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What I Learned from the Maasai with Village AIDS Clinics In the Shadow of Mt Kilimanjaro

VAC Demo 1 Maasai women with clean and dirty 2Today, I’m taking a small 3-seater bush plane to Mbirikani in south east Kenya to visit Africa Infectious Disease Village Clinics. I take the co-pilot’s seat after being admonished to not try and fly our plane.  We have a 50 minute flight from Nairobi to within 60 kilometers of Mt Kilimanjaro.

VAC bush plane 2It’s been more than 4 years since I’ve visited the Clinic.  On my last visit I met Ann Laurie, founder and benefactor, of AID Village Clinic.  At that point they were just starting their work with the P&G water purification packets. 

VAC Demo 1 Elder with Obama hat 2

 

 

We’re recently agreed to provide an additional 4 million liters of clean drinking water based on a report by the Clinic that the P&G packets were having a tremendous impact on the health of the community and that the clinic could not have achieved the level of success they’ve achieved in this community without safe drinking water.

 

 

 

 

VAC aerial 2We make a low fly-over to chase off the gazelles, make a soft touch landing on the dirt landing strip, and then generate a cloud of dust as the pilot brakes and cruises to a stop near an Acacia tree.  I’m met by Jackson Sakimba, the tall, efficient, and deep-voiced site manager, who is a Maasai.  Jackson shows me around the Clinic and I marvel at their nearly exponential growth in the last 4 years.  The Clinic now has 43,000 annual patient visits. 


VAC boma from air 2Because the Clinic is in a remote area they need to be self-sufficient.  They generate their own power through solar panels or diesel generators.  And, they have a cafeteria to provide breakfast, lunch, and dinner for their 140 staff.  Most of the staff lives at the clinic but many have families that they only see on weekends or every other weekend because of the remoteness of the Clinic.  Among other hospital necessities, they have an immaculately clean laboratory for analysis of blood, a microbiology lab, an x-ray that is useful for detecting tuberculosis, and a 50 bed hospital.  The newest addition that will be ready soon is a large maternity building.
The Clinic serves people on a first-come, first-served basis which seems standard to Westerners but not necessarily the standard in the developing world.  Only emergencies jump to the front of the queue. 


VAC CHW motorcycle 2After the tour from Jackson and a cup of tea, I’m handed over to John Saitoti, the outreach manager for the Clinic.  John leads a team of 11 community health workers comprised of nurses and clinical officers who use motorcycles to reach into the communities.  They serve a big area and the cycles provide the most efficient transport.  I’m eager to head out into the field but first we’ll spend a little more time at the Clinic.


VAC clinic demo dirty 2The Clinic outreach team conducts two demonstrations of the P&G packets every day at the Clinic – one for the outpatients at 10:00 am and later for the mothers who bring their babies for check-ups and immunizations.  Every day there are patients who have never seen the packets and for those who have seen it before, it’s a good reminder.


VAC clinic demo clear 2After watching the demonstration and hearing the “oohs and ahhs” when the filthy water becomes clean, I ask to speak with the Moms visiting today.  We hear that many of them have used the packets and I pull two of them aside with the help of John’s interpretation. 


VAC Noritit and Jumari Kasani 2Nortit Kasana is visiting today with her son Jumari.  She’s been using the packets for a year and collects her water from an irrigation ditch called Kalesirwa furrow.  She started using the packets when she brought in her older child to the Clinic with diarrhea and the doctor’s told her the water had made her child sick and to start using the packets to prevent illness.  Nortit tells us that it’s not difficult to use and she correctly tells us the steps for making treated water correctly.


VAC Maria and Meano Singhin 2

Maria Singhin has brought her grandson Meano to the Clinic.  Her family has been treating their water regularly with the P&G packets for 2 years.  They receive the packets from the community health work and she tells me the community workers are in the community almost every day.  She receives 24 packets at a time and that’s plenty for her family for a month.  This means they’re only drinking about 1 liter or less per person which isn’t what’s recommended but is typical of the Maasai who just don’t drink much water despite the oppressive heat.


