Following a recent visit to Kenya with People's Postcode Lottery, I was lucky to visit two other MSF projects in the north of Nairobi and nearby Kiambu County.
MSF teams have been working in Kenya since 1987 and, as the country has developed, so too has the medical care they provide.
The project we visited is located in Mathare, the second-largest slum in Nairobi with an estimated population of 300,000 jammed into roughly half a square mile.
Theatre is a key medium for getting important messages across to young children, especially on subjects still considered very much taboo
It only takes around 45 minutes to get from the central business district to Mathare in Eastlands district – Nairobi’s notorious traffic permitting, of course – but the two are worlds apart.
As you get closer to MSF’s office, the shiny corporate buildings fall away into a ramshackle collection of corrugated iron, where children wander the streets and piles of refuse are picked through on the side of the road.
It’s overwhelming and I felt a great sense of sadness at such parallel worlds only a few miles apart.
The Green House
Our first stop was the Green House, the project coordination office, which is, as the name suggests, painted green.
We arrived just in time to join the community outreach team on their visit to a local primary school, where they were to perform an educational puppet show about sexual violence.
The show kicked off with the local community theatre lead, Vinny, explaining to the children that they were going to be learning about their private parts and that these are not for anyone else to see, touch or photograph.
This set the scene for the 90-minute puppet show, which involved an uncle molesting his young niece, who called the MSF freephone number to report him.
Theatre is a key medium for getting important messages across to young children, especially on subjects still considered very much taboo.
The show was so powerful that by the end, the children were reciting the MSF freephone number they should call if they ever needed to, while the teachers were asked to continue relaying this important message.
Responding to local needs
When we returned to the Green House, we caught up with the Medical Team Lead, Cecilia, a medical doctor by background, with a focus on health system strengthening.
Cecilia joined the project in July 2016, having previously worked with MSF in Somalia and South Sudan. She manages a team of around 100 people across the medical, pharmaceutical and ambulance service sub-teams.
Cecilia explained that many of those living in the slum don’t have ID cards, medical insurance or money, severely limiting their access to healthcare in an emergency.
Our work in the area has needed to evolve as Mathare has, responding to the consequences of violence.
An MSF assessment in 2017 concluded that the burden of violence on health and mental health in the area was comparable in many ways to the most violent settings of Central America and Colombia.
The Lavender House
MSF has been working on sexual and gender-based violence (SGBV) in Mathare for over a decade and has become well known in this area.
The SGBV project at the Lavender House launched in 2008, with an emergency ambulance service following six years later.
Because MSF ambulances are always on the scene of emergencies and very visible, we tend to be the first point of contact.
Cecilia explained how important it is that we are not replacing the health system but supporting and advocating for change, with a view to the Ministry of Health taking over the emergency ambulance service in the future.
We now support around 30 Ministry of Health staff across four decentralised SGBV sites located in Kasarani, Dandora, Makadara and Mama Lucy Kibaki Hospital, as well as providing training and consultation room materials at two additional sites.
Mama Lucy Hospital has an SGBV clinic in the emergency department and is the first point of referral for the ambulances we dispatch from the Lavender House.
The Lavender House is – you guessed it – painted lavender and only a short walk away from the Green House. The medical director, Angela, talked us through the emergency services offered there.
When an ambulance is dispatched from the Lavender House, there is a driver, a nurse and an emergency medical technician (EMT) onboard.
We currently employ 12 drivers, 21 nurses, 16 EMTs, with three medically equipped ambulances and one life-support ambulance.
Crunching the numbers
From when the project opened in September 2014 to our visit at the end of July 2019, the call centre staff had taken a total of 29,788 calls, averaging 600-700 calls a month.
An initial assessment is done at the scene to determine if the ambulance should transfer the patient to the Lavender House or immediately to Mama Lucy.
Of the patients who ended up in emergency at the Lavender House during that time, 45 percent of cases related to the acute worsening of chronic conditions, for example, HIV or tuberculosis; 35 percent to violence and accidents; 13 percent to maternity; and seven percent to self-inflicted injuries or illnesses.
It was clear from our day in Mathare how MSF’s work has evolved to meet the needs of vulnerable populations and impressive to meet such a dedicated and passionate team striving to meet these
These numbers don’t factor in sexual violence as these cases go directly to the adjoining SGBV clinic.
The SGBV clinic treats around 400 new patients per month, some coming directly from the emergency room.
It is heartbreaking that 50 percent of sexual violence cases seen are children under 18, with half of those aged under 12. Equally so to learn that only eight percent of cases are men; we only receive the most severe cases where there is no other option, such as instances of gang rape.
There is still a great deal of stigma associated with sexual violence towards men and MSF is working to try and raise awareness about it, particularly among secondary school students.
Caring for survivors of violence
Upon arrival at the SGBV clinic, patients spend an hour with the clinician and an hour with the counsellor.
The clinicians will take the patient’s clothes for forensics, providing them with facilities to shower, including toiletries, towels and a change of clothes. Women are also given the emergency pill and tested for STIs and hepatitis B followed by pregnancy and HIV tests two months later.
The counsellor then asks patients to talk through what happened – importantly, this is the only time they will be asked to do so – then sets a follow-up schedule.
We are told that follow-up can be a challenge, especially given the socio-economic position of many, for whom coming back could mean losing a day’s wage. To address this, medical appointments are combined with counselling, however, only around 40 percent of patients complete five appointments over a three-month period.
The clinic provides meals for patients while they are waiting for appointments and can temporarily house patients, particularly women and children who arrive late at night when staff don’t think it’s safe for them to return home.
However, the clinic is not licenced as a 24-hour shelter. There is a social worker, Juma, who works alongside appropriate partner agencies, which can provide complementary care, especially in cases where the perpetrators are family members, and legal agencies for cases that go to court.
Meeting the psychologists
At the end of our visit to the centre, we spoke to Mercy and Ann, two of the psychologists.
The patients they see include children under five, refugees, survivors of repeated assault, survivors of incest and those with mental health illnesses.
Around 40 per cent of the cases they see are severe, including those wishing to terminate pregnancies, people with suicidal thoughts, survivors of gang rape and those who have experienced sexual violence under threat of arms, such as guns.
It is truly harrowing that these make up such a high proportion of cases the centre receives.
It was clear from our day in Mathare how MSF’s work has evolved to meet the needs of vulnerable populations and impressive to meet such a dedicated and passionate team striving to meet these.