Making the Link – Population, Health and Environment

As well as understanding the medical services and the need for them, I was also keen to understand what was happening to the environment, particularly the wild animals. Every morning we were woken by monkeys chattering happily in the trees over the campsite, but the vast majority of the animals that I saw were domesticated.

One morning, John took me for a drive up the dry river bed to see what wild life we could find. As we drove we seemed to pass small herds of domesticated animals every few minutes, mostly goats and camels, but occasionally sheep and cattle and almost all tended by children.

We stopped at one of the rare water holes where a man was bringing up buckets of water from about 2m below ground level into a trough for a herd of a hundred or so goats, tended by three undernourished children aged about 9–12. However, what truly amazed me was what I saw 100m away. Along the luggar bank and hiding from the sun under a big tree was another small herd of goats, looked after by a girl who looked no older than about 10, patiently waiting for their turn to be served at the water trough.
Four legs and queuing for a drink

An old man told us that some elephants had been seen that morning and pointed us in the direction they went. We duly found five and I got some wonderful photos – with one of the locals getting me in a good position for photos and another half dragging me back to the Land Rover for safety reasons. A great experience for me, but I couldn’t help thinking of the thousands of elephants that used to roam across the nearby plains.

The only other wild animal we saw that morning was a baboon – a situation not unlike the UK where we are used to seeing so many fields of cows and sheep and just the occasional fox. At least our herds are protected by fences and hedgerows instead of by undernourished child shepherds who have no school to go to. All this reminded me of the figures from the WWF Living Planet report, which showed that globally, wild life animal populations have fallen by more than 50% in the last 40 years. In contrast, United Nations reports show that in the same period, the human population on Earth has doubled. What are we doing to our world, whether it be Africa or Europe? Humans currently make up 32% of the global biomass of vertebrates with wild animals now less than 5%, the rest being livestock bred for human benefit.

For many Samburu men, having lots of children gives them high social status. Recently, a researcher from University College London (UCL) carried out a survey on the attitudes of Samburu men in rural areas within the communities reached with CHAT PHE services, with a particular focus on the relationship between environmental problems and family size. This programme involved focus group discussions and semi structured interviews and revealed support for environmentally–sensitised family planning promotion. These men highlighted their dependence on natural resources and challenges faced in providing for large families and maintaining livestock during droughts. They realised that these practices lead to natural resource exhaustion, environmental degradation and wildlife dispersal, undermining the key economic benefits of environmental and wild life conservation. The researcher concluded that relating family size to the environment is a compelling strategy to improve support for family planning among Samburu men.

The PHE approach is getting increasing attention in many developing countries and was highlighted at the recent Global Summit on Family Planning in London (FP2020). CHASE Africa, which started out in Kenya with tree planting, has taken this approach – matching the focus on the environment with a focus on family planning and women’s rights with support for programmes run by CHAT, Dandelion Africa, the Mount Kenya Trust and an expanding number of other centres in East Africa.

It is encouraging to hear that men are responding in this way as it is my experience to date that most women in rural Kenya want to hide their use of contraception from their husbands, as their husbands just want as many children as possible. The culture in many parts of sub-Saharan Africa is for the men to make the decisions on family size, and it is my understanding that discussion between partners on this sensitive subject is often limited. These research results suggest that a holistic approach bringing together family planning and environmental conservation is a good way of showing what can be achieved in terms of better nutrition and providing more opportunities for education, jobs and improving the general quality of life. It is a way of encouraging men and women to discuss related problems together. This approach has worked extremely well for the Blue Ventures programme in Madagascar which combines marine conservation with family planning in small, coastal communities.

I was only able to stay with the team for a few days, so arranged for a small aircraft to pick me up to fly back to Nanyuki. The airstrip was on a bare hill top with no more than a windsock, a “T” on the ground, one tree and a tiny, grass roofed shelter. As we flew away I was very conscious of how dry the area was, with any water at all in only one of the river beds I could see, and of the difficulties the local people had getting adequate supplies of water for themselves and their animals in the dry season.

It was sad to think of the disappearing wild animals with the likely loss of future jobs in ecotourism, the father who cried because he could not support even one of his 10 children through school, the women who were so anxious to stop having more babies, but felt unable to talk to their husbands about the problem and the many, many, often poorly nourished children: some just sitting around with nothing to do, slightly older ones tending their animals, with little prospect of school. I sincerely hope that the PHE (Population, Health and Environment) programmes undertaken by organisations like CHAT can give these communities the knowledge and support they need to help them develop sustainable and rewarding lives for themselves.

The work of CHAT in Samburu areas is effective and greatly appreciated by the local communities. Michael, one of the most experienced mobilisers, visits primary and secondary schools in the region every few months to give talks, show videos and lead discussions on key topics like HIV, family planning and the environment, helping the young people to understand what is going on and helping them to make their own decisions about what can be done. Nevertheless, getting the message to the many rural communities yet to be reached by such programmes of the benefits to themselves and their environment of conservation efforts and smaller families is a huge challenge.

Let us hope that these programmes can be expanded and many more comparable schemes can be developed throughout Kenya and indeed throughout the whole of Sub-Saharan Africa. As education and understanding of realities improves, so the barriers to the changes that can bring such benefits to the quality of life of so many people are slowly falling.

* Int. J. Environ. Res. Public Health 2017, 14(5), 528

Elephants!

A baboon

Fetching water for the herd

Queuing for a drink

Departure lounge…

The Airplane

Tales from the Sand River

Patients came down from surrounding manyattas (traditional homesteads). One woman brought a very sick baby only a few months old with a chest infection. As soon as the baby had had the first antibiotic injection, she handed him to Michael, the most experienced of the local mobilisers, and sat down to have a LARC) implanted under the skin in her upper arm, a simple, five minute procedure with a little local anaesthetic. She was so anxious about the baby that she sat with us for four hours so the next dose of antibiotics could be given by injection rather than just taking the medicine to give to the child by mouth back at her home.

