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.
I try my best not to watch too much television, but it happens and despite having 200+ channels of cable I often find myself just hanging around the networks. Since the new year, I have begun watching a new series on ABC – Off the Map. While the lack of creativity when it comes to plot themes is getting a little tiresome, I keep coming back week-after-week for its “professional” relevance (and I went to school with one of the stars!) Off the Map follows the trials and tribulations of a collection of doctors (mainly American) in the jungle “somewhere in South America” (a.k.a. Hawaii). Characters’ personal drama and a relatively swanky built environment aside, each episode so far has touched on themes found throughout medical anthropology.
