The unhealthiest place on the planet for children
By RUTHANN RICHTER
Tolea was born early one Sunday morning in August and left in a paper bag on the gray picket fence outside the parish church in Naivasha, Kenya. Two passing parishioners heard her cry and brought the girl, still bathed in her mother’s fluids, to the home of the parish priest, Father Daniel Kiriti.
It was hardly the first time the priest had seen an abandoned child. He runs an orphanage full of these youngsters — children left at bus stops or rescued from the streets. For Naivasha, with its lake of many thousand flamingos and luxury hotels that cater to Western tourists, is a town plagued by AIDS. Even the priest has family members sick or lost to the disease. Tolea was a sign of just how much his community was crumbling under the disease, and how children were suffering as a result.
After Kiriti choked back his tears, he took the newborn to the government hospital down the dusty street. There he learned she was HIV-positive.
A month after her birth, I would meet Tolea, a sweet, chubby-cheeked child whose home now is a closet-sized room at the church orphanage. She nestles contentedly in the arms of the housemother, her black skin glowing against her bright yellow sweater and pants.
“This child is in good hands,” says the American-educated priest. “But there are many, many more children who have no one to take care of them. Many die young because they have no one to care for them. So I’m not very optimistic for the children.”
A child born in sub-Saharan Africa today has the odds stacked heavily against her. While child deaths have declined throughout the world, sub-Saharan Africa remains the exception. Today, nine children under the age of 5 die every minute in the region — 4.8 million deaths a year, according to the U.N. Development Project. The numbers are hard to fathom; imagine the entire population of San Francisco dissolving into the ocean six times each year.
The African youngsters die of many causes: malaria, respiratory infections, diarrheal diseases and AIDS are among the prime killers, compounded by perpetual problems of poverty, malnutrition and lack of safe drinking water and sanitation. A million children die every year of malaria, for instance, many for lack of a $3 bed net to ward off disease-ridden mosquitoes. But what underlies the staggering rate of childhood death is the AIDS pandemic, which has led to neglect of youngsters and their basic health needs. For not only does AIDS kill children, but it increases their susceptibility to other ailments and has destroyed the family and social networks on which their well-being depends.
Not long ago, the odds for surviving childhood in the region were improving. After the launch in the 1970s of the World Health Organization’s campaign to vaccinate young children against major killers such as polio, diphtheria and tetanus, the number of deaths among young children in Africa and other underdeveloped countries fell dramatically.
But the AIDS epidemic in sub-Saharan Africa has wiped out all those gains.
I saw some of these problems myself when I visited Kenya for the first time in March 2004 at the urging of my friend and former Stanford graduate-school roommate, documentary photographer Karen Ande. Karen had been there five times before, photographing children and families affected by the epidemic, and she’d been transformed into an activist/fundraiser in the process.
She wanted a collaborator — a writer — who could help open people’s eyes to the problem. I had written about AIDS in the early days while a staff writer at UC-San Francisco, but nothing could prepare me for the emotional blast that comes from encounters with orphaned children out in the African bush, sleeping on dirty scraps of foam or living in tin shanties tending to emaciated parents too weak to lift their heads to eat. Like Karen, I became a convert to the cause.
In September 2005, we returned to Kenya to visit and garner more material for our writings, exhibits and presentations. This time I came armed with my Stanford credentials, which opened the way to meetings with specialists in children’s health.
The first stop was Kenyatta National Hospital in Nairobi, a teaching hospital and the country’s flagship medical center. There I met Ruth Nduati, MD, a professor of pediatrics and a leading expert on pediatric AIDS. The government medical center is a maze of cement-block walls, with the eight-story, 2,000-bed hospital rising like a bunker out of the core. The corridors were dirty and the halls teemed with waiting patients and families.
Nduati is a tall, lanky woman with an intense look. She appears haggard and with good reason. In the pediatric ward at the hospital, she says, the children lie three to a bed — 100 youngsters in a ward designed for 35. Three nurses and two nurses’ aides are charged with caring for the ward’s children. I learn later than some 30 percent of the children admitted to the national hospital die there.