Another patient was a girl aged about 15. She had been married at the age of 12 and had one child aged 10 months. She came with her husband (a refreshing sight) and chose to have a three month contraceptive injection. Another lady, aged about 27 (she wasn’t sure of her age) had four children and wanted a LARC to prevent further pregnancies. However, she was very anxious that her husband should not find out as if he did, she was sure he would beat her. A sobering thought, but a United Nations survey of women in Sub-Saharan Africa showed that just over 50% of women living in rural areas (and just under 40% of men) consider that it is acceptable for a man to beat his wife for at least one reason.

Jane is a young woman who came down from her manyatta because she wanted to help with the clinic. We all thought she was single, but it later turned out that she had three children, the youngest one being only a couple of weeks old, so she had to nip back to her home at frequent intervals to breast feed the baby. Later, Michael took me to visit her manyatta, which consisted of three grass huts. Her husband has two wives and the first wife had a hut for her and her six children, Jane had a hut with her three children. The third hut was the village shop, run by her husband. Despite being in a grass hut, it looked well stocked, neat and organised. It was the only communal building I saw in the village. Despite her domestic commitments, Jane joined the clinic team with enthusiasm and I was later pleased to sponsor her basic training as a mobiliser. I’ve recently heard that Jane now works as a Family Planning CORP, with CHAT supporting her ‘back pack’ door to door PHE mobilisation work.

Some villagers came down to the clinic just out of curiosity or to be sociable. One elderly lady kindly agreed to have her photo taken with me. She took one look at the photo and said I looked as old as her (cheeky, but she was probably about right)!

The next morning, we drove along the luggar to set up another mobile clinic for different manyattas. The striking image on arrival was seeing eight children squatting under a tree. The oldest can’t have been more than about nine, and two who looked no more than six or seven, were holding even littler ones. They were just sitting there, nothing to do, no adults in sight, so were delighted when Pauline and Rose joined them for a few minutes. Adults did, of course, come to the clinic. The most memorable was a local policeman, who brought his wife, who had four children. He thought that was enough and that she should have a LARC, which she did. Then he mentioned that he had also brought his second wife, who had two children and asked for her to have an implant. At the end, he casually mentioned his third wife. She only had one child, so he saw no urgency for her to have an implant and did not bring her to the clinic. This was a relatively small family (many have more than 10 children) and it was even more unusual that the husband should bring his wives to the clinic. I never understood how some men could have so many wives, without leaving other men with none! This may be partly explained by the Samburu custom that Morans (young men in the age group 18-30 who have gone through their initiation to manhood, which includes circumcision) often leave their village for lengthy periods to look after the animals and do not marry until they return from this period of their lives.

Sitting around the camp fire, I heard interesting tales. One story concerned a lady with four children who wanted no more, so had an implant, without telling her husband. Two years later he was concerned that she had not got pregnant again, so took her to the local witch doctor. His advice was that to get pregnant again, she should be smeared with the droppings of a black goat. She sighed and complied, then slipped along to the hospital to have her implant removed. She duly got pregnant again, so hubby was happy, but nipped back to the hospital soon after delivery to have the implant reinserted. Another woman wanted an implant, but her husband, who was with her, was reluctant. First she had to provide a urine specimen to be sure she wasn’t already pregnant. She went out to the bushes to produce a specimen, but when she came back in she said she had lost her purse. She asked her husband to go and look for it – plenty of time to insert a LARC before he got back. Tales of illegal abortion were often disturbing. One rough, physical method, described in gory detail and involving strategic kicks and abdominal pummelling, has been associated with rupturing of the womb and other internal abdominal injuries. It’s not surprising that such actions can lead to fatalities, but the demand for illegal terminations is so high, especially for young, unmarried girls, as the local custom is that they cannot marry if they have had a child and there are no safe, legal abortion options available to them.

The CHAT team is typically on the road (or should one say struggling across wild country) for about three weeks at a time. In some areas, not even Land Rover access is possible, so the team travels by camel train, but inevitably, this dramatically increases journey times, so the area covered is smaller. Clinics are held almost every day and on some days, up to 80 LARCs may be inserted. I have enormous admiration for all the team. Everything is done in a wonderful, cheerful manner under very basic conditions and their services are so greatly appreciated by the local people. There is a catholic mission quite close to Loikumkum, but the priest is usually away when clinics are held in the area.

A typical Manyatta

The Children waiting near the clinic

Michael holding the sick baby

Making use of the facilities

She said “I looked as old as her”…

From Nanyuki to Loikumkum

Nearly three quarters of Kenyans still live in rural areas, where the infrastructure is often very limited, especially with regard to health services and travel. CHAT (Communities Health Africa Trust) is a community based organisation based in central Laikipia, close to the foot of Mount Kenya. They provide integrated mobile Population, Health and Environment (PHE) services, with a focus on innovative family planning and a strong component of environmental awareness. CHAT targets slums as well as other urban, rural and remote areas. I was fortunate enough to spend a few days with the CHAT team in the West Ndotos in Samburu in northern Kenya – an opportunity to see for myself what life is like in an area so far from any major city or town, understand the needs of those who live there and see what is happening to the environment, particularly in relation to the still rapidly increasing population.

