~Debbie

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Malaria Prevention Methods in

The Gambia

Malaria epidemics have been devastating world populations since far before the discovery of malaria’s etiology by Alphonse Laveran in 1880 (World Health Organization [WHO], 2006). Today malaria is estimated to put 40% of the world population at risk and cause 350 to 500 million cases per year. Research has shown that there is an estimated 3 million deaths every year due to malaria. The mortality rate primarily burdens Africa, with up to 90% of the deaths occurring on the continent. The affliction is also globally felt amongst children under the age of five, who represent 90% of the deaths (Roll Back Malaria Partnership [RBM], 2005; The Global Fund, b). In total, malaria currently affects 109 countries and territories, which span continents around the world, except Antarctica and Australia (WHO, 2008). Throughout these areas, malaria disproportionately affects the poorest areas, with 58% of all cases occurring amongst the poorest 20% of the world (Roll Back Malaria Partnership, 2005; The Global Fund, a).

             With Africa being the most affected by the infectious disease, it is known that 74% of the continents population lives in areas that are considered to be highly endemic for malaria and 19%  or approximately 125 million people live in areas prone to epidemics (WHO: Regional Offices for Africa and Eastern Mediterranean, 2006). Malaria is estimated to cost as high as US$ 12 billion each year for African countries with an average annual reduction of 1.3% in economic growth (RBM, 2005; WHO: Regional Offices for Africa and Eastern Mediterranean, 2006). With 44% of the population residing in the African region living with under US$1 a day, there is a heavy financial burden due to the extremely elevated costs of malaria (WHO: Regional Office for Africa, 2006). Studies have shown that the economic burden to treat malaria can vary between US$1 and US$10 depending on the country a person resides in, and this is not including costs towards prevention methods (WHO: Regional Offices for Africa and Eastern Mediterranean, 2006).

            The West African nation The Gambia feels the constant effect of malaria, with 100% of its population at risk. The Gambia is located along the cost of West Africa, geographically surrounded by Senegal, and it has an estimated population  of 1,735,000 (United Nations [UN], 2006). Although exact statistics of malaria’s affect on The Gambia is not entirely known, it is estimated to cause 4% of all deaths in infants and 25% of all deaths in children under the age of 5. The country struggles to fight and manage malaria due to insufficient resources and funds (Department of State for Health and Social Welfare [DOSH], 2003). It was estimated in 1999 that 59.3% of the population lives on less than US$1 a day (WHO: Regional Office for Africa, 2006). The Human Development Index (HDI) ranks countries beyond their gross domestic product (GDP) and incorporates life expectancy, adult literacy and educational level. The Human Development Report ranks the country 155^th out of 177 countries. The Gambia’s ranking places the country amongst the Low Human Development countries (United Nations Development Programme [UNDP], 2007). Moreover, the United Nations ranks The Gambia as one of the forty-nine Least Developed Countries in the world. To be included amongst this list, a country must have an average gross national income (GNI) of under US$745, low human capital status, and economic vulnerability (UN, 2006).  Thus, the poverty stricken country is unable to allocate appropriate funding to fight malaria without assistance.

            While countries across the world continue to struggle with the devastating effects of malaria, many are moving towards projects that will eradicate the disease from their country. The eradication of the disease would not only benefit the well-being of the people but also the economic status of the country (RBM, 2005; The Global Fund, b). Malaria interventions that work to control and eliminate the disease include prevention, accurate treatment, and surveillance and monitoring (RBM, 2005; WHO, 2008; WHO: Regional Offices for Africa and Eastern Mediterranean, 2006). The most common preventive methods used globally include insecticide treated bed nets, indoor residual spraying, and intermittent preventative treatment for pregnant women. Using a combination of these methods, The Gambia’s vision is that malaria will cease to be a burdensome health problem upon the population (DOSH, 2003). Upon visiting The Gambia, there is a vast amount of evidence showing the effect of malaria and the methods being taken to intervene. The purpose of this study was to gather information from studies, governmental policies, and personal interviews, and assess the use and access of the Gambian population to the preventive methods against malaria.

Literature Review

Malaria

Malaria is a parasitic disease that is transmitted by the female anopheline mosquito. The disease is caused by four species of the genus Plasmodium; they include P. falciparum, P. vivax, P. ovale, and P. malariae. The majority of the deaths from malaria are caused by P. falciparum. The parasite is spread when the infected female anopheline mosquito bites a human. While feeding, malaria sporozoites are released into the bloodstream, and they are rapidly carried to the liver, where they invade hepatocytes and cause an asymptomatic liver infection. The sporozoite asexually reproduces daughter merozoites, which eventually cause the hepatocyte to burst. The merozoites are released into the bloodstream, where they quickly invade erythrocytes. The merozoites rapidly replicate within the cells causing it to eventually burst (Khan & Lai; Rosenthal; White & Breman).

