Counting People in a Broken Health System
I remember, a young woman, a freshly minted teacher named Leah- who was very fond of my father. I was a little boy then. She looked up to father as a senior teacher and a mentor to help her grow into the profession. My father and mother were fond of her and she was a common visitor to our house. In our young minds, age sets were binary: you were either nyithindo or jomadongo, children or adults. Children were the people you could play with, the people you called by their first names and complained about to your parents. Adults were a whole other matter, separated by a chasm that moved through time. They were people who even when informal in their manner, had to be treated with the formality that adulthood conferred.
Leah was confusing for my binary world. She was at a stage my elder siblings had not gotten to yet, somewhere in between a child and an adult. When she was around she cooked with us, referred to my mother as “mama”, and seemed more at ease with my teenage sisters and cousins. Yet she held adult conversations with my parents and could gently disagree with them in conversation. I probably had a little puppy crush on her. She straddled that space with some aplomb. My parents loved her. My elder brother’s eyes never left her swaying hips as she navigated the ten metres or so between our detached kitchen and the main house holding a tray of food or kettle of tea in her hands. My sisters could not wait to be her- she had all the big girl privileges: she could choose her own clothes, she wore jewellery, and she earned a salary at the end of the month!
Even after she moved to a different school further away, the warmth of her company whenever she returned to visit did not change.
One day, word arrived that Leah had died. The whole family was left reeling. My sisters cried. My brother went off to the simba- my second to last unmarried uncle’s house- lost in a daze of disbelief. Although my parents were stoic, they could not hide their pain. Nobody wanted to explain death to a little boy. Up until then death was an exciting and rare occurrence associated with screams tearing the bucolic night air from the direction of the home of an ailing elderly man. They were not people I knew. In my little sheltered, small town rural existence, I had never met anyone who later went off and died.
Leah died. She was the first person I had met, known, even loved, who died. She had died during childbirth. One moment she was full of life and carrying the promise of a brand-new life, the next moment she was dead. Cause of death. Maternal mortality. Leah had come up against maternal mortality and lost.
Maternal mortality is a sterile pair of words. It is impersonal and jarring. I did not know who the father of Leah’s child was but I felt for him. Maternal mortality is the sudden shot between the closed eyes, blissfully sucking on the lollipop of life. Maternal mortality is a rusty serrated knife piercing your back. One moment you are tingling with excitement and looking forward to holding a new life in your hands and looking at the incomparable poem of joy that is the face of a new mother. The next moment you are planning a funeral.
A woman went out, and two coffins came in. A big one and tiny little one.
I did not know these things then. But, I know them now. I became a pharmacist. Then I drifted, a journeyman into public health with a penchant for math. So I count things. I count ratios and rates, odds and people’s chances. I create pivot tables and run scripts. I find blips and upticks and trends. And to stay human I try not to think of counting Leahs and little babies who have not had the chance at a name. A simple name.
2017 has been a rough year for mothers, babies and families across the country. The year opened to a doctors’ strike that was a month old and would continue into March stretching for a 100 days. Public health facilities were on their knees. Clinical officers and nurses did what they could and sent those they could not handle to private health facilities, which sometimes is the same as being sent home to die. After a brief respite, the health system would once again go into the convulsions of massive labour unrest with the nurses’ strike. That strike would last 5 months before getting called off.
If doctors are the analytical mind of the health system, nurses are its beating heart. A formidable nurse-doctor team, with the backing of a working health system, is what makes maternal mortality quake in its shoes. For the better part of 2017, there has been no team. No team means that Caesarean sections and assisted deliveries are not happening. Blood transfusions and resuscitation are nowhere to be found. Incubators are not whirring; bleeding mothers are not stirring. Ambulances are running across the land blaring sirens of death.
One of the simplest pieces of health data that indicates the health of the health system is vaccination coverage rates. It is simple because vaccines are given at predetermined intervals and ages. When a baby is born they get BCG- the tuberculosis vaccine- and the polio vaccine. Kenyans have about 30 babies for every one thousand people every year. If there is a community of about 5000 people then we expect that a baby is born every two days or so and 12 children get birth vaccines every month. Vaccine coverage responds quickly, positively or negatively, to failures in the health system- when people cannot get to the health system for reasons such as flooding, when medicines or syringes are not available, when there is no energy supply for refrigeration and when staff are not at their posts because they are on strike.