With three of the team, led by Shanni Wreford-Smith (CHAT’s director), we set out from the office in Laikipia at 5.00 am. The pre-dawn drive along barely discernible rough tracks was enhanced by glimpses of a range of animals, particularly the striking silhouette of a giraffe surveying us with interest as dawn approached. With sunrise, the beauty of the open countryside was revealed, with little sign of civilisation for the next four hours. Crossing a river was a novelty. One of our team had to remove his shoes and wade across to assess both the depth of water and to exclude the presence of any large stones that might strand our Land Rover. He did a good job – we drove across the river with ease and I didn’t even get my feet wet. In due course, we reached Maralal, a small town which is the capital of Samburu county, to meet up with the other half of the team. Maralal has about 500m of tarmac road – the only surfaced road I saw in Samburu territory. I moved to the Land Rover of John Wreford-Smith, (age 86), who had been the government custodian of the forests in northern Kenya over half a century ago.

The challenging drive continued, this time with a heavy trailer loaded with fuel and supplies for the team for three weeks, bumping along a steep, rugged track. The mountain peaks in that area go up to 2500m, but there was good agricultural land at the mid-levels with flourishing crops of maize, wheat and beans – much greener than at the lower levels, which were very dry. Then we descended through a forested area to the plain where we were close to the border between the Samburu and Turkana tribes, an area with a notoriously insecure history. In 2012, Turkana tribesmen had rustled cattle from a Samburu area, but when police chased them into Turkana territory, 40 police had been massacred. John told me that when he first lived in the area, there were thousands of elephants on the plain. On that day, all we saw was one ostrich. The vegetation was mostly sage brush, but at least that is good camel food.

Eventually we reached our campsite on the banks of a broad but dried up sand river – the Loikumkum luggar – flat, spacious and plenty of shade for our comfortable tents. I had a small but modern and luxurious tent on my own. They told me that on a previous visit there, some people were woken up in the middle of the night by an odd rustling noise, only to discover elephants scratching their backs against the trees! A little spontaneous night running was required. We did not have the privilege of such a visit, but elephant droppings were certainly there. They also told me that on another visit, flood waters in the night rose to within a few inches of the level of the camp and they nearly had to pack in a hurry and move up to the local village, Loikumkum, a 10 minute walk away on higher ground.

Our cooks were outstanding. Vegetables were purchased en route and on one occasion, the goat for dinner was purchased by negotiation with one of the young shepherds tending their flocks along the river bed. One of the cooks would do the rounds to gather everyone together from their tents at meal times. A touch reminiscent of UK traditions was a small boy coming down from the village each morning with a churn of fresh milk. Established ablution facilities were distinctly limited, but making do was not a problem.

In Loikumkum, there were a few solid huts, but most people lived in grass huts spread out over the gently sloping ground. I was introduced to James at his home. He was 17. He was one of 10 children. Two of his older sisters were married, but the other eight and their parents lived in a grass hut about four metres in diameter. He was the only one at school and he wanted to be a journalist. He was at home as teachers were on strike at the time. To get to school, he had to walk for a day and a half, to Baragoi. He said his father was in tears because he was not able to support even one child at school. The dowry from the wedding of one of his sisters was helping to pay his school fees. He did get some support from the school and other sponsors. I do hope James gets the chance to realise his ambition. I was delighted to hear recently that he has now graduated from High School and has been offered a place at University. The younger children worked on tasks like looking after the domesticated animals. James himself was very conscious of the problems of looking after large families and felt that families should only have the number of children that they can support. I suggested he might help with the medical team, which he did with enthusiasm for the rest of the time I was there.

The clinic was held on the river bank. It consisted of a table and chairs for consultations and treatment, a small tent for privacy, when required for examination, and another table for the “pharmacy”. A reasonable selection of common drugs was available. There was only one nurse, Pauline, in uniform, assisted by several mobilisers. Mobilisers, known locally as community own resources persons (CORPs), who act as the link between CHAT and the local communities, have some basic health and environmental awareness training. They usually go door-to-door before a clinic to tell those in local villages when the CHAT team is coming and what services will be available, particularly providing information on family planning options. Most women prefer long acting, reversible contraceptives (LARC), either an implant inserted under the skin in the upper arm, which can last for 3 years or an injection, which lasts for 3 months. A few like the contraceptive pill, which is less convenient as it has to be taken every day, or for their partner to use a condom. Very few favour sterilisation or vasectomy. Pauline acted as a family doctor as other medical services were rarely seen in these areas. Rose, CHAT’s project officer, sat with an enormous book, recording all the procedures – a legal requirement. All those over 18 had to be tested for HIV and patients were also asked about any symptoms suspicious of tuberculosis (TB). If they did have symptoms they were referred to the nearest hospital for further tests. I understand that up to a third of such referrals are confirmed to have TB. Follow up of these patients is undertaken by mobilisers, in partnership with the government run Comprehensive Care Clinic.

The Team

The Campsite

Our morning milk

All you need…

James and Steve

The Clinic in Operation

Based on a grant from CHASE, our partner Communities Health Africa Trust (CHAT) have visited 45 communities in eight counties around Mount Kenya bringing family planning services and advice to areas in great need of their service. Over 7,000 people were reached over the two months of the outreach.

CHAT work with grass roots mobilisers who reach out to their communities with information and advice about family planning options. As well as family planning they also talk about environmental issues and encourage communities to think about the links between family size, the environment and resource scarcity: “It will help communities make informed resource allocation and distribution decisions in relation to their family size, influencing communal decisions and realising that their high population growth rate impacts negatively on the entire community. Men were especially receptive to this form of ‘logic’ thus bringing men and boys into the family planning conversation and participation.”

The mobilisers work closely with Ministry of Health “Back Pack” nurses who bring family planning supplies to the communities that the mobilisers have visited. In the most recent programme funded by CHASE, 39 mobilisers participated in the Back Pack outreach. Travelling on boda bodas between the communities (spaced between 10 and 15kms apart) they visited over 7,000 people in August and September.