When the parasites reach a blood density level of approximately 50/ ?L of blood, the symptomatic stage begins. The merozoites continue to quickly replicate within the bloodstream and progress to the next stage called trophozoites. As the trophozoites continue to grow and enlarge, they take on species specific characteristics. About 48 hours after the primary erythrocyte infection, the parasite enters the schizont stage, where it progressively consumes all hemoglobin and occupies most erythrocytes. Through out the process, some of the merozoites differentiate into gametocytes. In this form, the parasites can be taken up by another anopheline mosquito and transmitted to a new human (Khan & Lai; Rosenthal; White & Breman).

The first symptoms of malaria to typically appear are headache, fatigue, abdominal discomfort, and muscle aches, followed by fever. Other common symptoms that may be seen are chills, malaise, chest pain, and diarrhea. Physical findings may also include signs of anemia, jaundice, and splenomegaly. Common laboratory findings include anemia, thrombocytopenia, increased erythrocyte sedimentation rate and plasma viscosity, and liver function abnormalities. Malaria is diagnosed based upon these symptoms and a positive blood smear. The most common diagnostic test is the Giemsa-stained blood smear, and the severity of malaria is determined loosely on the quantity of parasites present (Rosenthal; White & Breman).

Global Programs

            To fight the malaria epidemic, programs have arisen from organizations to assist countries in the initiation of malaria policies, provide access to prevention and treatment supplies, and funding. One such program is the Roll Back Malaria Partnership which plays a substantial role in the fight against malaria. The program was launched in 1998 by the collaboration of the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), and the World Bank. The primary goal of the partnership is to halve the burden of malaria by 2010. By 2015, the goal is to have all malaria related Millennium Development Goals (MDGs) met. The goals include the eradication of extreme poverty, universal primary education, reduction of child mortality, maternal health improvement, combat diseases, and the development of global partnership for development (RBM, 2005).

            In April 2000, Roll Back Malaria (RBM) held The African Summit in Abuja, Nigeria, where forty-four of the fifty countries affected by malaria in Africa attended. In attendance were either the Heads of State, Vice Presidents, Prime Ministers, or the Ministers of Health from each country. They agreed to commit effort toward RBM’s vision to halve all cases of malaria by 2010. Notably, they resolved to ensure that by 2005:

§  At least 60% of people suffering from malaria have access to affordable treatment within 24 hours of the onset of symptoms

§  At least 60% of at risk groups, primarily pregnant women and children under five years of age, are provided with a combination of personal and community protective measures

§  At least 60% of all pregnant women who are at risk, have access to intermittent preventative treatment (RBM, 2000)

In 2005, RBM released new goals which increased the values to at least 80% and that the burden from malaria would be halved compared with 2000 (RBM, 2005).

            Another major contributor towards the fight against malaria is the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund was initiated by the collaboration between the G8 countries, the African leaders, and the United Nations. Since it started in 2001, the Global Fund has brought in US$4.7 billion, and it has committed US$1.5 billion in funding to 154 programs and 93 countries worldwide (The Global Fund, b). The Gambia currently receives two sets of grants from the Global Fund. The initial grant was set up in 2004 to cover the coastal region of the country. In 2007, a second grant was added to target the remaining health divisions of the country.  Both grants have heavy focuses on the implementation of prevention methods against malaria (The Global Fund, 2008a, 2008b).

Discussion

Indoor Residual Spraying

The Gambia’s primary goal in the prevention of malaria is vector control, which entails indoor residual spraying, insecticide treated bed nets, and intermittent preventative treatment for pregnant women (DOSH, 2003). Indoor residual spraying (IRS) is the process of applying long-acting insecticides on the indoor surfaces and roofs of all houses. The main effect results in the killing of the mosquitoes that enter the home and rest on the treated surfaces (WHO, 2006, 2008; WHO: Global Malaria Programme, 2006). To achieve maximum results from spraying, at least 80% of the local community needs sprayed (WHO: Regional Offices for Africa and Eastern Mediterranean, 2006; WHO: Global Malaria Programme, 2006). The effectiveness is also determined upon the acceptance of IRS by the local community and the willingness to continue to spray at least once or twice a year. Problems arise with IRS because the method can only be delivered by fully staffed and equipped services, which is not usually present in many countries. Continuous spraying tends to also lead to progressive refusal of the procedures within community homes (WHO, 2006, 2008).

