Kenya is at the same time just what I was expecting and not at all what I thought it would be. The one thing I can’t get used to is all the people. They’re everywhere. Everyone either walks or bikes here, making the city seem larger than it is. Vehicles are reserved for public transportation, wealthier residents and foreigners. Even New York City doesn’t seem as lively as Kisumu because the streets are constantly invaded by people crossing, bikes swerving everywhere and figures walking down dirt paths on the edges of badly paved roads.
I keep asking myself what it is that makes my eyes strain from trying to take everything in. It’s not beauty; Lake Victoria and the nature surrounding Kisumu are stunning, while the town itself is not. But somehow it demands just as much attention as an ancient Italian city. Every building, even the tiniest shack, has words and illustrations and slogans painted on. Just walking down the street is an experience; children yell “How are you? How are you?” and tiny hands reach out for contact. I’ve also shook more hands in three days than I ever have in my life. At first I was a little leery (I hate handshakes anyway, too many germs), but I feel welcome no matter where I am or who I’m meeting, which you just don’t find in the US. And tilapia. LOTS of tilapia. I’m surprised I haven’t sprouted scales yet from all the fish I’ve eaten out of Lake Victoria.
So far I’ve spent the better part of my time sitting in a lab at the CDC/KEMRI (Kenya Medical Research Institute) station right outside of Kisumu. Most of the SCORE activities are on a break now; drugs have been handed out already. Since the majority of those who contract schisto are school-aged children, interventions tend to focus on school-based drug administration with the help of teachers. The problem with this is that many of the children in sub-Saharan Africa do not attend school regularly or stop going after a while. Where prevalence is higher, community-wide treatment is used.
Two 4-year studies are being done in Kenya: one in higher prevalence areas (>/= 25%) and one in low prevalence areas (10-24%). In the low prevalence areas they will test school-based treatment every year versus every other year or two years in a row with then without treatment. In the higher prevalence areas they will test community-wide treatment in varying year combinations mixed with school-based treatments, as well as only school-based treatments.
I’m beginning to get a better idea of what this kind of research entails in the field, although I haven’t made it out yet. At dinner last night, one researcher studying malaria medicine uptake shared what she had encountered when speaking with villagers.
She spoke with some who used their bed nets as tablecloths because another village had received blue ones instead of white; they thought there was no repellant on the white ones. Other reasons for noncompliance ranged from the nets making it difficult to breathe to making the beds too hot.
This really made me think. I’ve been having an internal argument with myself over how I feel about the strictly drug-based nature of the SCORE program in Kenya.
Vertical approaches like mass drug administration that don’t address critical factors such as cultural values, beliefs and behaviors simply won’t work. So for schisto, how do researchers ensure that the drugs they hand out aren’t being misused, or simply thrown out? How do the locals feel about the drugs? Is there also some kind of health education going on to tell them how to prevent getting schistosomiasis? SCORE doesn’t address the issues of access to clean water and sanitation, but it does keep tabs on other such initiatives that might affect rates of schisto in areas where drugs are being administered.
On the other hand, drugs are often the only certain way to treat and even prevent schisto when livelihoods depend on contact with contaminated water and there are no other available options for someone to wash their clothes or bathe. What would you do if you had no clean water at home? Avoid bathing or washing dishes? No, you’d go down to the nearest free source of fresh water.
So I’ve found that’s it’s really a two-sided issue. You can complain all you want that just handing out drugs won’t help control disease without cleaner available water. But that doesn’t change the fact that right now, that water isn’t there. Addressing the social aspects of disease is crucial and absolutely necessary when trying to decrease morbidity and mortality, but it requires long-term commitment, funding and cooperation from the country involved. And that may be a long time coming.
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