In terms of family planning commodities distributed, 4,264 women were provided with contraceptives ranging from long-term implants to pills. According to CHAT’s meticulously kept records, some 55% of those who received a long-term method were new clients, and 73% of short-term methods were repeats. This second figure is particularly encouraging as it shows that CHAT’s outreach programmes are working, and working well.

Jane is one of CHAT’s mobilisers:
“When Jane, accompanied by her Back Pack nurse Fred, arrived at Soit Nyiro community in Samburu North on a boda boda, the community members were eagerly waiting for their services. [Jane had visited some days prior to tell them about the upcoming visit.]

The crowd was mainly made up of women and children waiting for the services in a nearby Manyatta [homestead]. Jane then spotted a group of men playing a game of ntotoi under a tree whilst enjoying partaking of their nkumbao [snuff] as women and young children go to look after the livestock. She took the initiative to talk to the men about family planning, integrating the information with environmental awareness. As she addressed them, they engaged her in questions on the relationship between the environment, their animals, family planning and family size.

An elderly man stood up and gave a story of how their environment used to be years ago: ‘In the old days, there were very many trees in the forests, wild animals used to roam around and rains were immense, but nowadays it is so open, you can see as far as Mt. Nyiro’.

After a lengthy discussion, they (the men) begun enquiring about the available methods of family planning, side effects and the time a woman would take before giving birth again. Samburu men from Soit Nyiro really appreciated the short discussion they had with Jane and promised to go and discuss the same issues with their wives.”

Jane commented on the impact of her visit: “Let’s always remember that a woman’s ability to decide on her own fertility is the bedrock of gender equality and economic empowerment.”

The counties that CHAT has been working in – August and September 2017

Map courtesy of d-maps.com – d-maps.com/carte.php?num_car=35011

We have received more news from our partner, Mount Kenya Trust.

“Supplies of family planning commodities are getting harder to source as the year continues. Ministry of Health hospitals have dwindling supplies and almost all short-term contraceptives are impossible to find. We are working hard with partners and the government to deal with the shortages.

During the month a total of 1,659 women received different family planning services. Of these women, 966 chose long-term methods, 693 chose short-term methods. A total of 21,930 male and 350 female condoms were distributed door-to-door by the mobilisers and during the clinics.

Njeri’s story:

Since her own shamba [Swahili word for a small plot used for growing subsistence crops and fruit-bearing trees, often including the dwelling of the farmer] is small, Njeri and her husband have to work on other people’s farms, mainly picking tea to supplement their income. Njeri is a 38 years old mother of three and comes from Embu, a village near Mount Kenya forest. Njeri has been married for ten years.

With no education, Njeri was married early and had her first two children in a span of three years. She admits that with the meager income they were getting from farming, raising her kids was a struggle and at times she would receive help from family and well-wishers. With hard times ahead, she then fell pregnant with her third born. Njeri started using the pill after her first two children. ‘My friends told me they use the pill so I did the same’, says Njeri.

Njeri says that she would at times skip the pill for months because she did not have enough money to buy the them or travel to her nearest clinics 15 kilometres away. She was amongst one of the first women offered a long-term method in 2014. She had a 3-year plan inserted. She has no aspirations of having another child and a few months before the method expires, she plans to have a 5-year (Jadelle) plan inserted this year.

‘I want to thank all the organisers and donors of the program for what they are doing to the community. As a beneficiary of the program, I have greatly benefited and I believed many other women would say the same’.”

We’ve had news from Gabriel Musundi, founder and CEO of Community Health Volunteers – CHASE Africa’s partner based in Kakamega, western Kenya.

There is an ongoing nurses’ strike in Kenya over pay and conditions that is affecting health services across the country. The current iteration of the strike began at the beginning of June, though there have been strikes going on for over a year now.

Lack of the availability of nursing staff has put increasing pressure on CHV’s mobile clinics – however, Gabriel is upbeat about the extra work that has come their way. A recent clinic in the village of Shimakondi near Kakamega was attended by 2,790 people – typically a clinic would expect to see between 600 and 1,400 people.

Of those 2,790 people, 298 women came for family planning services and commodities – this is a remarkable number.

Gabriel and his team are doing superb work reaching out to those who need their help during difficult times for the Kenyan health service.

We have recently received news from our partner, Mount Kenya Trus (MKT) of their recent mobile clinics in Embu County. Below are two stories gathered by MKT about their work.

Rebecca

When the Community Health Service Programme was started in Embu County, Rebecca, a 26 year old mother of three, was among the beneficiaries of the family planning programme.

Rebeccas say, “I had my first child when I was 16. Young and naïve I was a victim of early pregnancy and lack of information on reproductive health. I had my first born and in less than two years I was pregnant again. I took an initiative and got a family planning method Depo Provera which I heard from other women. I have been using the method for six years”.

Rebecca first learned about MKT’s mobile clinic from one of their Community Health Workers. Both are members of one of the women’s groups in Embu, which MKT works with on tree planting and rehabilitation of Mount Kenya forest. On attending the clinic, she was told about all the family planning methods available and given a choice – Rebecca chose a 3-year plan which she admits was the best decision she ever made on family planning.

The 3-year plan that she had inserted in 2015 has saved her quarterly trips to the facility, transport cost and hospital charges.

She commented that having family planning has enabled her to avoid unwanted pregnancies, raise and educate her children and has improved her relationship with her husband. Rebecca’s children are 10, 8 and 3 years old. She has no plans to have more children and her husband supports her decision.

Rebeccas promised that once her method expires she will have another long term method. With the information she got now, she can confidently visit a government hospital for any long term method. “I was so impressed and empowered by the services offered. I have encouraged several women to have a shot on the long term family planning method”.

