Dying for care in western Kenya

Boniface has been feeling ill since sometime last year. Now he is lying so motionless on the stained foam mattress in the corner of his hut that he doesn't even disturb the dozens of flies that have gathered all over his skeletal form. His body has shrunk inside his clothes and his knees have swelled out of proportion to his matchstick legs. According to Marylyne, the MSF community health nurse who is coming round to check on him, he has skin infections, ulcers and tuberculosis (TB), all due to a severely depleted immune system brought on by HIV/AIDS. He is receiving treatment for these opportunistic infections, as they are known, and his TB is easing slightly. Though it is hard to imagine how he was before, since he still wracked by fits of tortured coughing that double him up against the mud wall. Speaking is out of question as he struggles for breath. Perched above him on a stool in the corner of the hut is his wife, Evelyn, who cradles their young baby. Evelyn is also HIV positive but not suffering the same infections as her husband. The child has an angry rash across his abdomen, a likely sign that he too is infected. But until he reaches 18 months old, his HIV status will remain unclear as he still has his mothers' antibodies in his system. Until that time, MSF is giving Evelyn bottled milk to reduce his chances of becoming infected through breast-feeding. They had three other children, none are still alive. It is not clear what killed them, but AIDS would be the obvious guess. Boniface needs to begin taking life-extending anti-retroviral treatment (ART) as soon as he can, but this is not possible until his opportunistic infections are stabilized and he can show that he is able to take his drugs daily. When Marylyne is asked about his chances, she replies "sawa sawa," a kind of 'maybe' in KiSwahilli. Treatment can bring about miracles, but sometimes it comes too late. This whole family is being followed-up as part of a Medecins Sans Frontieres (MSF) HIV/AIDS project in Busia, a region in the west of Kenya bordering Uganda. The project comprises of HIV/AIDS care in nine health centres spread across the district with one reference hospital in Busia Town itself. Over 150 unpaid community health workers have also been trained about the basics of HIV/AIDS and it is through their local knowledge that MSF nurses such as Marylyne are able to identify and treat patients in villages across Busia district. She has her work cut out for her. Busia, like other primarily rural areas of Kenya, has catastrophically depleted health services. Staff are in desperately short supply, facilities are dilapidated and drugs are chronically lacking. The HIV/AIDS pandemic has stretched the already weak system beyond breaking point and quite simply, many people are dying due to the lack of care and treatment. The shortage of ART is a case in point. Of the 1.24 million people with HIV/AIDS in Kenya, 200,000 need ART today and only 17% of them are receiving it. The others will die. A lack of knowledge combined with stigma are additional factors. People come too late for treatment, or refuse to get tested, or deny the existence of HIV/AIDS entirely, blaming deaths on witchcraft. Whatever the reason, the fact is that people are dying unnecessarily all over Kenya. The deaths are not happening occasionally; they are happening every minute of every day. Eunice has an infection in her left lung, another common opportunistic infection. She has been rejected by her husband and has returned to her home village. Her children are grown up she explains. The youngest is 10 years old - an adult in this part of the world. She had come to MSF in time and is being treated for the infection. Through MSF she will have free access to ART and will most likely survive. As Marylyne carried out the consultation, a clamour came up from a nearby hut. "Her neighbour has just died," she said matter-of-factly. The shouting and wailing is the expression of immediate grief in Kenya. The neighbour had died of AIDS. Eunice barely flinched. People die all the time in Busia, that is the reality. Grief has to be distilled into brief intensity. Rapid recovery is also a necessity when your own existence is precarious. The situation in Busia is catastrophic, but it is not even the worst place in Kenya. Homa Bay, where MSF runs another HIV/AIDS project, is a strong contender for that questionable crown. There the HIV prevalence is up to 35%. In Busia, it is more around 30%, although nobody knows the exact figures. But with treatment, people survive. Jennifer is living proof of that. When she began taking ART in 2004 she was bed-ridden, unable to look after her children, barely able to move. Less than one year later she smiles as Marylyne counts her pills to make sure that she is adhering correctly to the treatment. "I can now get on with my daily life," she explains. "I know that even with this disease I can do the same things as those who don't have it." She is also attending a meeting group with other people with HIV/AIDS organized by MSF. This enables people to share experiences and help each other out - even start up small income-generating activities. "I used to think that I was the only one," she says shaking her head. But for every person who gets access to treatment, many more do not. As we headed on to the next patient, the sound of music could be heard from some distance away. This was a 'matanga' (funeral). The next patient was already dead. She had come for treatment too late and could not be saved. As we left toward the car, another shout went up. Yet another new death. But that's life in Busia.