            Within the country, the WHO assists The Gambia in multiple forms of IRS. The Gambian WHO program provides instructions on the proper methods for spraying insecticides within the community houses and what type of insecticide should be used. Similar information is provided in the instructions on larvicide spraying (personal communication, June, 2008). In discussion with The National Malaria Control Program a representative acknowledged the programs recognition of the WHO recommendations, and it was stated that the program provides targeted adult spraying and larviciding by chemical and biological pesticides. Targeted areas for spaying are communities that are surrounded by rice fields and other key vectors (personal communication, June, 2008). The Chief Officer of Nursing confirmed that the Global Fund would be soon beginning to initiate IRS (personal communication, June, 2008). Detailed information on the areas and accurate amount of spraying that occurs has not been reported. 

Insecticide Treated Nets

Personal protection interventions continue to be provided and promoted by multiple organizations. The use of insecticide treated bed nets (ITN) is a cost-effective method that is highly promoted. Mosquito bed nets are treated with insecticides to properly provide protection to the person sleeping underneath the net while the odor of the insecticide is used to attract mosquitoes. The widespread use of ITNs within the community assists in the reduction of the mosquito population (Wiseman, McElroy, Conteh and Stevens, 2006; WHO, 2006, 2008; WHO: Regional Offices for Africa and Eastern Mediterranean, 2006). The distribution of ITNs is promoted by many governments by waiving or reducing taxes and tariffs on bed nets, netting materials, and insecticides. RBM, WHO, and UNICEF have programs instated to deliver ITNs specifically to pregnant women and children under the age of five. The programs are in line with the Abuja targets to provide protective measures for the at risk groups (WHO: Regional Offices for Africa and Eastern Mediterranean, 2006).

            The Gambia’s National Malaria Control Program (NMCP) has been working in coordination with the Global Fund, WHO, UNDP, UNICEF and other groups to work on the distribution of ITNs. Upon interviewing a representative from the NMCP, it was stated that the Gambian government has removed all taxes and tariffs on nets, insecticides and netting materials. They work with other organizations to direct mass national net dipping campaigns at no cost to the citizens. The campaigns are carried out by each of the six district health teams, which coordinate care for each region of the country (personal communication, June, 2008). The Chief Officer of Nursing stated that Global Fund has been imperative in the distribution of ITNs by giving them out for free, demonstrating how to use them, and instructing on how to soak them correctly in insecticide (personal communication, June, 2008). Upon inspection, ITNs were observed to be used in the health care system, including the Royal Victoria Teaching Hospital, The Jammeh Foundation Hospital, and the Fajikunda Medical Clinic.

            Following the Abuja targets and the Global Fund recommendations, long-lasting ITNs (LLN) are given out free to all pregnant women and children under the age of five. According to data collected by the Global Fund, 155,636 LLNs have been distributed to children under the age of five in the coastal region of The Gambia since 2004, and 86,754 LLNs have been distributed to children under the age of five in the remaining health regions since 2007. Similarly, 46,787 LLNs have been distributed to pregnant women in the coastal region since 2004 and 7,976 in the remaining regions since 2007. The distribution of LLNs to pregnant women falls below the Global Funds target goals in all regions (The Global Fund, 2008a, 2008b). The Center for Innovation Against Malaria in Gambia found that the night before one of their studies only 48% of the women slept under an ITN (Center for Innovation Against Malaria [CIAM], 2007). The NMCP relates the issue to pregnant women having a lack of awareness of the benefits of ITNs, belief that the insecticide is harmful to their health, lack of desire to use ITNs, perception that bed nets are not fashionable, and view that netting materials are too expensive (DOSH, 2006a).

            The national Malaria Control Policy states that the allocation of preventative methods, such as ITNs, is hampered in The Gambia due to the high levels of poverty. The non-marginalized population, which has to pay for ITNs, is less prone to own bed nets. It has been reported that 26% of households do not own a bed net and 65% of these households state they could not afford one (Wiseman et al., 2006). The Center for Innovation Against Malaria (CIAM) reports that the cost for one untreated bed net is estimated at 200 dalasi (at time of the study D1 ? US$34) and one LLN is estimated at D300. To treat bed nets yearly with deltamethrin (KO Tabs), an insecticide, costs D42; however, this cost is typically covered by the government or outside organizations during mass net dipping campaigns (CIAM, 2007b). While costs continue to deter people from purchasing ITNs, there has been minimal movement on eliminating this factor.