Mary

Mary writes, “I have worked with MKT for 15 years as a member and a leader of one of the tree planting women’s groups. I was approached by an MKT official to join in and be trained as a Community Health Worker particularly focusing on family planning. I didn’t quite understand how family planning and conservation related. After training I got to fully understand the logic between sustainable families and conservation.

The first step I took was to educate the 100 women in my group on benefits of family planning and having a manageable family. Most women joined in the group to supplement what they get from the group with farming so they could educate, feed and raise their children. In my community women are the biggest contributors to the source of family income. Women farm, pick tea and manage most income generating resources.

With manageable families these hardworking women will be able not only raise and feed their kids but also have spare income to improve their lifestyle. To be an example I received an IUCD (intrauterine contraceptive device) during one of our outreaches. I feel empowered and I can confidently educate women and men on family planning and conservation. I believe that all the effort we are making will finally pay off. Where we will have an economically empowered society and a healthy forest altogether.”

2016 was a very exciting year. Our income grew by over 60% enabling us to expand our work in Kenya and to start our first project in Uganda. We have always wanted to expand our work into neighbouring countries, many of which have population growth rates higher than that of Kenya.

There are many excellent NGOs working to give people in Africa the chance to escape poverty, but not many acknowledge the link between poverty and access to family planning. We believe though that helping to meet the unmet demand for family planning is a positive way to give families a chance to escape poverty. With smaller families and longer gaps between births, everyone can be better nourished, access to education is improved, and the number of potentially dangerous, unskilled abortions is reduced. Smaller families require less food, water and firewood, reducing pressure on the environment. By allowing women to choose the number and spacing of their children, based on their economic and environmental conditions, the living standards and health of the whole family are improved. Can you imagine how difficult life would be with six children and an income of just a couple of pounds a day? This scenario is familiar to so many women in rural Africa. Enabling these women to choose how many children they want gives them hope and the chance to give their families a better life.

Currently there seem to be more and more stories in the press about population. So long the elephant in the room, the subject is at last being more widely debated. Perhaps the demise of the real elephant is finally making people realise that if we are going to save this iconic species we have to protect areas where it can live. A burgeoning human population needs more land in which to live and grow food, and wild places all over Africa are being turned over to agriculture. Indeed, many developed countries did exactly this many centuries ago – it would be incredible if Africa could avoid the same mistakes. Preserving space for the elephant to roam free is just one element of conserving and protecting Africa’s astonishingly varied habitats and biodiversity – a goal worth striving for.

Many scientists have been grappling with defining the limits of a sustainable population for this finite planet – a population which would give us all a reasonable standard of living. The UNEP’s report “One Planet, How Many People?” suggests that we are now at the limit of a sustainable population. The report goes on to say that despite fertility rates falling around the world we’re projected to reach a population of at least 9.3 billion by the middle of the century. Although fertility rates in general are falling, in Africa they remain high. If African fertility rates stay at today’s level the population of Africa will be 3.2 billion by 2050 and 16 billion by 2100. The key to Africa’s future prosperity – giving its citizens a chance of a lifestyle we take for granted – is helping to meet the unmet demand for family planning over the next decade.

News from our Partners

Choosing the right partners is key to delivering our work on the ground. In addition to continuing to support our existing partners we were pleased to start projects with two new partners in 2016, Community Health Volunteers (CHV) in Kenya and Conservation through Public Health (CTPH) in Uganda. Both these partners have benefited from help and support given by our existing partners.

Community Health Africa Trust (CHAT)

Community Health Africa Trust mainly operates in the remote northern areas of Isiolo, Laikipia, Baringo and Samburu counties where many people are semi-nomadic pastoralists who have poor access to healthcare. CHAT uses a variety of methods to reach their clients. Sometimes it’s a back pack nurse travelling on a motorbike, but when travelling further from base the trusted Land Rover is used. When the terrain becomes too challenging for wheels, a team of camels is the preferred form of transport.

In April 2016 some of CHASE’s funding was used by CHAT to carry out a two week motor mobile clinic in the east of Baringo County. Two weeks before the Land Rover set out, community health mobilisers travelled through the area creating awareness of the different health related services the mobile clinic would be offering and giving dates and locations for the clinics. In these remote, rural areas there are still many myths and misconceptions about family planning, such as family planning “causing infertility” or “reducing sexual desire”, “damaging a woman’s womb” and other health scares. It is the role of the mobilisers to discreetly talk about these issues, allaying fears so that when the clinic arrives more women will be prepared to try using family planning. During the two weeks that the Land Rover was out, 903 women chose to come to the clinic to receive family planning.

Community Health Volunteers (CHV)

We were introduced to Community Health Volunteers by a tree planting partner of ours working in the Kakamega Forest. CHV runs a private clinic on the edge of Kakamega National Park and was started by Gabriel Msundi who originally trained at the Kenya Wildlife College to be a tour guide. He is passionate about the birds in Kakamega forest and also about the health issues of his local community.

Gabriel built a simple clinic from two shipping containers in Virhembe Market in 2008 and now employs 27 staff who operate the clinic 24 hours a day, seven days a week.
In the latter part of 2015 Gabriel spent time with one of our other partners, Dandelion Africa, learning first-hand how they operate their mobile clinics. With the knowledge gained CHV carried out six mobile clinics in 2016. From a slow start things got busier, culminating with a clinic on Christmas Day which saw 210 women attending for family planning. Over the six clinics 1,319 women came for family planning and over 3,000 people attended for general healthcare issues.

Dandelion Africa

2016 was a very busy year for Dandelion, who carried out 37 mobile clinics seeing 10,615 people for primary healthcare. 37,575 children received de-worming medication and 8,472 family planning options were provided.