Nduati says 30,000 to 40,000 children in Kenya are born HIV-positive every year. Sixty to 70 percent die before their fifth birthday, she says with a grave look. Nearly all children with HIV get the virus from their mothers, so stopping this transmission could turn the crisis around. Nduati helped develop a national protocol to reduce transmission rates by treating HIV-positive pregnant women and their babies with antiretroviral drugs — a strategy applied some years ago in the United States that has reduced the number of infected babies to nearly zero.
Some Kenyan women now get these drugs before and during labor; their babies are treated just after birth. The program is funded in part by the U.S. President’s Emergency Plan for AIDS Relief, which is starting to make a difference for women and children in Kenya, Nduati says.
After the sobering hospital visit, we ride across town to the upscale Muthaiga district to meet with officials at the private, nonprofit Gertrude’s Garden Children’s Hospital. It sits on a hill on a winding, two-lane, tree-lined road near the home of the U.S. Ambassador and an American-style shopping mall. It’s a pristine, open-air facility with 28 beds and brightly colored murals. The largest children’s hospital between Egypt and South Africa, it is Kenya’s equivalent to Stanford’s Lucile Packard Children’s Hospital — a specialty-care facility that serves a mix of patients, both insured and uninsured.
Tending to kids with AIDS
The hospital has been in the forefront of developing protocols for a variety of pediatric problems, including pediatric AIDS. Among Kenya’s 15 million children, some 120,000 are living with HIV today, and 1,500 to 2,000 — fewer than 2 percent — have access to antiretroviral drugs, or ARVs, says Gordon Odundo, the hospital’s chief executive officer. It’s only in the last few months that pediatric formulations of ARVs, long in use in the United States, have become available in Kenya, Odundo says. “Children have been neglected,” he says apologetically. Now the hospital plans to put another 500 children on these life-saving drugs within a year, including youngsters in the Nairobi slums.
Daisy Kaane, 12, a patient at Gertrude’s Garden, is one of the rare HIV-positive children in Kenya now being treated with antiretrovirals. She is asleep in a private room when we arrive; her mother, Edna Kaane, is leaning over the girl’s bed with a look of distress. She says Daisy was first diagnosed as HIV-positive last October, when she was suffering high fevers and frequent bouts of coughing. She was found to have tuberculosis, which infects those with HIV much more readily than others. She has other problems as well, including headaches and seizures. Her physical health has improved since she went on ARVs, her mother says. But the young girl is having trouble coping with the disease; she is afraid to go to school and is not progressing in her studies, says her mother, a neatly dressed woman who works in the finance department of a local company.
“Her main problem is psychological,” Daisy’s mother says. “She knows what ARVs are. She has started asking so many questions. ‘Why me?’”
The mother says she doesn’t know how to respond. “How do we pass the information on to her? It might break her. She might give up,” she says.
The conversation never turns to the issue of how the girl became infected, for it’s an extremely sensitive topic. When a society attaches stigma to the disease, as is the case in Kenya, parents often fail to have their children tested because a positive result can implicate the whole family, says Emily Nguu, the nursing director at Gertrude’s Garden.
As we leave the hospital, Colin Forbes, MD, a consulting pediatrician there, offers to drive us back to the hotel, on the way pouring out his frustrations. As he deftly makes his way through Nairobi’s notorious rush-hour traffic, he rails against a medical care system that allows children to die of diseases that are entirely preventable and treatable.
“The primary cause of death is the too-sick, too-late syndrome,” says the Canadian-trained physician. “You can call it bronchitis or neonatal tetanus or gastroenteritis or anemia. All these things are preventable. The children come too late, and they are too sick to be saved.”
He bemoans Kenya’s lack of medical resources and health-care personnel to put basic pediatric practice into action.
“Eight out of 10 children can’t get electrolyte treatment for diarrhea. I’m ashamed of that,” Forbes says. “Most district hospitals can’t treat severe diarrhea with electrolytes and fluids because they don’t have the IVs or the laboratories.”
He says corruption at many levels leads to the disappearance of medications and vital equipment from government facilities, robbing children of decent care. “I’m angry — I can’t accept what they’re doing to the African child,” he says.
Ministering to orphans
While many children die of HIV/AIDS, the disease has an insidious impact on those who survive, only to lose their parents to the disease. An estimated 15 million children in sub-Saharan Africa have lost one or both parents to AIDS, including 650,000 in Kenya (although some believe the number is closer to a million), according to the United Nations Joint Programme on HIV/AIDS.