Intermittent Preventative Treatment

During pregnancy, malaria has an increased risk of adverse consequences. Normal presentation of the disease may occur, but the parasite may sequester in the placenta, causing complications to the fetus. Common complications include abortion, stillbirth, congenital infections, and intra-uterine growth retardation (DOSH, 2006b). To prevent malarial infection in pregnant women intermittent preventative treatment during pregnancy (IPTp) has been implemented. The standard regimen is a therapeutic dose of sulfadoxine-pyrimethamine (SP), commonly known as Fansidar, twice during pregnancy. The first dosage is administered after 16 weeks of gestation and before 28 weeks gestation, and the second dosage is administered from 28 weeks gestation to 34 weeks gestation. Proper administration to the women is ensured during scheduled ante-natal clinic appointments (DOSH, 2006b; RBM, 2005; The Global Fund, b; WHO: Regional Offices for Africa and Eastern Mediterranean, 2006).

            In line with the national Malaria Control Policy goal to provide effective IPTp, The Gambia is working towards ensuring all pregnant women receive adequate care, which is influenced by the potential access and antenatal services available (CIAM, 2007a). According to the Global Fund report, 31 clinics in the coastal region of Gambia have implemented IPTp since 2004, and 37 clinics in the remaining regions have implemented the program since 2007, which accounts for 84% of the health clinics in these regions. In the coastal region, 51,700 pregnant women have been on IPTp since 2004, which is far above the goal of 29,600. In the remaining regions, 7,266 pregnant women have been on IPTp since 2007; however, the goal was for 20,025 pregnant women to be receiving the intervention. A common hurdle that must be overcome is pregnant women’s reluctance to take Fansidar. Many women have inadequate knowledge about the benefits of Fansidar and believe that it is dangerous to take during pregnancy. Desensitization is necessary to teach the community, specifically women, the benefits of taking the medication (DOSH, 2006a).

Recommendations

As technology continues to increase worldwide, new methods need to be implemented in the monitoring and surveillance of malaria within The Gambia. Low levels of data collection need to disappear and be replaced with detailed reports about the actualization of the effect of malaria on the Gambian population. Research also needs to be available to better identify what methods of intervention and prevention are most beneficial towards eradicating malaria. By identifying these methods, money can be properly budgeted and allocated to the accurate programs. Further research needs to be completed on the affects of IRS on the communities and environment to ensure that no damage is occurring. An increase in the monitoring of the distribution of ITNs is necessary to make certain that all members of vulnerable populations are being properly protected against malaria. Due to high levels of poverty, changes need to also occur in the access of ITNs by the general population that does not qualify as a vulnerable person. An increase in IPTp needs to occur by an increase in education about Fansidar, and the importance of ante-natal clinic visits needs to continue to be promoted.

Conclusion

As The Gambia continues to develop and progress economically, the people will begin to confront new and further dilemmas. However, the devastation of malaria will continue to be felt until proper control can be gained over the infectious disease. Through the assistance of organizations like Roll Back Malaria, the United Nations, and the Global Fund, the government of The Gambia will hopefully one day be able to state that malaria no longer exists amongst their population. The eradication of malaria will continue to be, not only Gambia’s vision, but countries across the world that continuously struggle with the disease. Unremitting and constant research needs to occur until a solution to the malaria epidemic can be found. Promotion of the ideas that will eliminate malaria needs to exponentially grow in hope that one day malaria will no longer be existent around the world.

References

Center for Innovation Against Malaria. (2007a). Annual Report 2007. Banjul, The Gambia.

Center for Innovation Against Malaria. (2007b). Facts and figure for debates in the National

Assembly on malaria. Banjul, The Gambia.

Department of State for Health and Social Welfare. (2003). Malaria control policy. Banjul, The

Gambia.

Department of State for Health and Social Welfare. (2006a). Messages on the prevention &

control of malaria in pregnancy in The Gambia. Banjul, The Gambia: National Malaria Control Programme.

Department of State for Health and Social Welfare. (2006b). The Global Fund to fight AIDS,

tuberculosis and malaria: Guideline for intermittent preventive treatment (IPT) in The Gambia (2nd ed.). Banjul, The Gambia.

Khan, N., Lai, A. Epidemiology. Retrieved July 9, 2008, from Brown University, Malaria

website: http://www.brown.edu/Courses/Bio_160/Projects1999/malaria/malmain.html

Roll Back Malaria Partnership. (2000). The Abuja Declaration and the plan of action. Geneva,

Switzerland.

