Notes on Mfangano – Community Health

Before I set-off on my travels at the beginning of July, I posted about community prevention – I mused about how community prevention has to come from within communities, and more importantly how communities’ embodiment of wellness is just as important as the tools they may or may not have at their disposal for achieving this. After participating in an intense conversation about the structural and behavioral changes that communities (in this case, in the broadest sense of the word – populations bound together by geography, demography, or something else) need to help them live in environments in which “healthy” choices are the given choices, I set-off for Mfangano.

Not knowing entirely what I’d find on the island, I arrived unsure of how “community health” would present itself in this corner of the world. As I gained my barrings on the island, and met and became friends with the people, I witnessed health – and community engagement with health – in an organic state. Starting from the end of my time on Mfangano…

On my last day on the island, having acquired a low fever over night, I made my way (via motorbike!) to the Ministry of Health (MoH) run health center in the village of Sena. It was a busy Friday morning, with islanders there to collect ARVs, participate in a free eye-care service being provided by a collection of missionaries, and consultations for a variety of other ailments and conditions. Unfortunately, I was scooted to the front of the line and rushed into a consult room. After describing my symptoms (many of which are common to traveling and being in a new environment) and saying “aahhhhh”, I was given a list of five medications, including malaria treatment. After several questions from me, I convinced the nurse that maybe I should have a malaria test…just in case.

Waiting for the test result (negative) and to collect my medications from the pharmacy gave me the opportunity to soak in the atmosphere of the center. There was a mix of Kenyan and foreign health care providers; mother’s with small children; and elderly couples leading one another up and down steps. The lab was a small, dusty room with a windowsill and it cost me all of 30 KES (the equivalent of $.37) for the consultation and the medications. Providing the only government sponsored care on the island (besides weekly mobile ARV clinics), this health center serves as the first point of care (sometimes 2nd after a CHW) for nearly all islanders in non-emergency situations. The health center at Sena is the health service epicenter for Mfangano.

About a week earlier, myself and the group of US researchers were offered the opportunity to travel to the island of Remba, further out in the lake. A meer speck on the horizon as you sail west from the south-east coast of Mfangano, Remba appears to be more like a large rock than an island. As we approached, the sun glinting off the tin roofs, we began to see that while Remba may be a geological speck in Lake Victoria, it is definitely not a human one! Fishing boats crammed every available piece of shore-line (our own had to squeeze in) and besides the plot of land designated for the football pitch (and small play area/farming area/”open space”) and maybe three trees, the island is packed with tin buildings and people.

Fueled by the profitable, deeper waters of this part of the lake – only about 500 meters from the Ugandan border (this based on a companion pointing out into the lake at the border) - Remba is overflowing with fish, foreigners (representing at least three other countries in East Africa), young men, alcohol, and HIV. My immediate sensory reaction was how still the air was, stale, with smells and heat hanging. Walking around the island, which does have distinct “neighborhoods”, we seemed to be in a slum - overcrowded, no latrines, trash everywhere, the lake as the only source of water – yet, it is not. Remba is a wealthy place and is seen by many, both on and off the island, as a desirable place to be, despite being relatively lawless (which gets it in the news for skirmishes and violent outbreaks). This desire has made Remba a cross-roads of HIV in the Lake Victoria region, and at times has had an adult infection rate hovering near 60%.

The first permanent health care facility was just recently opened, but even this will not have permanent staff – a mobile ARV clinic has been coming to the island once a week for several years. Nearly the entire group expressed, either at the time or later on, feeling extremely uncomfortable on Remba. Yes, it was something new, something foreign for many of us, but there was something else going on too. Even our guides (friends from Mfangano) expressed distaste and levels of uncomfortable-ness being on the island. One saying, “it is a scary place. If there was a disease here, there would be no way of escaping it, no one to help.” The community health of Remba is not removed from that of Mfangano, it has a huge impact on it and the surrounding region – the islands like overlapping circles. Remba’s health is about money and all the things lots of money can bring you, including, in this corner of the world, HIV. As one of my colleagues so eloquently stated, on Remba we were seeing HIV – how it lives, how it spreads, how it thrives, how it is part of life. Maybe this was that added something none of us could quite put our finger on.

Finally, early on my time on the island, I spent one morning on the Organic Health Response’s (OHR) farm. Sitting on land in Kitewi donated, and now run by Joel Oguta, the farm is nearly a complete opposite of Remba. It is green and lush, free of trash and people. The farm was started as the first phase of OHR – Joel’s dream to introduce organic and sustainable farming to the island. Now, in collaboration with OHR’s Ekialo Kiona center, Joel and the farm are embarking on a project to change the community’s nutritional health – one vegetable at a time. In addition to the current demonstration farm which is routinely trying out new produce to see what can thrive on the island (and then giving it away to those in need); research is being conducted on what produce and herbs are beneficial to those individuals on ARV regimens, to increase their nutritional capacities; and there are plans for running courses with community farmers on how they too can grow and provide pest control organically. While the OHR farm welcomes WWOOFers, it is the brain child of Joel and could only be described as locally run.