Vaccine coverage has dropped precipitously in communities that rely primarily on the public health system. Less than 5% of Kenyans have private health insurance, so this means almost every mother who is not on Facebook. Vaccines protect children individually but also as a group in what is called herd immunity. The chances of a vaccinated child getting the infection they have been vaccinated against is lower than for an unvaccinated child and if they do get the infection it commonly runs a shorter course and is less severe and less likely to lead to death.
This means that they are less likely to spread it to other children who also, if vaccinated, are less likely to catch it. Vaccination is therefore equivalent to children locking arms and standing shoulder to shoulder against vaccine-preventable diseases. Unvaccinated children are a big hole in that wall- their own risk rises massively but they also increase the risk for vaccinated children.
More ominously still, falling vaccination coverage is an outward sign of an ailing health system. For four years of my working life, I kept verbal autopsy tables: Excel sheets where in a community the size of a small district it was my business to know who died, where, when, and why. I learnt what makes people die. In what seasons people killed one another and when people killed themselves. I got to know intimately how the health system fails babies, children, mothers, and other people and how the consequences are felt in communities are far removed from tables and graphs.
As the Kenyan health system convulses, children are dying from immunizable diseases. People are missing precious doses of chronic medications such as diabetes and HIV medicines. Women are bleeding to death in ambulances and that is one Leah, too many.
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Women at Sea: Testimonies of Survivors Fleeing Across the Central Mediterranean
Anyone crossing the sea to escape a dangerous situation or to find a better life is in a vulnerable position, but women face the additional burdens of gender discrimination and, all too often, gender-based violence, along their routes. Women represent only a small proportion – around five per cent – of those who make the dangerous journey from Libya to Italy.
On board the Geo Barents, female survivors regularly disclose practices such as forced marriage or genital mutilation (affecting either themselves or their daughters) as being among the reasons they were forced to leave their homes. Women also face specific risks during their journeys – MSF medical teams report that women are proportionally more likely to suffer fuel burns during the Mediterranean crossing, as they tend to be placed in the middle of the boat where it is thought to be safest. . Many women rescued also report having experienced various forms of violence, including psychological and sexual violence and forced prostitution.
“The minute I was alone, they would have raped me.” Adanya, 34 years old, from Cameroon.
Among these women is Decrichelle, who fled a forced marriage to a violent husband with her baby. They left their home country of Nigeria and went via Niger to Algeria. When they arrived in the desert, Decrichelle’s daughter fell ill and she could not do anything to treat her because she had no access to care or medicine. The young girl died, and Decrichelle had to leave her behind before continuing the journey to Algeria: “an immense and inconsolable sadness” for her.
Decrichelle attempted to cross the sea once but was arrested and sent to prison, where she was released immediately, only to be taken by taxi to a brothel. Some Cameroonian friends helped her escape. For six months, she lived in the campos (the abandoned buildings or large outdoor spaces near the sea where traffickers gather migrants) before scraping together the money to pay her way for another crossing. “I want to be in a place where I can live like a normal person of my age. I want to be able to sleep at night,” she says. “I wanted to be here with my child. It hurts me to think that I am safe, and I left her in the desert.”
Beyond the difficulties women face on migration routes and in Libya, MSF teams on board the Geo Barents often witness the strong bonds that develop between survivors on the women’s deck. The women come together to support one another with daily tasks and childcare.
“In Libya, I was sleeping under trucks and buses as I did not have any money.” Afia, 24 years old, from Ghana.
“I want to tell women: it is not your fault. You are exactly the same person as you were before. You are even stronger,” says Lucia, deputy project coordinator aboard the Geo Barents, who has herself experienced rape. “I think it has been really moving to see these women, who actually escaped what I experienced for an hour of my life, and in their struggle, their strength and their hope, [they do not stop] this fight,” she adds.