As well as running the mobile clinic, Dandelion is well underway in building a clinic at Sarambei, which should be opening in July 2017. Once built, Dandelion will apply for an SC11 registration so that they have government recognition. The clinic will have a big impact on the community because women will have a safe place in which to discuss, learn about and access sexual and reproductive health services. Currently, the nearest hospital where women can have safe deliveries of babies is 20 kilometres away and the rates of HIV transmission between mother and child are high due to home deliveries. Giving birth in the new clinic will save the lives of many women and their babies.

With the help of Dandelion’s Wendo Aszed and CHASE supporter Steve Bown, we have been able to make a new video that follows the work of a day-long mobile clinic as it visits a rural community. You can watch the video by going to: https://youtu.be/CF8UHrN8N8o

New Project with the Big Life Foundation

At CHASE we are trying to focus our work in areas of high biodiversity. With this in mind we approached the Big Life Foundation who operate in the area around the Amboseli National Park to see if they would consider helping to implement a family planning project. Amboseli National Park in southern Kenya embodies many of the critical issues facing areas of high conservation value. With increasing human populations around the park there is an increasing amount of human/wildlife conflict. The staff at BLF were interested in finding out more about how a project would work. CHASE funded a visit from two of Dandelion’s staff to make a feasibility study on how a mobile clinic project could be established, and to spend two days training 20 Community Health Workers. One issue this trip identified was that the local MoH in Loitokitok had a severe shortage of family planning commodities. Generally, we get these for free and as this report goes to press we are trying to find a further source of free commodities.

The location of the proposed project is on the Imbirikani group of ranches where approximately 15,000 Maasai live. In this area FGM and polygamy are still common practice with very few women using family planning. The project is due to start in March 2017.

Conservation Through Public Health (CTPH)

Conservation Through Public Health is based in Uganda and conducts programmes to protect gorillas and other wildlife from catching diseases from humans and livestock. The mountain gorilla is a highly endangered species with about half of the world’s population, estimated at 650 individuals, found in Bwindi Impenetrable National Park. Gorillas and humans have a 98 per cent genetic resemblance, making transmission of diseases between the species highly probable. The human population around the park has risen dramatically over recent years and there has been an increasing amount of human/wildlife conflict. Humans enter the park for firewood and game meat while wildlife damages farmers’ crops. CTPH’s unique approach to biodiversity conservation led to Gladys Kalema Zikusoka, a practicing vet and one of the founders of CTPH, being invited to London in November 2016 to give the Tusk Conservation Lecture.

In a recent survey, the majority of the people in the villages around the park said that they realise that the gorillas attract tourists who bring wealth to the area. The survey also found that although most people had heard about family planning very few women had used it.

In November 2015 Stephen Rubunga, one of the co-founders of CTPH, spent time with Dandelion Africa to learn more about how to conduct mobile clinics. With the knowledge gained and funding from CHASE Africa, CTPH set about scaling up its family planning services with plans to conduct three mobile clinics around the Bwindi Impenetrable National Park in late 2016.  In these remote areas most people do not have access to family planning. During our pilot mobile clinic nearly 100 people from Nyabaremura village in Rubuguri parish were provided with family planning counselling and commodities, as well as HIV testing.

Mount Kenya Trust (MKT)

Mount Kenya Trust works with national and local government divisions such as Kenya Forest Service and Kenya Wildlife Service to protect the national park around Africa’s second highest mountain.  It is a constant battle to try and stop the poaching of wildlife and bush meat, logging of indigenous tree species, illegal grazing, crop cultivation and charcoal production, pressures which arise from the burgeoning human population.

MKT has been very successful in engaging the local community with their conservation projects and the community health project launched with CHASE in 2014 has changed the lives of thousands of families.  21,000 family planning treatments (equivalent to 30,000 women each receiving one year of contraceptive cover) have been provided free of charge, with many women opting for the three year implant. Giving women the chance to choose when they want their next child gives them an opportunity to earn an income and help themselves to escape poverty. The project has also helped over 13,000 people receive primary healthcare.

The Kenyan Government is committed to reducing the total fertility rate and one of the best ways to make this happen is to enable girls to go to secondary school. On average, women who only went to primary school have 5.4 children whilst those who finish secondary have 2.9. As secondary school is so expensive in Kenya girls born into a poor family with lots of children often miss out on secondary school.

It will still take many years, but the success of the family panning project run by MKT will mean in the future more girls will get the chance to go to school.

Friends of the Mau Watershed (FOMAWA)

Kenya faces an increasingly severe shortage of “tree products”, firewood, poles for power, and timber which all come from the higher areas where the climate and soils are suitable for growing trees. We continue to fund the planting of trees at schools, and many of the first schools to plant are now generating useful income from selling their timber with the help of FOMAWA.

In addition, many local people are seeing how the schools are benefiting  and are planting trees themselves as a future source of income. With FOMAWA’s influence and guidance they are now looking upon trees as a potentially valuable crop and are giving them the husbandry required so that they grow well.  Making money is the biggest incentive, but there is also the knock-on effect of the benefit to the environment.

In 2016 CHASE funded the purchase of 2,000 avocado seedlings.  Most of these have been given to pupils who have shown real interest in environmental matters at schools covered by our tree growing projects.  They have taken them home and planted them there.
Avocados are easy to propagate from the pip of an eaten fruit and will produce fruit from the fifth year, and will continue to do so for another fifty years. In Kenya the tree will fruit rather haphazardly all year, so if there are many trees within a neighbourhood there will be fruit available nearly all year round. Any fruit that is not needed can be sold in the market.

