traffic controllers’ work is pedestrian compared to this, pun intended.  I have repeated this route enough that I now recognize the one person who is suffering from alcohol addiction, he is in the same place every morning; the hundreds of others are simply trying to survive.  The streets are lined with every type of seller of goods and services you can imagine, each with a tiny hut enclosed on three sides, their wares and services spilling out to the street that is filled with garbage.

In some ways my experience in Kenya is exactly as I imagined it would be.  In other ways, I feel my brain saturated and heavy from all that is new and I never imagined.

Until next week,

Tammy

Fieldtrip to Kenya, Part 1

 

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Elly Weke, Shamba Maisha study manager, conducts a farmer training to study participants.

 

April 25, 2017

Dear Friends and Family,

As many of you know, I’m conducting research in Kenya for my MS program at UCSF.  At the suggestion of Brent’s mom, Laurel, I’m going to share my experience with a weekly newsletter over the next four weeks.  If you’d rather not receive this, please let me know.

I’m now in Kisumu which is in the Nyanza region in the west, bordering Lake Victoria.  This is the primary site of our study, however it’s expanding rapidly and as such there are other sites in this region where I’ll have the opportunity to learn.  There is much activity in the streets today because the primary elections are taking place.  Long lines of people waiting to cast their ballots and police and military patrolling the streets are as relevant to my research as the agricultural livelihood training and HIV care protocols that comprise our study.  It’s nice to see citizens actually voting and apparently giving up a lot of time to do so.

My coursework in foundations of global health, socio-cultural and structural determinants of health, global health economics, global healthcare systems, and health policy gave me the chance to explore how and why some low and middle income countries experience progress in some areas of health and economic growth while others do not.  However, there is nothing quite as educational as feeling the tension of the Kenyan people during this precarious moment.  I’ve spoken with a variety of Kenyans today about their fears that history will repeat itself; their memories still fresh from the 2007 post-election violence with large death tolls and even larger mass raping followed by internal displacement of people.  But they assure me that this time it should be different because the heavy presence of police and military we see today were not there a decade ago.

In my coursework, while I was writing my hypothetical plan on how to engage the Kenyan government to support the infrastructure required to solve agricultural development’s sluggish results for smallholder farmers that would then lead to improved health outcomes, I kept questioning why the people of Kenya didn’t organize and protest more.  As I researched civil unrest I learned that it’s not just the government Kenyan citizens protest against, but also each other as there are conflicts between tribal communities.  The process of researching Kenya’s political and cultural systems and how they impact health has been quite humbling.  I’ve realized there is no way I’m going to fully grasp the structural barriers facing Kenya’s people in my hyper-fast one-year MS program.  All the more reason I’m so grateful to be here now.    

Today I had the opportunity to sit in on my first conference call with our projects’ joint Kenya Medical Research Institute and UCSF research teams when I realized, I’m learning a new language.  As I listened to these experts report on their progress and troubleshoot hurdles, the factors they brought to the discussion again circle back to the socio-cultural, political, and economic forces at play in our study participants’ lives.  I can’t wait to learn more. 

Until next week,

Tammy 

Mr. Trump, you’re wrong. We’re nothing alike and we don’t want the same things.

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Dear Mr. Trump,

I tried my best to avoid any news coverage of your inauguration because it makes me ill that you are now commanding my country.  But I found myself intrigued to see how Hillary Clinton found the strength to attend this series of unfortunate events.  So when a news story appeared on my google search page indicating you made some sort of gracious nod to Hillary’s attendance, I had to see what it was about.  You can read the quote here but strangely the video with you speaking these words has mysteriously disappeared from the Internet.

I’m glad you made a point to acknowledge her presence.  I mean come on, what other human being alive or dead has that kind of composure to attend such an event, given she was the person the majority of the American people actually voted for to become our president, not you.  Surreal can’t even begin to capture it.  Remember when you called her a nasty woman during the debate and said you were going to put her in jail?  But here is where you made my tears start again, when you said at this inauguration lunch in Hillary’s presence, “We are all good people and we all want the same things.”  Then you laughed and tried to make light of what you’ve done and plan to do.  You attempted to make a joke of the gravity of decision making involved in your despicable cabinet choices, each of them a threat to the foundations of democracy, by chiding the Senate minority leader Schumer suggesting you know he’s going to approve each of your cabinet picks quickly.  Seriously?  Do you think this is a television show?  You did make a reference to central casting in the video clip of the inauguration lunch.

You really should ask someone else to do all of your speaking.  You can’t even begin to understand how ignorant you appear to even the most sophomoric of onlookers.  You’re a dunce, a rich one, but still a dunce.  The only reason I’m not worried anymore about you initiating a nuclear war is because I don’t actually think you’re smart enough to memorize the codes.  Or if you have a work-around for memorizing them I’m holding faith that some General will put you in handcuffs and declare you unfit to serve before they’ll let you use the codes.

But back to your comment that spurred me to write this piece.  To quote you again, “We are all good people and we all want the same things.”  We aren’t all good people and we don’t all want the same things.  Your platform and Hillary’s platform were extremely different.  You’re a bad person and many of us who think so also think many of the people who helped elect you are also bad people.  Because at the end of the day, a democracy is held accountable to and by the people who elect its leaders.  So your supporters will be held just as accountable as you when this mess is over.  After you cause damage to the civil rights of all, our economy, the planet, and to our global relationships, you’ll go back to your obscene gold tower leaving all the people to clean up your mess.  Maybe that’s part of your big job creation plan?

And this is the point.  That’s why you lost the popular vote by millions.  We don’t all want what you are planning to do and it terrifies us that you somehow swindled your way into this office.  What does Putin have on you anyway?  The extreme differences between us and you and the minority of Americans who voted for you, are not light-hearted politics.  No.  They are fundamental differences in human decency and an understanding of the Constitution.   Those of us who are nothing like you or the people who voted for you are scared to death to watch you and your Right-Wing-Fundamentalist-Christian-first vice president unleash your psychotic brand of governance upon this great nation that has worked so hard to move away from hatred and inequity and still had so much to do.  But now after these four years are over we will have even more work to do.

It would be convenient for your statement to be true, wouldn’t it?  It would be better for you and your kind if we were all alike because then you might be better just by having some similarity to us.  But you’re not like us at all.  The people you were referring to, implying we were all alike, were the very people who are wondering when you’re going to get impeached, or worse, when someone is going to attempt to harm you or storm the palace, I mean the White House.

In closing, I’ve worked with many billionaires in my career and they all seemed to have shared characteristics around critical thinking, judgement, consideration, leadership, innovation, and higher-order intelligence.  I found it fascinating to observe these similarities and draw conclusions about what it must take to build organizations with such scalable value that deliver returns to shareholders and change the world for the better.  These billionaires were also philanthropists, that’s why I had the privilege to work with them.  But you, you’re absolutely nothing like any of them as best I can tell.  You’re certainly not philanthropic as a billionaire should be or I would know about it because there aren’t that many people in the country who work in principal gifts and we all talk to each other.  Principal gifts are individual gifts of $10 million and above, in case you didn’t know.  But besides not being a real philanthropist like the billionaires I’ve worked with, you’ve also never built anything that has changed the world or delivered value to the masses, you’ve only delivered value to yourself and your family.  So let’s see how you’re going to translate those real-estate, television, junk jewelry, beauty pageant skills into helping the masses with their multisectoral, complex issues holding them back from prosperity.  If the American people just wanted an outsider, there were so many better options, if only they had run.

Here’s to wishing for your swift impeachment.

Signed,

A Nasty Woman