Roll Back Malaria Partnership. (2005). Global strategic plan: Roll Back Malaria 2005-2015.

Geneva, Switzerland.

Rosenthal, P.J. Malaria. Current Medical Dx & Tx. Retrieved July 9, 2008, from the Access

Medicine database.

The Global Fund. (2008a). Grant performance report: Gambia (No. GMB-304-G02-M).

Geneva, Switzerland.

The Global Fund. (2008b). Grant performance report: Gambia (No. GMB-607-G04-M).

Geneva, Switzerland.

The Global Fund. (a). The Road to the Fund. Retrieved July 9, 2008, from the site:

http://www.theglobalfund.org/en/about/

The Global Fund. (b). The Status and impact of the three diseases. Malaria (pp. 34-45). Geneva,

Switzerland.

United Nations. (2006). Measuring progress in least developed countries: A statistical profile.

New York, NY: Office of the High Representative for the Least Developed Countries,

Landlocked Developing Countries and Small Island Developing States.

United Nations Development Programme. (2007). Human Development Report 2007/2008. New

York, NY.

White, N.J & Breman, J.G. Malaria. Harrison’s Online .Retrieved July 9, 2008, from the Access

Medicine database.

Wiseman, V., McElroy, B., Conteh, L., & Stevens, W. (2006). Malaria prevention in The

Gambia: Patterns of expenditure and determinants of demand at the household level.

Tropical Medicine and International Health, 2, 419-431.

World Health Organization. (2006). Malaria vector control and personal protection (WHO

Technical Report Series No. 936). Geneva, Switzerland.

World Health Organization. (2008). Global malaria control and elimination: Report of a

technical review. Geneva, Switzerland.

World Health Organization: Global Malaria Programme. (2006). Indoor residual spraying: Use

of indoor residual spraying for scaling up global malaria control and elimination. Geneva, Switzerland.

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African Region: Basic indicators 2006. Geneva, Switzerland.

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Africa Malaria Report 2006. Geneva, Switzerland.

 Welcome to my blog! The entries are many, and most of them long, but they only begin to document the thoughts, feelings, and experiences from each day of my trip with the Brueggeman Fellowship. These are the pages of my journal. I have included nearly everything–even thoughts I am ashamed of, indications of lessons not yet learned, not to mention grammatical flaws–in order to share some of the fullness and human-ness of my trip. You are welcome to read all or as many of them as you would like. Here are a few in particular, depending on your time and interest…

• Lessons Learned… July 12, 2008
• Friday, June 13, 2008
• Monday, June 16, 2008
• Sunday, June 22, 2008 - St. Al’s Festival
• Tuesday, July 8, 2008 - Safari

 I spent exactly four weeks at Hekima Place, a home for girls in Karen, just outside of Nairobi, Kenya (www.hekimaplace.org). Most of these girls are orphaned because of HIV/AIDS. I also helped with French and English at Hekima Primary School.

 I cannot speak highly enough of this opportunity. It taught me life skills and lessons–independence, self-initiative, cultural appreciation, openness, and more–that will carry over into the rest of my life.

I am forever grateful to Dr. James Buchanan, of Xavier University’s Brueggeman Center for Dialogue, who developed this program and supported my project in its entirety, guiding me through the process. This gratitude extends to Cynthia Cummins, who also works on behalf of each of the Fellows, helping with the details of our projects and always sharing her listening ear. These two people were our greatest advocates and the reason our lives will be forever directed toward a whole and just world, in which we are free to live and learn. 

I am grateful to Jean Skoblar, whose stories about her trips to Kenya inspired me during my high school years and planted the seed for my own desire to visit there. My deep thanks must also go to my family and friends for their openness to learn along with me and their love and support.

Finally, to the wonderful people at Hekima Place and Hekima Primary School… it is because of you that this was more than a trip, and I hope to visit again someday.

With Love & Baraka (Blessings),
Jenny Makena

Being a parent is the most important job that a person can have. It has the greatest impact on a human life and, consequently, on humanity.

This has been my greatest lesson on this trip. If I have taken anything away from this—which I have, many things—then this is it. These young women and girls whose paths I have been blessed to cross have taught me about the fragility and strength of the human person, heart and soul. I have fallen absolutely in love with them, and in so doing, I have also glimpsed the pain and heartache and incredible joy that come with loving a child. I am not a parent myself, so I can only imagine how much more intense it must be, but I imagine that the experience is quite like is often said—it is like a piece of your heart is constantly walking around outside of your body. The experience of saying goodbye to them was quite difficult. I absolutely miss them and have been crying the whole of takeoff.