One Tree Per Child Project (OTPC)

In November 2016 OTPC held an event in St Stephen Walbrook church in London, hosted by John Dee and Kevin McCloud. At the event, CHASE presented a report on the OTPC project we had initiated with Mount Kenya Trust. The aim of the project was to plant 500 trees at each of three schools, improving the school environment and teaching children how to grow and look after trees. A highlight of the project was a visit by the UN Mountain Ambassador, a Tibetan monk, in October 2016 on the day the children planted their trees.

FP2020

In 2012 world leaders gathered in London for a summit on Family Planning. Out of this summit FP2020 was born, which set the objective of offering 120 million additional women family planning options by 2020. FP2020 is hosted by the United Nations Foundation, which builds public-private partnerships to address the world’s most pressing problems. It is supported by philanthropic, corporate, government and individual donors.

In 2016 CHASE made a pledge to reach 100,000 additional women by 2020. This pledge appears on the FP2020 website.

The family planning and basic healthcare service will be provided by mobile clinics operated by our partner organisations, with the support of the county Ministry of Health. We have already been supporting our partners to do this for nearly five years and want to expand our work to meet the high demand for family planning among those who are not yet using it.

CHASE Africa looks forward to being part of a larger effort to ensure that the Global Strategy for women’s, children’s and adolescents’ health is achieved.

FP2020 runs a programme called the Rapid Response Mechanism giving grants which will help meet the target of reaching 120 million more women. In 2016 with help from CHASE, one of our partners, Dandelion Africa, applied and was given a grant to run more mobile clinics. We will be encouraging our other partners to apply, and we received a small grant for helping with the monitoring and evaluation.

New technology is helping to meet the unmet demand for Family Planning

Many women use Depo-Provera as their preferred method of contraception, but this means having to visit a clinic every three months to receive an injection. For those living in remote areas this can mean a long trip to the clinic. It would be so much easier if they could self-administer this form of contraception. A new product called Sayana Press does just this. Sayana Press is small, light, easy to use, and requires minimal training, making it especially suitable for community-based distribution—and for women to administer themselves through self-injection.

Sayana Press has now been recommended by WHO in contexts where women have information, training, and support. Throughout 2017, PATH, a leader in global health innovation, is conducting research on self-injection of Sayana Press in collaboration with ministries of health in Senegal and Uganda, and learning how to support women in these settings to self-inject safely and effectively. With lessons learnt from this research it is hoped that Sayana Press will soon be available in Kenya, allowing women to use it in the safety of their home.

Our financial year

Income = £165,376

Expenditure = £156,854

This post is by CHASE Ambassador, Steve Bown.

I have been a professor of medicine at a London teaching hospital for more than 25 years. Over these years I have become increasingly uncomfortable with the way the global environment is being destroyed and degraded by human activity. The climate is changing, forests are disappearing, desertification is overtaking previously fertile land and natural resources (particularly fresh water) are being consumed faster than they can replenish themselves.

By far the most important factors contributing to this unhealthy state of affairs are over consumption of natural resources and a rapidly growing population. Those who have least, mainly in developing countries, suffer the most. In the last 40 years, the human population has doubled while populations of wild animals have halved. Unwittingly, the medical profession has contributed to this as over the last 200 years, the main focus has been on saving and prolonging human life without any consideration of how this has altered the balance between the human population and all other life on Earth.

The global population is still increasing at the rate of about 83 million per year, exactly the same rate as 35 years ago. Most of the growth is in developing countries and they are paying the price in environmental degradation and loss of sufficient sustainable resources essential to life such as food and fresh water. Many people realise that over consumption must be addressed. Only slowly is the world waking up to the seriousness of the problems associated with over population. For a sustainable future for everyone, both over consumption and over population must be addressed in all countries.

I first heard of CHASE Africa through the charity “Population Matters”, whose key aims are to educate and raise awareness of the seriousness of the problems arising from over population and over consumption in both developed and developing countries. Global consumption is already 50% greater than is sustainable in the long term.

I soon arranged a visit to Dandelion Africa, one of several health related charities in Kenya supported by CHASE Africa. It was an eye-opening experience! Dandelion was founded by Wendo Aszed, who gave up a position in banking to found Dandelion in 2009 with the core aim of raising the quality of as many aspects of life as possible for those in the local communities around her home district, especially the women. Her outreach clinics go to isolated rural communities who have previously had few or no health services. The clinics provide basic general medical services including vaccination and HIV screening, but the key focus is on family planning. So many women are anxious to limit their family size so they can afford to feed and educate their children. Many less educated men still want many children so during these clinics there is a constant focus on education through discussion groups and short dramas – not to tell individuals what to do, but to explain the consequences of large and small families and let individuals decide for themselves what is best. Clinic days are fun days out for the children, but for the older ones, it is also educational with talks on hygiene, coping with menstruation (so girls don’t miss school) and avoiding pregnancy.

Wendo also runs other support classes in schools and microfinance groups for adults (men and women). Throughout, the emphasis is always helping everyone to help themselves, not just handing out charity. Her empathy with all age groups from young children to elderly widows is quite remarkable. It is rare to encounter such an individual and I have enormous admiration for her. As an ambassador for CHASE, I am doing all I can to support their activities with Dandelion and the other related charities in Kenya they support, particularly CHAT (Community Health Africa Trust) and the Mount Kenya Trust. I do this largely by giving personal talks to a wide range of groups in schools, universities, many adult organisations and to University of the Third Age meetings. My aim is always to present the facts on population growth, both in Kenya and around the globe and how the problems are, or are not, being addressed. The commonest reaction is to say “I never thought of things that way”. One recent comment was “very interesting, lots of questions, but all a bit scary!” How true that is!

