May 26, 2006


Friday afternoon. We go to the aids wing of the district hospital in Eldoret, a wild west town of 40,000 in the highlands above the Rift Valley. Marina has been very clever, she has lead me into the country slowly as though a long qualification is required. First to the game preserve, to heritage, to the ‘idea’ of Africa, to what little is left you could say of its origins; then closer in, but still on the flanks, to the colonial notion of a far away place, wild and inescapably beautiful. But ever in a compound, ever protected. Ever cut off.

Then finally, on the third day, to this second story room we’re in right now, with ten people, men and women in their 20s and 30s and one woman, in her late 40s. They look like professionals. They are attractive people, well groomed, with big smiles, confident looking. They remind me of insurance sales people I used to work with. In fact, they are trainers and outreach workers and they look like trainers and outreach workers anywhere in the world. Janice, the woman in her 40s, is a forceful personality, in her closely cropped hair, with her theatrical manner and voice. She introduces me to the group with the suggestion — and I'm guessing here — that because Marina is in Africa, and by gracious extension, African, therefore I am also African and being a father I am the father of everyone in the room. Everyone addresses me as 'Dad.'

'Hello, Dad.' And I'm thinking, is Janice playing with me or is this merely a clever graciousness? Later, I talk to her in the hall, say goodbye, and she seems both distant and close. I can't make her out. But then she has the illness, herself.

After Janice's introduction, one by one, we go around the room and each person identifies themselves. Most begin, ‘I am hiv-positive, ‘ and they might add, “living positively”, which has become the catch phrase in the last several years, a mantra from Magic Johnson perhaps to remind oneself that the stigma can be faced and life goes on. Despite the awfulness of the disease and all it has done to ravage humanity and make filth of a life. In West Pokot the infection rate is around 10 percent, although figures are suspect. Perhaps, 7 percent. And falling although the worst has yet to come......

So these people dressed in skirts and slacks are the front line soldiers whose job it is to go to towns and villages and persuade people that testing is worthwhile, especially for children, that condoms are not filled with the virus, that this is not an American plot to kill Africans, one of those myths that many here believe. And that living and facing this disease is the way to shed the stigma, not hiding, not fearing.

It’s tough work. And consider that these workers who themselves have the disease also have families. And they’re having children and having sex.....

Afterwards, Marina goes off to see someone. I stay in the courtyard of AMPATH, the large NGO, whose three story building this is, and whose game this is as well. They’re the organization spearheading getting drugs and food to HIV patients in the West Pokot District — one of say four districts where the virus in Kenya has hit hardest; the others are around Mombassa on the coast, Lake Victoria, three hours to the east, and to the south. All tolled there are 2 million people here who are HIV positive. Along with 900,000 orphans, in other words, children with one or both parents dead from the illness.

After I run into Janice I sit on the brick boundary of a circular garden in the courtyard. I notice a neon green grasshopper. I put my finger out; it shakes the tip of my finger and leaves its leg in the air as though to say, ‘I enjoyed meeting you.’ I try to continue our conversation but it jumps away, and then again. It moves toward a deep hole in the cement and I stand up and try to steer it away back toward this little circular garden, but it doesn't want to go that way and it occurs to me that I may increase the very danger I’m trying to eliminate, so I walk away. Everything is a metaphor in Africa.

Marina returns and we walk out to the parking lot of the hospital. And now there is an interesting little exchange that tells you much about the interior of the problem in fighting AIDS. Marina is arranging a taxi to take three trainers to their home after this seminar. In the background a man is singing from a low building with bars. This seems to be the facility for mental health patients. I ask the taxi driver what the man is singing but he doesn’t know because they’re from different tribes.

I notice a woman standing a few yards, away, white, in her 40s, clearly an American, with the sunglasses and body authority so engrained in Americans. She's from Iowa and exchanges greetings with Marina who asks about the possibility of getting more services to some of her patients. This is a long and convoluted story, but suffice to say Marina’s NGO works in part as a subcontractor to AMPATH, does some of the outreach work and shares in the grant money which AMPATH pulls in by bucket full. And to its credit. But there is some acrimony here. The NGO business is entrepreneurial by nature. The directors often act like Greek colonels or Donald Trumps for that matter. It’s all about control and since you’re so far away from the donors and administrators in New York or London or Geneva, anything goes. And if you can show the numbers, you get more money. And if you are a powerful personality you can attract more money. And the more money you get and the more numbers you get — the more people you can document getting your service — the more donors you get. The whole edifice of NGOs is built on the notion of critical mass — of patients and donors. Efficiency, however you define that, becomes the guiding principle, but as your organization grows bigger, and more and more management controls are applied to handle the ever bigger number of patients, the humanity sometimes begins to leak out. And in terms of management flexibility may be sacrificed. So the director of AMPATH, who is by all accounts a dedicated and creative genius, has set up his organization of clinics and satellite offices like a MacDonald’s franchise. There is one model for each clinic and you don’t deviate from the model, which is both good and bad. In effect, you leave little room for error, or innovation.

Marina’s NGO is small. She has four employees; AMPATH has dozens and big time grant money. Marina's notion is that there isn’t just one model and that all models need to remain organic, all models must be joint ventures between the NGO and local staff, and of course between doctors or social workers and patients. In effect, it’s the Paul Farmer notion that you give someone what they need and you treat one person as you would treat many and you treat all people as though they were your mother, father, sister, brother, son, daughter. As you would if you were in America or Europe.

And so Marina and this woman from AMPATH are standing in the dirt parking lot of the aids wing with the crazy man singing in the background and Marina wants to know if food distribution and drug distribution can be localized. The other woman in an imperious way, responds and right away you can hear her defensiveness. Marina steps toward her and the power dance begins. The other woman says, "well, we’re thinking about it but there’s nothing we can do right now “ And then she adds to leave hope on the table, “we’re continuing to discuss it.” In that tone of organization-speak, which is to say, “mind your own business, we’ll get to it when we goddamn well please.”

But Marina is not put off and having presented her thesis in front of a room full of Yale’s finest minds in the school of public health isn’t going to be deterred by such old and transparent obstacles.

“Okay, but I still don’t quite understand why we can’t get these services to people who have to make several trips, to get drugs in one trip and food in another....”

Marina steps still closer, the other woman backs up. “But we have only a few people coming to these sites and it’s going to be a long time before we reach the critical mass that will make it worth while to....” The other woman is now retreating to her vehicle. “We’re going to keep discussing it but like I said, we just can’t do anything right now.’”

Right now is any time soon,. Right now is in the next few months, by the end of the year. Meanwhile, the patients must get to market today, must get medicine by tomorrow, must get their children tested as soon as possible. The well meaning woman from Iowa, who has herself been in the Peace Corps, is lost in the model, in the diagrams and grant proposals, and the expectations of people far away, who want the atta-a-boy feeling they’re doing something for the world.

But ‘on the ground,’ in the heart of darkness, the heart is your only hope, and once in you’re in, once you’ve made contact, your humanity is all that’s possible.... Nothing else will do, you have no other protection.

At the end of this, I’m thinking, Enough time spent on dialectics, reasons and withdrawals. Too long wandering among interesting ideas and pretty possibilities. Time to commit, to put your money down on something, to engage fully.

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