I know I must go, however. There is a time for everything, as one of the students at
St. Martin’s Boarding School read today. It is better to leave on a good note anyway. Another thing I feel so strongly in my heart is that I must do something. I must stay connected to

in the near future. Furthermore, I must act on all of this in the
U.S. as well. Maybe I will work with orphans there. Maybe I could be an advocate for abused children. I don’t know exactly where it will take me, but I do know that my fire for this advocacy has been ignited, that I have what it takes, and that I have a heck of a lot of LOVE to give. Truly.

I also think that this experience has pointed me in the direction of Social Work, particularly with orphans and/ or mistreated children. I also want to adopt kid(s), as well as have my own, and be a good parent. My vocation will be to LOVE, especially in creating a home and family for everyone I can. I must do this.

Paris drained me. Spring 2007 in
Europe, though wonderful in many ways, did not feed my calling or my mission of becoming a woman for others. Summer 2008 in
Kenya has done completely the opposite. I feel alive with purpose and goodness. I feel loved and so capable of sharing love. I have seen my natural inner and outer glow return. I have spread sunshine.

gave me the Kenyan name Makena, which means “joy/ always happy” in Kikuyu. I will live out my name and share it with the world. I was born to celebrate life and to spread the celebration.

I return home now in thanksgiving, in trust that God will care for these hearts and minds that I have physically left behind, and in faith that He will provide opportunities to follow this vocation that is placed on my heart.

The flight from
Nairobi to
Paris overnight, as well as the flight from
Paris to
New York, were pretty long, and I didn’t get much sleep. It’s nice to be back in
France for a bit and hear and see French again. I not only cried during take-off in
Nairobi, but also during landing in
Paris. I felt so energized and happy in
New York! I felt great. I had a smoothie and scone for lunch, washed up, chatted with a motivational speaker about her job and how you can make what you want to do/ be in life (recurring theme), and waited for my plane. I had to switch planes because the PA system was not working on the first one. We left one hour after we were supposed to have arrived in
Cleveland! Yikes. A nice woman on the plane let me borrow her phone to send a text. I loved
Kenya, and I love traveling, but I am loving being an American citizen in
America today.

I woke up at approximately 8:45 a.m. and packed. Mum Gladys insisted that I come with her and other volunteers. We went to
St. Martin’s Boarding School for their annual parent meeting, as well as to celebrate Purity’s birthday, and see her and Jane. It was in Kangemi, a shantytown. I was anxious to get back and be with the girls. When we got back, Sara, Christie, Eunice, and Ann helped me look for my lost cell phone. We all danced and hung out before having dinner in Baraka. Afterward, there was ice cream, cake, singing, dancing, and speeches! (Grace Muthoni was the MC, Ann from standard 6, ? from standard 7, Beatrice Njoki from standard 8, Leah, Coletta, and Fiona from forms one and two, Mums Jane and Gladys, Sara, Christie, and Emily.)  Mum Gladys and the girls gave me the Kikuyu name Makena, meaning “always happy or joy.” We took pictures. The Maisha girls sang to me. I comforted Njoki, who couldn’t come to the airport. I got hugs goodbye from everyone. (Ironically, “Stand by Me” was playing and being sung at a couple of points today.) Gladys, Lovi, Elishpa, Beatrice from class 7, Maggie, Linet, Nancy Atieno, two other girls from Maisha, Dorcas, and Ann all took me to the airport. I got two hugs each. J I started crying as they left, which Ann sort of smiled/ laughed at. J Grace Muthoni wrote me a goodbye letter—so sweet!

In line and getting to plane, talked with an American from Georgia who travels all over for his work with the military. I sat next to a Frenchman from Marseille at the beginning of the plane ride.

I spent the whole day at

. In the morning, I helped clean the kitchen in Baraka and cut veggies (yuck… onions) for cooking. I took pictures, visited the shamba, and got a wheelbarrow ride. Miriam told me that I was heavy and had eaten too many chapatis the night before. J I asked Grace Muthoni (head girl at HPS) to help me bake cookies. Sara also helped. There were many people in Baraka’s kitchen, including Mum Grace, who wanted the oven to bake Purity’s birthday cake. I baked and passed out the cookies with Eunice. I bathed and changed into my African outfit. J We went to

Karen
Center, where I went to the ATM and also said goodbye to Lisa. Later, I said goodbye to Sr. Uche. We picked up the Karen C girls, and I gave them cookies. Mum Gladys let me finish interviewing her before dinner. We ate supper (githeri). I invited Baraka girls to Amani to dance and listen to music while Maisha watched a movie (”Herbie”).