VAC Kili and giraffe 2John and I head out to the field.  It’s a very hot but clear day and we’re treated to a magnificent view of Mt Kilimanjaro.  Almost like on cue from a movie set, two giraffes walk in front of the massive mountain and pose for our cameras.  I sure wish it had been this clear when I hiked Kilimanjaro with Kenna, Jessica Biel, Alexandra Cousteau, Emile Hirsch, Isabel Lucas, and the Summit on Summit: Kilimanjaro team.  Seeing the mountain brings back great memories of the success of that work to build awareness of the global water crisis.  Our work generated 2 billion media impressions about the global clean drinking water crisis.


VAC demo 1 John with clear and dirty landscape 2On our hour drive to the first community, John and I get to know each other.  I’m not surprised but very impressed when John tells me that Ann Lurie paid for John to attend the Liverpool School Tropical Medicine to obtain his Masters.  Ann’s also funded the education of a surgeon in South Africa and a global health expert to attend Dook University for the Clinic.  And, I’m thrilled to learn that she’s hired my old friend Gary Saffitz, retired from Johns Hopkins Centers for Communication Programs, to help with oversight of the Clinic. 


VAC demo 2 maasai women 2John is a Maasai so I ask him about some of his culture and he asks about mine.  John was raised a traditional Maasai in a collection of mud huts called a boma.  The Maasai are traditionally polygamous so each boma has many huts with each hut the home of one of the wives and her children.  Their precious cows are kept in the center to keep them safe at night. 


John’s father has 7 wives and John has 42 siblings including all of his half-siblings.  We both have 2 daughters of our own and, while mine are older, we find that we have similar dreams and aspirations for our children.  We want them to have a good education, health, and happiness. 

VAC demo 1 elder 2I ask John if it was a difficult decision to leave the traditional Maasai life and become a clinical professional at the Clinic.  John tells me that his grandfather was a paramount chief during colonial days and through this his family was exposed to the benefits of education.  This helped lead to his father supporting John’s choice to become a health worker.


Cows and farming have not left his heart and he has 30 cows that he pays to have kept on a farm near Nairobi.  I ask him how many cows he thinks my talented and hard-working daughters are worth and he flatters me by telling me probably 30.  Then he confesses that among the Maasai, it’s a standard practice.  No negotiation.  Five cows are given per bride no matter the wealth of the husband.  I’m sure my daughters will be ecstatic.


While John has no problem with his father’s polygamy, he’ll not go that path.  I appreciate John’s openness to my questions and ask about some of the other practices of the Maasai that get a lot of attention.  He tells me that female circumcision or more appropriately called female genital mutilation is still the norm although the Clinic is working hard to discourage the practice.  The rite of initiation is a good thing, but it needs to be replaced by a ceremony that is not so destructive to women’s health and enjoyment of life.  I tell John that I just don’t understand why any man would want his future wife or daughter to undergo that horrific practice.  We have a good conversation about the rationale for the tradition of female circumcision when men had many wives versus current day practices where polygamy is decreasing.  We’re both hopeful that the days are numbered for this practice.


VAC Maasai warrior 2Contrary to popular media, John tells me that it’s a myth that a Maasai man will readily share his wife with another man.  This myth started based on the Maasai custom that if a man from your same year of initiation visits, even if he is a stranger to you, then it is customary to feed him and allow him to sleep in your hut.  Custom holds that the Maasai host does not sleep in his own home when a stranger is visiting but gives his hut to his year mate.  It’s true that sometimes the year mate may take advantage of the situation, but this could be compared to situations such as in the West with affairs between married people.  It’s not appreciated by Maasai men and therefore a myth.


VAC Moran 2As we’re driving, we come across a young Maasai walking alone across the parched land.  This is a “Moran” or single male who has gone through the circumcision ceremony and now has 5 years to walk-around enjoying life before his elders decide it’s time for him to settle down and get married.  John explains that to be a Moran is like being a rock star and they’re very popular and famous among the Maasai women.  I ask John if he became a Moran when he was a young man.  He laughs and said that he did, but because of his commitment to his education, he took a fast-track and was only a Moran for two days versus five years.  John chuckles to himself as if thinking those were two very nice days!