Meanwhile, when male survivors are asked about the people they left behind or the reasons for their journey, a woman is always mentioned in their stories. Ahmed, 28 years old, was born in Sudan to Eritrean parents who moved to Sudan to escape the war. Having lived all his life as a refugee, Ahmed never felt that he belonged in Sudan. He wished to leave, but as an undocumented person, unable to return to Eritrea for fear of military conscription and an oppressive dictatorial regime, he decided to travel to Libya and cross the Mediterranean Sea to Europe.
Ahmed’s mother was the only one who stood by him when he decided to convert from Christianity to Islam, despite harassment from his other family members. “[Converting to Islam] affected me, affected my friendships… for sure [I faced issues because of that]. At first, from the family… in the beginning, I was secretive… until my family knew; then the harassment started. But my mother accepted me. She told me, ‘Whatever makes you comfortable, do it.’” Ahmed says his mother is one of the reason she was able to make the journey from Sudan through Egypt and into Libya. “She has a really big role in my life. She was continuously supportive and motivating me, wishing me the best. She is my inspiration… I hope to meet her again.”
“I know if I tell my mother I am in Libya, she will be crying every day.” Ibrahim, 28 years old, from Nigeria.
Nejma, cultural mediator on board the Geo Barents, explains her bond with survivors like Decrichelle and Ahmed: “I am African and I am Middle Eastern. I am a mother. I am a woman. There are so many things that link us together. Maybe also the fact that I had to flee. That is a big part of it. I think it helps me understand where people are at the moment we find them; it is an understanding that books could never teach me.”
As a refugee herself, Nejma shares what helped her to move forward in the places she fled to. “[Survivors need to] keep the strength… once they disembark in Europe, it is not the end of the journey,” she says. “It is a different challenge: to not let go of who they are, to never forget who they are, where they are from. To be very proud of their origins. Because you will not know where to go if you do not know where you came from. And I want my brothers and sisters from Africa and the Middle East, or anywhere, to remember who they are. It will make it easier to move forward.”
These stories of the women on board the Geo Barents were collected during rotations of the ship at sea. The portraits and testimonies were captured by two female photographers, with a view to amplify women’s voices, while respecting cultural sensitivities:
Mahka Eslami is an Iranian photographer, who was born in Paris and lived there until the age of seven before her parents returned to Tehran. While studying engineering in Iran, she worked as a journalist for the Chelcheragh. She returned to France where she finished her engineering studies before branching out into documentary photography and transmedia writing to become an independent photographer. Her work has been published by Le Monde, Libération, Society, Néon and Les Inrockuptibles.
Nyancho NwaNri is a lens-based artist and documentarian from Lagos, Nigeria, whose work revolves around African history, culture and spiritual traditions, as well as social and environmental issues. Her documentary works have appeared in numerous publications including The New York Times, The Guardian, Aljazeera, Reuters, Quartz andGeographical Magazine.
MSF has been running search and rescue activities in the central Mediterranean since 2015, working on eight different search and rescue vessels, alone or in partnership with other NGOs. Since 2015, MSF teams have provided lifesaving assistance to more than 85,000 people in distress at sea. MSF relaunched search and rescue activities in the central Mediterranean in May 2021, chartering its own ship, the Geo Barents, to rescue people in distress, to provide emergency medical care to rescued people, and to amplify the voices of survivors of the world’s deadliest sea crossing. Since May 2021, the MSF team on board the Geo Barents has rescued 6,194 people, recovered the bodies of 11 people and assisted in the delivery of one baby.
This story was first published by Médecins Sans Frontières/Doctors without Borders (MSF).
Nairobi, Nairobae, Nairoberry
Cacophonous, labyrinthine, gluttonous, angry, envious, charming, paradoxical, mysterious, confusing, alluring.
Nairobi. A cacophony of matatu hoots and booming bongs from church bells. All in inexplicable harmony. Like a Beethoven piece. A muezzin’s melody moves the ummah from a minaret here, a bus conductor — shouting from the most pimped out mathree — moves umati there. A hawker here. An ambulance there. But there’s also a silent monotone. The sound of hope dying. Of someone stealing two billion every day, of the clock going tick-tock from your 9 to 5. There’s that saying: if a tree falls in a forest and no one is around to hear it, does it make a sound? But what if it’s in the middle of Waiyaki Way? Just because someone thinks giving us an expressway will absolve him of war crimes. While in reality, all it does is leave all the marabou storks homeless.
