Sunday, December 9, 2007

The Lord's Gift and Flying Toilets

Living With Corruption
It is 9th December 2007 and I have just watched, for the third time in two days, a CNN special program entitiled, ‘Living With Corruption’, yet another first rate documentary on Africa by the incomparable Sorious Samora. Maybe it is just because I live in Africa and have great interest in the subjects he covers of maybe it his totally unpretentious manner, but I find him one of the best documentary producers around today.

As the title suggests, ‘Living With Corruption’ takes a hard look at corruption in Africa. Some might ask, so what’s new, it’s a subject well chewed over by the media on an almost daily basis. This film gives a new slant, it looks at how corruption rules the lives of the ordinary man and woman in the street. It demonstrates all too horribly and clearly how corruption pervades every level of society, and Samora suggests the entire Continent.
This at times infuriating film depressed and angered me on a number of levels; first because it reminds me of what I have witnessed almost every day of my past six years in east Africa and second because in many ways, Samora is ‘preaching to the choir’, the people most likely to see this film will be people who already know and have an interest in the subject. These are the same people who have witnessed the issue for years and have failed singularly to do anything to change it, I count myself amongst this group.

I doubt that the USA’s domestic CNN channel will make room in its twittering vacuous 24 hour ‘news cycle’ for a program as sober as this. Not least because CNN’s Directors have long since assumed [ or indeed created] an American audience with the attention span of a humming bird, that simply could not concentrate for almost an hour.

Of the many scenes that angered me, the shots of Samora walking at night down narrow alleys of Kibera slum in Nairobi ranked pretty high. His camera pans to the streams of raw sewage and describes the plastic bags under foot as being filled with human waste. There is such a dearth of pit latrines in Kibera, (as in most urban African slums) that the people have solved the problem by shitting in plastic bags and then hurling them as far away from their own dwellings as they can. The practice is called “The Flying Toilet”.

When I lived in Nairobi some years ago, I wrote a piece in early 2003, about HIV/AIDS and public health, essentially criticising the then ‘new’ PEPFAR initiative as being too narrow in its focus. My argument then and now is that attempting to stem the tide of AIDS by offering medicines to those in need is in many ways a pointless task. Giving medicines to people whose living conditions are so appalling they cannot find clean water with which to swallow their medications and cannot find food enough to re-generate their lost body weight, seems an exercise in futility that does no more than make the donor community feel good in the short term.

I entitled that piece The Lord’s Gift and Flying Toilets. Watching Samora’s film prompte me to revisit the piece, it is depressing to see that almost five years on so little has changed for the better and most for the worst.
I have reprised the article below…………..

Medicines for the Hungry
Even if it all comes together and “the Feds” get the money and resources to do what the President has directed, I have serious doubts about the [plan’s] overall impact on the disease, at least in East Africa, because it takes too narrow an approach to the issue and offers a single templated solution. The Harvard economist Jeffrey Sachs recently commented: “…the US administration has latched on to a simplistic vision of what to do, based on a single example, Uganda. It knows little of measures in place in other parts of the world, and that each country needs to shape the best local response”.

I think he’s right. My brief sojourn into HIV/AIDS in this part of the world has taught me that there is no template: even communities abutting each other need different plans of attack. But above all else it has taught me that it is a disease of poverty and that no plan will work unless it deals directly with the underlying social causes of poverty as key objective. A Kenyan friend puts it more bluntly. “Giving medicines to the hungry that live in shacks with no heating, lighting or toilets, consume dirty water and are illiterate will not reverse the scourge.” Another commented: “No community or government can tackle disease when its people are barely surviving on $1 a day.”

This Hecate’s brew of hunger and AIDS is impacting upon Kenya in a multitude of ways. The Country has a population of about 30 million, around 80% live in rural areas and could be broadly considered as farmers. But the demographics are changing rapidly. Farmers who once grew cash crops such as cotton and peanuts cannot find enough healthy members of their family to harvest so they have turned to subsistence crops like maize. But when disease stalks the land on a biblical scale even subsistence farming fails. So the people, particularly the young move to the cities to find security and work. HIV/AIDS is accelerating the pace of urbanization in Kenya and in doing so it is creating another dimension of social problems, which in turn must shape the way HIV/AIDS is managed in those communities.

Living in a Ditch
Kenya’s capital, Nairobi, is a city of approximately 2.2 million and growing daily. Over 60% of the population lives in slums euphemistically called temporary settlements and the numbers are growing at an unstoppable rate. The most infamous is slum is called Kibera. It has the dubious distinction of being the biggest in Africa, with about three quarters of a million people occupying 226 hectares – three-square meters per person. It was most trenchantly described by the BBC’s East Africa correspondent, Andrew Harding as, “Wood fires, fried fish, excrement, and rubbish – the rich stench of 800,000 people living in a ditch…six hundred acres of mud and filth with a brown stream dribbling in the middle…and at least one third of Nairobi lives there.”

The majority of Kibera’s residents work in and around the city, in light industry and the service sector. Most live in tin-roofed shacks connected by mud tracks, which usually double as open sewers. There is an erratic electricity supply for those who can afford it. It is a dangerous place to live. Robbery and violence is commonplace. Drugs, prostitution and heavy drinking of an illegal and potent homebrew called Chang’aa are common recreational activities. The police rarely patrol; vigilantes provide security for a price and sometimes exact terrible punishments: ‘necklacing’ is not uncommon for theft

Lord’s Gift
TB and dysentery are endemic and there are frequent outbreaks of virulent infectious diseases such as meningitis and hepatitis. Rats and other vermin are constant health risk. The HIV prevalence is estimated to be 20% (5% above the national level) but I have failed to find out how this figure was determined). Public health standards would shame a refugee camp. There is little or no running water; contractors bring in most in aging water trucks with logos such as “the Lords Gift” painted down the side. It is sold at exorbitant prices and carried home every day by women and children. Only a hardened Kibera dweller would drink it without boiling. The sewage system is a combination of open sewer and pit latrine. But as numbers multiply there are not enough latrines and in desperation, people resort to the “the Flying Toilet”. In simple terms those with no access to a latrine evacuate into plastic supermarket shopping bags and hurl them as far away from their own shack as they can. The result needs no description.

Reality Check
Now: against this medieval background lets remember our clear and simple mission is to reduce the number of new HIV infections, treat a number infected with Anti Retroviral Therapy (ART) and a considerable number more for the opportunistic diseases of AIDS. In this scenario prevention through education and behavioral change is an uphill struggle. Clinical diagnosis and medication are overshadowed by the need for clean water an adequate diet. How effective will ART be when the patient drinks water laden with cryptosporidia and eats one meal of porridge a day? For those who will never receive ART and who will spend their last days in their shacks in what is euphemistically called Home Based Care, the greatest need is a clean place to lie, a caring nurse, relief from pain and a death with dignity.

This is the reality that our “Emergency Plan for Aids Relief” must deal with. It can only succeed by a broad approach, socio-economic, educational and health. Each country stricken by this plague has unique problems and each must deal with them in an individual fashion. It requires the complete involvement of the people, communities and government. Solutions cannot be designed and imposed by even the most clever, generous and wealthy outsiders. America cannot solve this problem alone and in a way of its own choosing. To have any hope of success, we must act now, the numbers are growing inexorably. It needs huge sums of money, focused, trained human resources and a ‘coalition of the willing’.

This last cliché raises another spectre. If by the time this reaches print we are at war in Iraq, then war will eclipse every other international human priority, HIV/AIDS included. Wars divert attention; wars consume resources. Will America still be able to meet its promises?

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