Ann gave me her CRE notebook today with a letter slipped in it! It was really cool, and I was so happy, because she said she enjoyed our talk last night. She also sat next to me toward the end of supper and helped me finish my githeri. What a sweetheart. She and some other girls listened to my MP3 player and danced. She is getting really good at the “Bop to the Top” dance and singing, too. She even came out of her shell a bit and was dancing it in the open when her peers were in the room.

Mum Gladys let me finish my interview with her today. She shared with me her hopes for

staff attempt to do this holistically, making sure the girls have their needs met, including spiritually. They attend their respect religious services—Catholic, Pentecostal, and Anglican (the Anglican Church of Kenya, or ACK). Mum Gladys added that almost all of the children have been mistreated before. As of July 2008, there are 48 girls (including Emma), three uncles, and eleven mums, as well as little Johnny. Emma is in college, but she has not been able to raise enough money for the tuition and may have to take a break (200,000 Kenyan shillings per year?).

When I asked what I can do, as well as friends and family back in the
United States, to support

as a whole. Individuals and groups have chosen to sponsor big projects, such as the most useful borehole recently put in. (I can speak as a visitor that it truly has made an incredible difference there.) Finally, there are two boards—one in the
U.S. and one in
Kenya. The Kenyan board serves as the advisory board. The
U.S. board “runs this place,” as Gladys explained, dealing with the financial upkeep and sustainability of this home for girls, averaging about $11,000 per month this year.

At

Hekima
Primary School in the morning, I announced contest winners and gave out sweets. My, how Kenyans love sweets! J I gave one sweet to the young man who takes care of the grounds. He looked so happy later when I saw him opening it.

Christie and I ran to

Karen
Center. Sam took me to a shop and then to the Bomas markets. He helped me bargain for souvenirs. Then Nakumatt for cookies and back to HPS, where the students were busily cleaning for the annual parents’ day tomorrow.

Teacher
Virginia put together a thank you/ goodbye party for me! It was so nice! They had cookies, chips, sweets (of course), cake, and an orange drink. Mr. Maranga wrapped a gift and gave me a card on behalf of everyone (a beautiful scarf). They went around and said thank you/ good luck. I also gave a small speech and started to tear up. We were laughing because Teacher Virginia said that, as the hostess, I had to “keep my mouth busy” (keep eating) until everything was gone. Also, when Charity said that she has a young, unmarried brother, Tr. Virginia piped up, saying that she has already booked me a Maasai man (according to tradition, the soda and bee incident from last week indicates that I will get married in Kenya; she is married to a Maasai).

I helped Charity, Esther, and Rose with pronunciation, after saying goodbye to the teachers. Lovi and the Karen C girls picked me up. At

, I played cards with some of the girls before chapati dinner! After dinner, I talked to Sara about culture shock, while I hung up my laundry. Then, back at Baraka, I hung out with some of the girls.

Ann asked if we could go over to Amani then to practice “Bop to the Top” some more. I had asked her before dinner if she would tell me sometime about her life before HP. She asked for another set of lyrics to “Bop to the Top” because she didn’t have the original I gave her. She got rid of them when she was mad that one day. I didn’t get mad at her for it, but I asked her not to get mad like that at me again (not sure if that was a fair request). There was no use in making her feel badly about it. She has enough on her plate, and I know how much she appreciated them at first.

We went into Amani, and I suggested we talk, then sing, then dance. We never got to the singing and dancing. We talked until around 9:00. I told her Mum Gladys said she’d be open to sharing, and I asked her if she would. She said it is a long story, but she’d try to make it short…

I journaled the entirely of my conversation with Ann that night. Her story is incredible—one of great sadness and loneliness, but also one of hope, a testament to that Higher Power I call God looking out for one of His little ones. I would call it a miracle. However, after much reflection, I have chosen not to share that story here. Ann has asked me to respect her secrets, and after all, it is not my story to tell. I can say, however, that it has moved me toward greater compassion and understanding. I am grateful to her for sharing with me courageously and openly. Ann’s life has widened my appreciation for the story, and the miracle, in everyone.