Nairobi. A labyrinth of lipstick-stained shot glasses and semi-filled ashtrays. Where a party starts regardless of where the limbs of the clock point. And only ends when everyone is browned out and on the brink of calling the one that got away. Nairobi is looking for coins during traffic because you want to help the beggar, who is patient enough to receive the donation before snatching your phone. It is being stagnant in that same traffic for long enough to buy crisps made with transformer oil and served in compact disk wrapping. And like clockwork, you put the window back up because Nairobbery isn’t just a play on words. But the ones that hurt the most are the conmen, because nigga I trusted you!
Nairobi. Where gluttony is second nature. A kaleidoscope of too much gold tequila and too many smokie pasuas. Of good pasta and wine in overpriced restaurants. Of ramen noodles and pre-cooked meat. Where nothing is ever enough. We drink and eat to our fill because life sucks. Why wouldn’t it? Our last president’s advisor was the bottom of a Jameson bottle and our current one’s advisor is Jesus. The spirit guides the nation either way, I guess. But still, Nairobi tastes like chances and do-overs. It tastes like anxieties and aspirations and I know it doesn’t feel like it but today you omoka na 3-piecer then one day you omoka, for real.
Nairobi. Reeks of piss and thrifted clothes. Fresh bakeries and Subway. Old currency and that one cologne every man in their early 20s wears. Smells like fighting your titans and sending a million job applications. Nairobi. Where you can go weeks without a lover’s touch but only days without a cop grabbing you by the wedgie into a mariamu because you shouldn’t be idle as you wait for your Uber outside Alchemist. Because of course in that time you should take up a sport, play an instrument, solve world peace, et cetera.
There are few occasions when pride will linger. Like when Kipchoge finishes a marathon in under two hours. When Lupita wins an Oscar. The hubris you feel when your copy makes it to the billboard on UN Avenue. Or when your lame joke gets five retweets because Kenyans on Twitter will massacre you if you think you’re the next Churchill. Orrrr that one time we were all watching Money Heist and so gassed that Nairobi was one of the characters.
Sadly, Nairobi pride also comes in with its individualism. Everyone is out here on their own trying to get some bread whether they’re in the upper class getting baguettes and rye bread or in the lower class getting Supaloaf. I get it though, the city doesn’t let anyone rest from the grind and the hustle and the drudgery. And the wealth gap is bigger than Vera Sidika’s bunda. But ironically, the city is a paradox. An optical illusion. Sometimes the people are so ready to convene in community that it kinda revives the fickle hope you have in humanity. From safe spaces to fundraisers to a simple hearty conversation with your Uber driver.
And there’s obviously that murky feeling of greed that comes from 90 per cent of our politicians. When you’re at the bottom of the food chain it’s called hunger, but the higher you climb the more you want and it becomes indulgence. Greed makes them say and do all kinds of things. Like apologising to Arab countries that are exploiting Kenyans because they don’t want to be cut off. Y’all know any juakali guys we can commission for guillotines? – Heads gotta roll. Because how will I steal cooking oil and flour and end up in a cold cell but they’ll steal billions and end up with a second five-year term?
I think wrath is the most Nairobi-esque of the cardinal sins. We’re angry at the police. At the government, at global warming, at nduthis, at KPLC, at Zuku, at Safaricom, at KCB, at each other. Agonizingly though, our anger fizzles out as fast as it blazes up. I don’t think we’re ever angry enough.
And then there’s the envy. You know you’ll get there eventually but that gets lost in translation when you see someone with better because that sparks something in you even though we are all on different paths at different paces. Whether it’s a BMW or an airfryer, the question stays: Why not me? And also I’m personally jealous of the people who’ve managed to move out of Nairobi to Naivasha, Watamu or wherever. It feels like they’ve figured their way out the maze while I’m still at a dead end wondering whether I can just hop out the sides. Doesn’t matter what it is, our eyes are as green as the parks and spaces we so desperately need in this godforsaken city.