VAC demo 2 woman with earlobes 2Back to the business at hand, I learn that the program at the Clinic to provide the packets to people living with HIV/AIDS is going very well.  As part of their very first work, the Clinic started providing the P&G packets to women who were pregnant as part of their efforts to help prevent mother-to-child transmission (PMTCT) of HIV/AIDS.  This work continues and there are typically about 200 mothers on the program at any time.  Following my last visit, Ann and I agreed to expand the program beyond PMTCT to all the HIV/AIDS patients at the Clinic who have dirty water.  This greatly expanded the program since about 5,000 people with HIV/AIDS are receiving support.  John tells me that there is high acceptance and use among this group of vulnerable people who are prone to opportunistic infections without clean water.


VAC demo 2 girl drinking with woman in background 2I’m pleased to hear that the program has also expanded to provide the water purification packets to malnourished children.  The Clinic uses the high protein, ready-to-eat food called PlumpyNut for emergency care of malnourished children.  But they know that recovery is faster if the child also has clean water because without it, frequent diarrhea makes it more difficult to take in all the nutrients from the PlumpyNut and quickly reach a healthy weight.  The Clinic makes it a requirement for any family receiving PlumpyNut to also use the P&G water purification packets.


VAC water carrying 2 2As we learned back at the Clinic, the outreach workers are also providing the packets targeted to areas that have highly contaminated water.  The packets are not needed in all of the area the Clinic supports because clean water flowing from Kilimanjaro in a pipeline reaches many people.  The Clinic makes the packets available for people who collect water from streams and irrigation ditches and where there’s a high rate of waterborne illness.


VAC water carrying 1 2John tells me that the work to provide the packets in many of these areas is going well with good acceptance and regular use by the communities.  But to take full advantage of my visit they’re not taking me to the success areas.  I really appreciate this opportunity to learn and add value.  Today we’re visiting two areas where the adoption has been slow. 

VAC kids at stream 2In this area, there are both Maasai living year-round and seasonal migrant farmers who rent land from the Maasai to grow crops during the rainy season.  John says that the slow adoption is only among the Maasai.  The acceptance and use among the migrant farmers has been high and they appreciate the packets.


VAC demo 1 elders 2John and his team have called a meeting of the elder Maasai men to discuss their opinions of the packets.  Joyce Jimanite and 3 other Maasai women are attending this gathering.  In behavior change terminology, we call Joyce a positive deviant because she has become a regular user in this community that generally has low use of the packets.  Joyce has been using the packet regularly for 3 years and understands that without using them her family is at risk of waterborne illness.  In fact, diarrhea and vomiting used to occur regularly in her family but now is very rare.


VAC demo 1 stirring 2In discussing the water packets with the men, we learn that there is a lot of misunderstanding.  One of the barriers to use is the fact that some of them believe drinking purified water may result in a thinning of their blood and make them weak.  Unlike Joyce, many believe that the high rates of diarrhea in their community are caused by malaria and not related to the contaminated water. 

VAC demo 1 mother & child drinking 2John and his team have recently started doing microbiological analysis of the water for indicators of fecal contamination, e.g., fecal coliforms and E coli.  John has a simple and eloquent way to explain this microbiological analysis.  Instead of trying to get these men to understand the concept of bacteria, John explains that the Clinic has a measure for the amount of feces in their water.  John had told me earlier that the microbiological analysis of the stream water for this community showed so many bacteria that it exceeded the count capacity of their analysis.  So, John is correct when he now tells the men that the Clinic’s measurement showed that their water has a very high level of feces.  The men look worried when they hear that they’ve been consuming a large amount of feces in their drinking water.  Based on their expressions, I think we’ve made some inroads. 


VAC demo 1 man sipping 2Evidence that we’ve had a dint is the ready acceptance of the elders to drink the treated water.  I have the first glass of treated water, but then every single elder enjoys a glass of clean water.  They promise to work to build acceptance in their community.


VAC demo 1 man drinking earlobe 2

 

 

 

 

John and I then drive to another community with low acceptance of the packets.  This time we’ll meet with only the Maasai women.  We visit their water source and see that it’s a stream a couple of miles from their bomas.  In the short-time that we’re at the stream, we see several women coming to collect their family’s water. 