There are many organisations in Africa trying to provide services like CHASE, but the scale of the problem for the whole of Africa is mind boggling. There are many barriers to overcome – cultural, religious and logistical – but the green shoots are appearing. The latest report from Dandelion said that for the first time, the number of new children registering at a local nursery school had fallen, more women are in work and the general standard of living is slowly improving. We all need to do what we can to accelerate this process.

One of the biggest problems is to persuade people to talk about over population rather than ignoring it. Once people understand the facts, they start to realise that action is required. My aim is to make everyone talk.

Throughout Kenya there are areas that have been designated as national parks and reserves, areas under threat that need to be preserved for future generations. Through our partners, CHASE Africa is working in two of these vitally important areas – the Mount Kenya National Park and Kakamega Forest National Reserve. Both areas face the consequences of Kenya’s fast population growth – the destruction of habitat and increasing pressure on resources.

There are also issues of poverty that are being addressed through the work that is being done by the mobile clinics that we fund. Free access to family planning opens up previously unavailable choices to women – the opportunity to choose the number of children they have and how close together they will be. Choice is the beginning of breaking the cycle of poverty in which many families in these regions find themselves. And families with choices have better futures – better maternal health and better child health.

The Land

Mount Kenya National Park

The Mount Kenya National Park was established in 1949 to protect the Mount Kenya, its wildlife and environment. It covers 276 square miles, centred on Mount Kenya itself – Kenya’s highest mountain. It is the main water catchment area for two large rivers – the Tana, the largest river in Kenya, and the Ewaso Ng’iso North. Mount Kenya’s ecosystem provides water for over 2 million people. The whole area is some 90 miles north northeast of Nairobi.

Kakamega Forest National Reserve

The Kakamega Forest National Reserve lies to the northwest of Nairobi, near to the border with Uganda – it was designated a National Reserve in 1985. It is Kenya’s only tropical rainforest. The whole forest covers about 90 square miles, with the reserves, in the northern part of the forest being only 17 square miles – less than a tenth the size of the Mount Kenya National Park. Despite its size, the reserve is home to nearly 400 different species of plants and is famous for its birds. The forest is also rich in rare minerals such as gold-bearing quartz and feldspar – this makes it attractive to those who would extract and sell these minerals, at the cost of the forest. Logging for timber and firewood is also on the increase.

The People and the Work

Mount Kenya Trust

We have been working with the Mount Kenya Trust (MKT) since 2014, having heard about them from people we already know who are working in the region. MKT itself was established in 2000 and its aim is “to help protect and restore the integrity of the forests and wildlife of Mount Kenya by partnering with Government Agencies, communities and other stakeholder organisations in the region”.

With a team of nine, and working with volunteers, MKT runs a whole range of different projects, including running mobile health clinics reaching out to local communities with healthcare and family planning. These clinics and MKT’s no-nonsense approach are what draw us to work with them.

In December 2016, Henry visited one of MKT’s day clinics. The visit started with a trip to the Timau Sub-County Hospital in Meru Country to pick up a doctor, nurse and supplies for the clinic. From the hospital the group travelled to a small church and setup the clinic. At the clinic they welcomed members of the local community who were seeking healthcare for themselves and their families. The clinic also offered family planning to those who wanted it – counselling and advice are offered to help women make the best decision for themselves and their families.

During the month of December, MKT ran eight such clinics and a total of 1,092 women chose to use their family planning services. Of those women, 472 chose long-term methods and 620 chose short-term methods.

These numbers are typical of a month’s worth of clinics which means that throughout the year MKT is reaching many thousands of people. In family planning terms – with the combination of short- and long-term methods – the clinics provide nearly 24,000 Couple Years Protection every year.

Community Health Volunteers

In the Kakamega Forest we work with Community Health Volunteers to bring mobile clinics to rural communities. CHV in Kakamega was founded in 2006 to “create awareness to the residents on HIV/AIDS, as well as on issues of sexual and reproductive health”. The team of volunteers who all live in the area they serve is headed up by Gabriel.

Before starting CHV, Gabriel was a bird guide, like his father before him. During his work he visited homes around the edge of the Kakamega forest. There he was shocked to see the number of people who had contracted jiggers (Tunga penetrans) – a parasitic insect that burrows into the sole of the foot, where it grows causing itchiness and pus-filled sores that often become infected.

Treatment is easy and costs pennies but treatment was well out of the reach of the poor households that Gabriel visited regularly. Together with other bird guides, Gabriel bought, and gave out, jiggers treatments as he went round forest. Over time he realised that there were more serious health issues in the communities he visited, and from that realisation was born CHV which now runs a clinic in Vihrembe, Kakamega. The clinic is part financed by a church in the UK – a collaboration that came from a chance bird watching encounter! The clinic is now working towards getting a status as a government recognised clinic – which will bring in more funding.

As a way of expanding the work and reaching larger numbers of people, in 2016 CHV successfully started running mobile clinics funded by CHASE Africa. Under Gabriel’s leadership they will continue with a number of clinics every month for 2017 and beyond.

Parks, reserves – and people – with a future

We must remember that preserving the national parks and reserves is only one aspect of working for the future, and although it is a hugely important aspect in a country like Kenya, perhaps more important still is giving women choice. Being able to choose the size of their families – the number and spacing of their children – allows women to plan for the future, work their way out of poverty and give the children they do have many more options and opportunities.

By working with MKT and CHV we are able to bring much needed family planning treatments to many communities. Over time this will bring many benefits to those who are able to access MKT’s and CHV’s services– not least that pressure on resources will be reduced as women are given a choice about their families, hopefully contributing to a long term future for these two important national treasures. If the wildlife is given space to flourish, tourists from around the world will want to visit, a great boost to the local economy.