Nairobi. The city of miniskirts and cheers baba jackets. Lust dripping down the sides of our mouths because we can’t seem to contain it under our tongues. I don’t even know why people bother to go to Vasha for WRC when they live in the city of sexual debauchery where the only thing that’s on heat more than the sun is whatever’s between people’s legs. Where even Christian Grey would pause and do a double-take. Where ropes aren’t just for skipping and leashes aren’t just for dogs. If you find ordered love in the city, you must have saved refugees and orphans in your past life. This is the city where the flesh is truly willing.
You know that intense sloth-like feeling when you wanna wake up for Sunday brunch at Brew Bistro or K1 and then later watch Hamilton race at around 4 when all the mimosas have hit your head and you’re surprised that your wig is still intact? Or the next day when you’re trying to get out of your covers and you’re thinking about that beastly Nairobi traffic you’re about to face and all you can do is tweet “Nimewacha pombe mimi”. Truthfully though, other than that and a few other instances, the pace is too fast for me. I just wanna be in a dera next to the beach drinking a passion caipiroska and eating viazi karai cause why are y’all always running?
And y’all are way too fast when coming up with new words too. There’s like a million words for currency, ass, sex, sherehe, et cetera. Truly, there is a certain linguistic je ne sais quoi when it comes to the Nairobian’s language. It stops being a transaction of random syllables and begins to become an understanding of feelings, emotions and behaviour. I, especially, like how we knead it into our art. We sneak it into our music and get phenomena like gengetone.
We compress it into our films and get Nairobi Half Life. We squeeze it into our visual pieces and get Michael Soi. One thing about Nairobians is we do not cower in silence, we have words to say and we shall say them. Even if that means running a president out of Twitter. That’s why our writers are as staggeringly sensational as they are. Ngartia. Sookie. Grey. Muthaka. Laria. Abu. And those are just my friends, dawg.
But it’s not just the writing. The fashion. Rosemary Wangari. Nicole Wendo. Samantha Nyakoe. The music. Mau from Nowhere, Vallerie Muthoni, Karun, Maya Amolo, XPRSO. Just a Band. The films. The painting. Muthoni Matu. Zolesa. The architecture. The cinema. The theatre. Too Early for Birds is back! et cetera. Man, I gotta tell ya, when God was cooking up the cauldron of this city, he went hard on the talent. Quote me on this: a lot of exceptional creatives from this city are gonna hit the world with a head-splitting bang in a couple of years.
Nairobi. Despite the crowds, the queues and the poor drainage, it still has a charm. Mysterious. Confusing. Alluring. Despite the fact that you can only truly enjoy the Nairobi experience if you’re a bird or an expat, me I love it still.
Nairobians, keep sinning, keep winning!
The Enemy Within
Death hangs heavily over people with cancer – it is always there, reminding you of your mortality.
So, this is what happens when a doctor tells you that you have cancer. The first response is disbelief (how can this be true?), followed by anger (I don’t deserve this, I never hurt anyone), and then a deep sense of grief and loss (what will I miss when I die, and how will my loved ones cope without me?)
They say cancer is the result of pent-up anger and resentment. Apparently, years of holding on to these emotions make your cells misbehave and become toxic. Cancer cells end up eating up healthy cells, leaving the body so full of poison that it collapses from lack of vitality. The jury is still out on whether lifestyle choices generate cancer in the body because people who lead healthy lives seem to be as prone to cancer as those who don’t. Nonetheless, when you find out you have cancer, your first reaction is to blame yourself. It is sort of like being told you have HIV. (Was I responsible for this? Was I reckless? Should I have used a condom?)
Friends and relatives will tell you that breast cancer is beatable, that they know so many women who had breast cancer and lived healthy lives years after treatment. What they don’t tell you is that all the literature points to a short life expectancy after the discovery of cancer. The chances of recurrence are high, even with chemotherapy, mastectomy or radiation, the traditional methods to “cure” breast cancer. I have read studies where women who had chemotherapy had an equal chance of recurrence as those who didn’t. So, death hangs heavily over people with cancer – it is always there, constantly reminding you of your mortality.
Most people are so afraid of cancer that they can’t even say the word. The receptionist at an oncologist’s office actually asked me what kind of “C” I had – never used the word cancer. Yet she deals with cancer patients every day. Another oncologist I consulted couldn’t even make eye contact with me and rushed me through a diagnosis I couldn’t understand, perhaps believing that my cancer was contagious?
