Any time I hear these words come out of my mouth in sub-Saharan Africa, I expect complications (delays, toilets, sick patients, darkness, frustration, large insects…) in the future:
“How contaminated can this water be?”
“How long could this take?”
“You would think that this would be simple.”
“It must be some other part of the goat.”
“That location is very close to here.”
“I only saw small cockroaches.”
“Surely the hospital has [critical, basic medical supply]”
“He said he was just around the corner.”
“At least we have electricity.”
“I am sure the internet will be working by then.”
She walked all this way to collapse in my exam room.
Monica is thirteen, but she bears the weight of two adults. At home, it is only this teenaged girl and her mother. Her mother is bedridden, terribly sick with a combination of HIV, TB of the spine, and malnutrition. It is up to Monica to take care of her.
Monica needs to take care of herself too. She also has HIV, this virus that destroys the body’s defenses and leaves it weak and vulnerable. She tries to take her cocktail of medicines every day, but that can be very difficult when you are only 13 and you are the one worrying about food and shelter and care for yourself and for your mother.
“There is no one to help us,” she says.
Monica has been sick since Saturday, with a high fever, headache, and vomiting. She has not been able to eat much. And today, she decided that she was sick enough that she needed to get herself to our clinic. The $1 that it would cost to get a ride on the bus to the clinic was far too much for the budget in this little household. This clinic is a one-hour walk from the girl’s house. Somehow, she managed to walk for that one hour.
I think that this brave and struggling girl used up all the energy she had left on her walk, just barely holding it together to get to the clinic. Here I find her, on the floor of my little office exam room. I piece together the sad story of what brought her here, to my floor.
The clinical officers tell me that I cannot admit a child to the hospital wards without a parent or guardian to stay with her. And yet, how could I possibly send this one back home? Is she sick enough for me to fight the legal battle to keep her here? And what happens to her mother at home? What to do, what to do… No one to pay. No one to be the responsible adult. Only this sick girl with too much weight already weighing her down. No good options.
So often, my challenges here are not just with the medicines or with the infections or even with the decisions about how to best treat a child with a complicated disease using very limited resources (although those are definite challenges!) Instead, these are the issues that twist me up and sometimes break my heart: What to do when there are no adults to care for a child? What to do when your community has fragmented? What to do when a family crumbles under stigma and discrimination? What to do when poverty’s vicious cocktail of malnutrition and violence and stolen opportunity renders my drug cocktail ineffective?
The highlight of the week here in Kenya was holding “a team-building” for my study team. (“Team-building” is used as a noun here.) My study coordinators organized a day-long event for our personnel from 8 different clinics across western Kenya, some of which are at least a three-hour drive away. Our study evaluating disclosure of HIV status to children has been in place for almost one year, and we are also transitioning to involve a new North American field coordinator. It was a good time for everyone to come together.
Looking around this group of talented, laughing individuals, I was humbled to think about what they are accomplishing. Together, they follow hundreds of families with children with HIV, assessing how the families are doing clinically, emotionally, and socially. In the past year, we have recruited all of these families at 8 different clinics; developed new materials to help with disclosure counseling; started counseling individual parents, guardians, and children; and instituted group counseling sessions for children who have learned about their status. So much good work!
We gathered at a riverside resort a little bit outside of Eldoret. The team-building featured lots of games and a goat roast (nyama choma) for the entire crew. We actually purchased the goat in town and sent it to the site early that morning by motorbike to be prepared for our feast. Certainly, not every day in Kenya is fun and games, but this one came close.