During my first visit to Kenya, we met with some orphaned boys who wandered the streets of Gilgil, a town about a 40-minute drive from Naivasha on dusty, pockmarked roads. The boys had been scrounging in garbage bins for food and pestering shopkeepers with petty thievery. A local businessman had set them up in a rented tin shack and given them a bit of money for food, as well as odd jobs to keep them occupied. One of the boys had come down with malaria during our visit; he was lolling about on the ground on a dirty, worn-out sleeping bag.
A local café owner, Jane Kinuthia, recognized the growing need for a children’s shelter and set up the Saidia orphanage in 2004 in a cement-block building she’d used for her defunct catering business. She and her colleague, social worker Teresa Wahito, now run a shelter for 28 children with financial help from Jill Simpson, a retired nurse and longtime children’s advocate.
During a visit to the orphanage, we meet Mary Maishon, a toddler with a broad forehead and bowed legs. After Mary’s mother died of AIDS, her grandmother abandoned the family, leaving Mary and her siblings with their grandfather, a casual laborer and alcoholic who left them alone much of the time. The three children had been living in a one-room metal shack, sleeping on a dirt floor with a single blanket to cover them in the chilly highland town on the fringe of the Rift Valley.
When Mary came to the orphanage in July 2004, she was thin, did not speak at all and scooted around on her knees, Kinuthia says. Mary now walks and is extremely talkative. One bright afternoon, she joins the other children on the weed-covered lawn outside the orphanage, smiling and singing songs while munching on a special treat of butter biscuits and pineapple juice from her American visitors. But Mary still has bouts of depression, periodically becoming withdrawn, unable to eat or go to the bathroom, Kinuthia says. She imagines her grandfather will come someday and give her sweets and hold her hand.
“They [Mary and her siblings] have feelings that they have been rejected and thrown away and nobody wants them,” Kinuthia says.
Government and other service organizations offer little psychosocial support for orphans, who may suffer the progressive loss of family members, and in some cases, separation from siblings.
“These children are traumatized before their parents die, and as their parents die, it’s a continuation of the same trauma,” Nduati says. Many have the same severe emotional trauma as children who sur-vived the genocide in Rwanda, she adds. She and others say the AIDS epidemic is producing a generation of children ripe for recruitment by terrorist groups in a region already fraught with political and social instability.
“The orphans not only have their own suffering but have the potential for adding to security risks in the region,” she says.
What to do, what to do?
So, where lies the solution? On the global level, the answer is embodied in campaigns like the U.N. Millennium Project, which aims to cut poverty in half and reduce the under-5 mortality rate in sub-Saharan Africa by two-thirds by 2015. Jeffrey Sachs, PhD, the Columbia University economist who directs the project, maps out a strategy for these goals in his latest book, The End of Poverty.
“…One cannot fight a war against weapons of mass destruction through military means alone,” Sachs writes. “The weapons of mass salvation … anti-AIDS drugs, antimalarial bed nets, bore wells for safe drinking water and the like — can save millions of lives and also be a bulwark for global security.”
I ask people both here and in Kenya about the Millennium Project, and they agree it’s an admirable plan, but it isn’t working. Sachs acknowledges that the program is falling behind, in part because developed countries, especially the United States, have been unwilling to commit the funds to carry it out.
“The Millennium goals are really important in the policy environment and for our political leadership. They’re long overdue and provide a clear framework. But they’re not the whole answer,” says Jennifer Astone, executive director of the overdue and provide a clear framework. But they’re not the whole answer,” says Jennifer Astone, executive director of the Firelight Foundation in Santa Cruz, Calif., which supports community-based organizations helping vulnerable children affected by HIV/AIDS. “There is the issue of how it’s translated on the ground to help kids. You do that by engaging families and communities.”
She and others, including Forbes, the pediatrician, argue for directing more resources to grassroots organizations that can mobilize people at the village level.
The solution, too, lies in the resilience and resourcefulness of many Kenyans — people like Father Kiriti, who, despite an avalanche of problems, continue to approach life with dignity and spirit and a determination to make things better.
The priest, who privately grieves for family members ill with the disease, devotes much of his energy to actively preaching HIV prevention, such as condom use and other behavior changes. Only through such changes can the suffering end.
“Nature is going to take its own course,” he says one morning over tea. “We will hit the bottom” before things improve. But then a better day will come.
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