In addition to the Cyber-VCT at the EK center (which I wrote on in an earlier note), the farm is literally growing a healthy environment from the center of the community. Instead of just focusing on prevention, the people of Mfangano east are focusing on well-being. Yes, it has been shown that knowing your serostatus (whether or not you are HIV +) can positively affect  your choices and likelihood of passing the disease on to others, and this is a preventative tool. However, on Mfangano, knowing your status opens you up to a whole world of possibilities for living positively with or without HIV.

Community health on Mfangano is organic – it has evolved to have several arms embracing the island. There are the structured and institutionalized health services designed to preserve and serve as triage to the current state of community health, seen at the MoH health center in Sena. There are the outside influences, desires, and temptations which are all too human, yet perpetuate the disease which has come to define many lives here. And there are the growing, plentiful, and rich farm and community center which are breaking the surface for a new way to health. The embodiment of wellness was evident to me on Mfangano – the community is gaining tools “we” feel are useful for achieving better health and coming-up with some of their own – with community engagement becoming the easy choice.

I’m still pondering community health, and community prevention, and community well-being and I don’t think there is any one right answer. I do believe that defining, promoting, and achieving community health has to be done at the community level. Goals set for many, wherever in the World they may be, do not address the real and organic nature of living communities – cultural well-being as much of a goal as physiological and mental well-being. While I in no way feel I have done justice to my time on Mfangano, or produced an ethnographic description worthy of my education, I do hope that in these three notes I have told a part of the story. A story about an island, its people, and their health.

Images are author’s own – Mfangano and Remba Islands, Lake Victoria, Suba District, Kenya.

Notes on Mfangano – The People

I was truly blown away by the depth and beauty of the people I spent time with. While I was doing my best to be a participant observer, I fear I was not simply witnessing how they lived their lives but enjoying and being awed by them. Here are the stories of some of those people…

While on Mfangano, I lived with the Okeyo family (all visitors and volunteers on Mfangano in association with OHR live with host families). I was generously given my own little house on the family compound and ate my meals with Maureen, Rosie and Janet. The three youngest daughters of Baba, our father and patriarch. Baba was a fisherman before his back went bad and now makes nets. He has two wives, “the mothers”, and has provided for a large and fairly prosperous family. Polygamy is becoming less and less common in Kenya, however the Okeyos are seen in the community as an example of how “functional” families with multiple wives can be. Their children have nearly all made it through at least secondary school, some have found jobs on the mainland, and a number are closely involved with the running of the EK Center. I found it hard, impossible really, not to fall in love with the Okeyo children – spirited, kind, funny and wise. Whistling became our mode of communication, but we got all the important stuff said. Luckily, Maureen produced a detailed family tree in an effort to helpe me keep everyone straight!

Peter serves as one of two security guards for the Ekialo Kiona Center. A native of Mfangano east, he has worked for EK since 2009. Peter’s role is to keep the EK properties secure, and he takes this position very seriously. According to Peter, he enjoys working at EK because he is “doing my [sic] part to protect and promote good things in the community.” EK “is a program out of the community to help people with HIV/AIDS lead better lives” and everyone should know this!

Serving as a community health worker (CHW), the coordinator of the OHR Sisterhood Exchange program, and a member of the EK Steering Committee, Pamela is an ever present feature at EK. Originally from Mbita, Pamela has been a part of OHR since just after its inception in 2007. Soft spoken, yet quietly influential, as a CHW she has obtained a level of prestige not always achieved by wives and mothers on the island. Making her a logical choice for leading the Sisterhood Exchange program – a group of HIV+ women who have been given the opportunity to travel to the mainland (some for the first time!) to learn various craft skills, providing these women with new levels of education and economical provisions for their families. Pamela told me she was so happy to be part of EK because as a CHW, her involvement was helping her learn more about her work and do more as a volunteer. She is pleased by the benefits EK will bring to the community and in helping people with HIV/AIDS (“hopefully reducing stigma!”).

Richard, the Excutive Director of the EK Center, has been at the heart of the Mfangano east community solidarity for many years. Personally affected by AIDS, not unusual for this community, his desire for the community to help the community is apparent in everything he does. While chatting with me one day, under the shade of the trees at the back of EK, Richard told me of how Ekialo Kiona is in his heart; how he will do whatever it takes to make this thing succeed; it is “our home” and we are really very proud. The trust the community has already put in EK, Richard does not take lightly. Cyber-VCT isn’t happening anywhere else and neither is the level of trust EK affords within the community, “knowing your status is sill voluntary, but people now feel they SHOULD know their status!” Before we parted ways for the afternoon, he stopped me and said “remember, EK is almost run entirely by people FROM Mfangano!”