The thing is that cancer is not like any other disease that can be cured through surgery or drugs. It requires months of treatment and constant monitoring. It’s not like having malaria or a broken bone. It is like having an enemy residing in your body, hostile, predatory, waiting to pounce at any moment.
It seems a positive frame of mind is critical in recovering from cancer. I got calls from women who told me they bounced right back into their lives after months of treatment as if nothing had happened, that I mustn’t believe all the literature, that I should get all the treatments done and go back to living a normal life. They didn’t explain to me why they have been working from home since their treatment started and since their so-called “recovery”. Others are more honest about their experiences. A South African women called to tell me that her experience with chemotherapy had damaged her heart, and she is on life-long medication that makes her urinate every few minutes, which means she can no longer work in an office. Instead of destroying the cancer, the chemo destroyed healthy cells in her heart. She is cancer-free but now disabled in other ways. Another friend told me her aunt died not from the cancer, but from the chemo.
What the doctors and the optimists don’t tell you is that both chemotherapy and radiation have debilitating impacts on your body. They literally are poisons injected into your body to kill another poison. Sort of like a vaccine but not quite because they do not boost your immunity. Both chemotherapy and radiation therapies involve weeks of hospital visits that cost an arm and leg. Nausea, burns on your body, fatigue are common side effects.
A friend from Boston who has studied alternative ways of healing from cancer (including not getting any treatment at all) tells me that each woman with breast cancer has to make an individual choice about what kind of treatment she should get. Doctors trained in Western medicine will be quick to put you on chemotherapy and the other treatments without giving you other options. Desperate and eager to cling onto life, the patient with cancer readily accepts any treatment, not realising that not only is it a very long process, but very costly as well. Mental preparation and psychological support are also necessary before embarking on the long and arduous journey called cancer treatment. People become life-long patients; some recover well, others not so well. Some women opt for no treatment, preferring to lead a good quality of life before the disease ravages the body.
I am looking at alternative methods of healing, including Pranic healing that works on your energy fields and chakras. So far it seems to be helping me, but only time will tell if I will be a success story. I have certainly started eating more, and those dizzy spells in the morning seem to be getting rarer.
The biopsy results are not yet out, so I am still not sure what the oncologist will prescribe, but in Kenya, the modus operandi seems to follow the same script: mastectomy, followed by chemotherapy or radiation and some kind of hormone treatment. Am I ready to go there? Not sure. Women who lose their breasts speak of feeling like an amputee; the loss of an organ that defines their femininity impacts their identity and self-esteem. Others are more casual about losing their breasts, (“It’s just fat,” one woman told me). `
The other thing about cancer is that when you have it, you think of nothing else. Everything is a blur. Someone wants to make small talk, and all you want to do is look the other way or scream. (Can’t you see I have cancer? Do you really want to discuss the weather?) You think about your life in vivid film shots. Your past suddenly comes into sharp focus, both the happy and sad days. You begin questioning the meaning of life in ways you never did before. Cancer prepares you for death the way a fatal car accident doesn’t. Is sudden death preferable to dying slowly because you can’t see it coming? Not sure.
But let me not be the purveyor of doom and gloom. The reason I am writing this article is that I have learned wonderful things about myself and other people. One of the things I have learned is that people can be kind and generous when they know you are in pain. People I don’t even know and have never met have sent me good wishes, prayers and even money for my treatment. Friends and family have sent food and offered accommodation. An Indian friend called to say that if I opted to go to India for treatment, I could stay in his home for as long as I needed. These generous and kind offers have literally brought tears to my eyes.
What I also learned is that my life’s work has not been a waste, and that my readers love and admire me for my writing. I didn’t realise I had inspired so many people, not just in Kenya but around the world, through words I have penned. That is a really important things for me to know and hold onto right now – to realise that I had a gift that I used well, and which helped others. And to know that when I go, my writing will live on.
I also learned that life is very, very short. So, we must not postpone the things we need to do. If your job makes you unhappy, quit. If a relationship is toxic, leave it. If people around you are making you feel bad about yourself, walk away. Surround yourself with people who love and cherish you. Love is very important for human survival, so distribute it freely. Be kind and generous. This thing called life is temporary, so enjoy every moment and live it as if every day is your last.
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