Are we ready for that day?
My first posting as a doctor was to Homa Bay District Hospital. Homa Bay is a small town by the shores of Lake Victoria in western Kenya.
My first posting as a doctor was to Homa Bay District Hospital. Homa Bay is a small town by the shores of Lake Victoria in western Kenya.
At first, I was very reluctant to go there as I had never been that far from my family and friends or from a big city. I remember a conversation I had with my father, in which he urged me to go, wisely pointing out ‘you never know what you were supposed to do for the people of Homa Bay.' 
During a trip from the coordination office in Nairobi to Homa Bay, in a conversation with the project coordinator, I wondered loudly about my connection to the town of Homa Bay. It felt a bit strange for me that out of four organisations I have worked with in the past eight years, three have HIV projects in Homa Bay and this county always seems to be drawing me back to it.

The beach in Homa Bay in 2008, from the MSF photo archives © Brendan Bannon

More than half of my working life has involved this lake side town in one way or the other. Its uniqueness is drawn from many things; the people, the scenic setting, having churned out notable politicians, such as the eloquent Tom Mboya, in Kenya’s political history and the stalwart Mbita constituency member of parliament Millie Odhiambo among others.
But it first caught my attention for one reason; a current HIV prevalence of 25.7 percent, the highest in Kenya. This was much higher in the range of 30 to 40 percent back in 2008 and still remains so in some pockets of the county. 
Translated to simple terms, this means one in every four adults walking on the street is living with HIV in Ndhiwa.
When I first started working in Homa Bay in 2008, I had a strong focus on treating individual patients with little regard to the larger social and economic impact of disease. So I got a bit worried when I soon discovered that up to 90 percent of the beds in the medical ward were occupied by patients presenting with opportunistic infections secondary to HIV infection.
I remember asking Dr Oduor who was the physician then what the medical wards were like before the age of HIV. ‘For starters, we had fewer patients and were dealing mainly with malaria and respiratory infections. The death rates in the wards were also comparable to other facilities but with the advent of HIV the death rates shot up dramatically’.
For me it was rather worrying that one condition could account for such a high proportion of admissions. Coincidentally, I was born about the same time as HIV was discovered, so I did not have the hindsight of how things were before the pandemic.
Maybe, I will get to see the end of this pandemic in my lifetime. This is where I first met MSF, who were running Clinic B, the HIV clinic at Homa Bay District Hospital. I even had a unique encounter with a photographer from MSF who took a photograph of me in the paediatric ward attending to a patient who I still remember to date because of their near brush with death. I never knew I would eventually work with MSF in the same small town of Homa Bay. 

This is the old photo of me in 2008 taken by an MSF photographer, Brendan Brannon. 

Fast forward to 2015 and MSF conducts a study to look at the major causes of admission and death in the medical wards at Homa Bay district hospital (now called Homa Bay county referral hospital). The study included 690 patients admitted between December 2014 and March 2015.
The preliminary results presented to the county team showed that 49.1 percent of patients were admitted due to HIV related conditions. A significant (45 percent) proportion of these admitted with HIV related conditions had severe immunosuppression with CD4 counts less than 100. It got me asking the same questions I asked when I was back in the county in 2008.
What are we missing? Why do we still have such high morbidities related to HIV in the age when universal access to ARVs [antiretroviral treatment] should be then norm? 
The scenes that haunted me eight years ago still replay themselves, even now. You will not miss this should you pay a visit to the county referral hospital.
A 20 to 30 year old, lays in bed severely immunocompromised, probably suffering from Karposi’s Sarcoma or another related condition. One of his/her grandparents sits at his/her bedside, despondent. They wonder what the future holds, not just for their grandchild, but for the great grandchildren s/he will be leaving under their care. 
On my part, the questions are not limited to the social ones asked by the loving grandparents; they include economic ones that we have to answer as a nation and as a subcontinent. Who will teach in our schools; who will dig in our farms; who will guide the next generation into fully productive citizens; who will take care of orphans to break the vicious cycle of poverty that now more than ever looms over them like a dark cloud? 
And finally, can our economic output one day outstrip the drain that this and other diseases have on our systems? When organisations such as MSF, USAID and PEPFAR will no longer support the care of those infected, what shall be the impact on our national budget? Are we ready for that day?