We woke up at 5:30 a.m. for 6:00 a.m. breakfast and 6:30 a.m. morning game drive. It was so cold! But we saw the sunrise behind the hills, and it was awesome. We saw lions, ten feet from our van, eating a zebra. We saw hippos. They look so mean. The morning was great (game drive and breakfast). The ride back was awfully long, bumpy, hot, and uncomfortable. We made several stops along the way. Finally, we got back around 4:45 p.m. and rested a bit.

I went to Maisha, and Leah showed me the upstairs area for the high school girls. It was so cool! They have a sweet space. Leah and I had some great conversation. She wants to be a nurse or doctor and go to university in the U.S. However, she absolutely loves acting and “dramatizing to music,” as she says, so she was so excited to learn that she could study theater there. I told her about Jackie. She would like to meet her. I’m going to try to find a show we can all go to when she and Beatrice come to the
U.S. in December.

After having dinner in Maisha and hanging out with Edith, Flo, and some of the other girls, I chatted with Mr. Maranga and Sr. Uche outside about single parents/mothers and what’s happening to the family unit. Later, I talked with Mum Gladys in Amani, regarding a problem with Sara and Emily spending so much time with Michael. Also, we talked about some of my questions, particularly relating to the girls. She mentioned Ann specifically, saying that Ann would be very open to telling me about her life before Hekima Place and that Ann has been through counseling and went through a period where she felt like nobody loved her. Gladys said it was very sad. I am so sorry that I did not know it was okay to ask her before. We’ve had so many opportunities!

(This part added later.) I had a hard time not crying last night when I entered Baraka. I am sad to leave in a few days. I helped the girls with some things and mostly just hung out while they finished homework/ before they went to bed. I hugged Ann and thanked her for her card. She was happy that I liked the stickers! J She said goodnight before going to bed. Some of the other girls and I hung out and had a good time together.

After my shower, I called Jackie to try to get hold of Mom. I frightened her, which I’m sorry about, but I needed to talk about my sadness about leaving and my confusion about the struggles these young women at

have been through. After talking with Mom, Mom sent me a comforting e-mail. I read and chose writing contest winners, prayed, and went to bed.

As Christie and I were getting ready to leave for safari, Madina knocked on the door, handed me a letter, and said, “Ann asked me to give this to you.” !!! It was so sweet and such a great surprise! Ann wrote me a letter before I left for safari! J It made my morning.

Kashu (pronounced “cashew”) picked us up, and we were on our way. We took the same route as when class 8 went to Naivasha. Christie and I were a little freaked out at times, but we have mostly laughed. We stopped at an escarpment to overlook the Rift Valley. Later, we stopped at a Maasai community market/ shop that had toilets and toilet paper! It was amazing. J The sellers wouldn’t bargain much, though, so we left. The last hour we spent driving on a super bumpy road. We wove through random dirt roads up hills until we ended up at a campsite in the middle of nowhere. We were comforted that Spurwing’s site was nearby. Seriously, there was no one here. The bar was empty. The only people here were a couple of Maasai guys in western clothes, Kashu (who isn’t explicit about plans), and us–two, single, young white women. Hmm. I think we were both freaking out at this point. But there was nothing we could do, and we had to have faith.

Our tent is called Simba. It’s actually really nice! We have two beds and a bathroom, complete with hot shower, sink, toilet, and toilet paper! Alleluia! And, p.s., the shower I took after dinner was one of the most comfortable, warmest, and loveliest showers ever. Mmm.

We had an awesome lunch at the site with Kashu. Then, Christie and I rested on our patio (so nice), playing cards, talking, and reading students’ compositions for the writing contest. We headed out for our evening game drive at 3:15. A Maasai friend of Kashu, David, joined us. The Mara is gorgeous and EXPANSIVE! We saw tons of zebra and gazelle, as well as elephants, lions, giraffes (even babies), topi, hartebeasts, wildebeasts, buffalo (or “boofalo,” as they call them), a hyena, ostriches in the distance, birds, and vultures. It was the perfect day for it!

We came back and had supper around 7:30 p.m. First, we sat around a campfire, chatted with Kashu, and looked at the most perfect star-studded night sky. Dinner was so delectable. The beef’s flavor was amazing. They even turned on music for us. Oh, and I forgot to mention that we got two wazungu neighbors! That makes us feel better. J Now we are showered and getting ready for an early-morning game drive.

Some of what I learned today:

• At around age 50, elephants go off by themselves, because they can no longer keep up with the pack. Elephants live to be about 60 or 65.
• Lions are best around age five or six. They live for about 14 years. One of the lions we saw had a giant gash on one of its hind legs.