 

 

 

 

 

VAC water gathering with cow 2A cow sips water on one side of the stream while a woman fills her 20 liter water container on the other.  Around the developing world, gathering water is largely the task of women and girls and that’s certainly the case with the Maasai.  In fact, a couple of men are standing around watching the women as they go about their chores of gathering water and washing clothes.


VAC water collecting with man watching 2We meet the women at one of the bomas.  There are 15 women gathered for us to meet and only three of them regularly use the packets to treat their filthy water.  We again have a positive deviant show us how she uses the packets and explain why she uses them. 


VAC demo 2 filtering 2When we open the conversation with the women, we hear some of the same barriers expressed by the men.  While thinning of the blood is not mentioned, it’s clear that many of the women do not accept the connection between their dirty water and diarrhea illness.  I cringe when one of the women grabs the untreated water and shows us that she can drink it.  Thank God she didn’t give any to her baby resting on her hip.


VAC demo 2 woman with dirty water 2We hear that many of them do not like the taste of the treated water.  As I always do, I’m the first to drink the treated water.  I can see their point that the water has an off-taste.  The packets have a small amount of chlorine that kills the bacteria and viruses.  It’s similar to municipal water that people drink around the world that has been disinfected with chlorine but this taste is foreign to people in rural villages.  We explain to the women that this taste indicates the product is working to kill the germs in the water.  In addition, I tell them that if they prepare the water in the evening and don’t consume it until the following morning, that much of the off-taste will dissipate.  In fact, one of the positive deviants explains that she does this and her family is now used to the taste of the treated water. 


VAC demo 2 baby drinking 2However, I also notice a taste that isn’t really like a small bit of chlorine.  This water tastes a bit chalky and leaves a bitter after-taste on the front of the tongue and back of the throat.  I don’t think this is from trace amount of the chlorine.  This is a volcanic area and I know that the water quality in these areas can be complex.  Perhaps there’s a natural mineral in the water or maybe it’s not related to the volcanic soil and is an agricultural run-off that is making the off-taste.  It’s possible that the dirty, untreated water is masking the taste of the offending agent.  Whatever the case, it’s a barrier to wide adoption of the packets and a good reminder that there is no one solution to the global water crisis.  There are several proven options and perhaps another option is best for this specific community.


VAC demo 2 Maasai woman P&G and PUR 2I suggest to John that we show the women the new package design that will be in Kenya in about October when we switch from PUR Purifer of Water to P&G Purifier of Water.  The women ask lots of questions but basically want to hear that the ingredients inside are the same.  I tell them it’s only a package design and the contents are exactly the same.


VAC demo 2 John talking with Maasai woman 2Like with the Elder men, there’s no resistance to drinking the treated water when the 30 minutes has elapsed and the water is ready.  The children seem ravenous for the water and it seems to me that the ability of the Maasai to consume a small amount of water must be a learned response that these children have not yet adopted. 


As we’re getting ready to leave, the eldest woman collects the remaining treated water in her jerry can.  She says that it’s important for the children to drink this water.  And, she thanks Village AIDS Clinic and P&G for bringing them these packets.


VAC demo 1 Maasai woman with clean and dirty CSDW 2As they say in Swahili “Pole Pole” or slowly, slowly we’re making a difference in some of these hard to reach communities.  Behavior change communication is hard work and takes sustained, effective, and credible communication.  One and done will not get it done.  Just take the success of the Village AIDS Clinic.  They’ve shown a steady increase in the use of the P&G packets.  The first few years had low use.  In fact, during my first visit the Clinic was only using a couple thousand packets a month.  

Through steady and sustained outreach, the effort continued to grow and now the Clinic uses a monthly supply of 36,000 packets.


I really enjoyed my brief cultural immersion with the Maasai and AIDS Village Clinics.  While there’s more work to do, it’s clear that our work is having an impact.  I’m thankful to AIDS Village Clinic for hosting me and to the entire team for their dedication and self-less work to help others.

Comments

Greg,
Thank you for your visit and the Blog -- some very helpful information here!
I hope all is well with you.
Sincerely,
Ann Lurie

A wonderful read.

Great work going on in Mbirikani. There is nothing as wonderful as empowering a community. Many lives have been and are still being changed by the great work and commitment of selfless people like Ann Lurie.

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