On only my second day on the island, I was afforded the pleasure of spending a few hours with Charles (with the help of my trusty translator Walter), a community elder and representative for Mfangano east to the island council of elders. Having lost a son to AIDS just the week before, Charles (about 71 he said) came out of his field to share tea with me and tell me the story of the island. In an animated fashion he told me, in Suba (the minority language still spoeken, but by very few in this corner of Lake Victoria), of the fleeing Ugandan royalty who chose to make their new home on Mfangano. He told me of how the villages came to be, and why Luo is now the prominent language spoken on the island (most children grow-up semi-quad-lingual speaking Luo, Swahili, English, and some Suba). As he escorted me back to Kitewi (I was headed for my first swim in the lake!), we met one of his granddaughters who he told me proudly was going to finish secondary school – just like he wanted for all the young women of his family.

While seemingly “traditional” and “conservative” at first glance, the people of Mfangano east are dynamic… Many are 7th Day Adventists or attend evangelical Christian services (quite common for this part of Kenya); the children do not learn evolution in school; and nearly all supported the recent constitutional referendum (which in addition to tackling corruption and land abuses, will also ban all forms of abortion). Yet, Baba and Charles have both been to seminary or higher education elsewhere in Kenya (and Tanzania!); young boys made orphans by AIDS and alcoholism have been absorbed and jointly cared for by multiple families in the community; the community wants to train its (female) CHWs to be their primary emergency responders; and the community is taking on AIDS. These lives are not easy, but they are complex and joyful. The people of Mfangano east embody their vision for a healthy community.

Images are author’s own – Mfangano Island, Lake Victoria, Suba District, Kenya.

Notes on Mfangano – The Island

Last week I returned from a whirlwind month of airplanes, sleeping on a variety of surfaces, and time on three continents. As I mentioned in my last post, at the start of July, I traveled to Kenya to do some work with the Organic Health Response (OHR), a young, community-based organization with which I serve as the grant coordinator. The main purpose of my visit was to do a “rapid ethnography” – to observe, participate, learn and absorb as much as I could in the short time I was there.

I returned to the US with a bug or two (not to worry, not malaria!) so have been slower in sharing my thoughts and stories than I would have liked. Mfangano does not have electricity (more about this in a bit) and barely any internet, so posting while there was impossible. In an attempt to give a full picture of my experience and what I learned, I’m going to split my notes into three installments: the island, the people, and the community’s health.

Mfangano is an island in eastern Lake Victoria, Kenya. The island is accessible only by boat…well, several boats. In somewhere around 12 hours, I flew from Nairobi to Kisumu (3^rd largest city in Kenya), then several hours on a bus (way there) or matatu (way back) from Kisumu around the northern coast of the Gulf of Kavirondo to Luanda. From there, a ferry from Luanda to Mbita and then a wooden boat from Mbita to Mfangano – with stops at smaller islands along the way. I arrived after the sun set, and approached the east side of the island in the dark. The spray off the water, combined with exhaustion and excitement, made the clear night sky overwhelming.

I awoke the first morning to see the island for the first time. It’s green. It’s lush. It’s beautiful! The majority of people on the island are fisherman or subsistence farmers. I lived with the Okeyo family in Kitenyi – a large and diverse family with 2 mothers, 16 children, and even more grandchildren. The family compound, like many on Mfangano east, is comprised of a variety of mud and tin roof homes on a large plot of land sloping up the island. Mt. Kwitutu is dominating, but has not kept people from farming its slopes and plateau.

One road circles the island, and in addition to the village to village boat services, motorbikes, bicycles, and walking are the sole modes of transportation. The Ekialo Kiona Center and the OHR Organic Farm are both in Kitawi which is in the center of the OHR catchment area on Mfangano east – incorporating the villages of Mala Masa, Kitawi, and Kitenyi. A diesel power station has been constructed in the main village of Sena and power lines have been up around the island, ready to go, for nearly two years…yet there is still no power. Even without a regular power source (solar panels are going up at EK this month!) EK had over 300 members join in June, its first full month of operation, with joining simply meaning knowing your HIV status through VCT (voluntary counseling and testing)!

With an adult infection rate of over 30%, knowing your status is the crucial first step to community wellness. In my next notes, I’ll tell you about the Okeyos, EK staff, and other community members who embody Mfangano and the mission of EK/OHR.

This post is going up on the same day Kenyans voted on a constitutional referendum which was part of the political deal aimed at easing tensions which arose after 2007 presidential election. The majority of the violence after that election occurred in and around Kisumu.

Images are author’s own – Mfangano Island, Lake Victoria, Suba District, Kenya.