IT WAS LUNCHTIME, and a barefoot Esther Ipeche, 13, trudged home down a dirt road to her family’s tin shack in Naivasha, Kenya. She was ferrying her youngest brother, 3-year-old Patrick, on her back while her two other brothers, ages 7 and 8, followed alongside. Esther had been the primary caretaker in her family since her mother fell ill with AIDS six months before and her father disappeared.
Her mother, Susan Andukais, was resting on the only bed at home, her brittle body enshrouded in a faded lavender polyester jacket. She feebly clasped my hand, the polite form of greeting in Kenya. She looked much older than her 34 years, her face wrinkled and withered by a life of work, worry, and disease. Her own mother had died of AIDS, and she seemed about to inherit the same fate. Her lungs had been clogged by TB, a common byproduct of HIV, and she had frequent fits of coughing. Esther spoon-fed her a bit of milk.
“When I see my mother sick, I feel bad,” the young teen said softly in Swahili. “When I find there is no food, I don’t know what to do.”
Susan died in April, leaving Esther and her three brothers to manage on their own. They are among the 650,000 children in Kenya who have lost their parents to AIDS. By the decade’s end, there will be an estimated 18.4-million orphans in sub-Saharan Africa, more than half the population of Kenya itself, according to the latest figures from the United Nations Programme on HIV/AIDS.
I met Esther and her family on a trip to Kenya in March with photographer Karen Ande, a friend and former Stanford graduate-school roommate. Karen had visited the East African country five times before, documenting the African pandemic in photos of orphaned children, like shy little Judy, with one eye and a case of AIDS that took her life at age 10.
Karen wanted a collaborator—a medical writer such as myself who could help tell the story of Judy and others like her. I had covered the U.S. AIDS crisis both for a daily newspaper and as a UCSF staff writer at San Francisco General Hospital, the epicenter of the epidemic in this country. But nothing could match the epic proportions of the African pandemic, and I thought I would go see it for myself. When I set out, I had no idea just how much the experience would change my perspective on life and on the world at large.
In Naivasha, we spent a week touring the back roads with Teresa Wahito, a soft-spoken 55-year-old community social worker who knew everyone’s problems first-hand. Naivasha is a high plain of a town about 50 miles northwest of Nairobi, on the fringe of the great Rift Valley. In the dry season, the dirt rises in clouds, leaving a thin film of dust on one’s clothes by day’s end. A community of an estimated 100,000 people, Naivasha was at one time a popular tourist stop because of its nearby flamingo-filled lake, though 9/11 has brought tourism and the local economy to a standstill. More than half the adults in town are unemployed, and those who do have jobs earn an average of $1 a day.
It’s a sprawling community of small farms, with tin and mud huts scattered for miles off the few main roads amid stands of acacia and fields denuded by cattle and goat overgrazing. There’s no running water, but three Kenya shillings, or less than a penny, will fetch a jerry can of water off the local donkey wagon. There’s no indoor plumbing or garbage service either, with plastic bags littering the roadsides; few residents can afford the luxury of an electric light.
The downtown is a hodgepodge of brightly colored concrete kiosks where small business people, most of them well-spoken in English, sell everything from Nike shoes to aspirin to camera batteries. We stopped in one day at Lenny’s supermarket, a 1,000-square-foot store that shared a block with a hardware store, a vegetable stand, and a “hotel,” a shack covered with turquoise-painted tin cans.
Teresa, the social worker, took us down one of Naivasha’s rutted, unpaved roads to the home of Susan and her family, a tin-roofed shack with an uneven mud floor and just enough living space to accommodate Susan’s bed, a wooden bench, and a chair. We brought the groceries from Lenny’s shop—$8 worth of rice, maize meal, cooking fat, bread, milk, tea, salt, sugar—enough to keep the family marginally fed for a week.
Esther, wearing a simple lavender skirt and blouse, set about making lunch, stooping over a charcoal fire in the corner to stir corn meal into water for ugali, the Kenyan staple. Her short-cropped, braided hair had the reddish tinge of kwashiorkor, a severe protein deficiency akin to starvation. Patrick sat on the floor in a stained, frayed T-shirt, seizing his share and eagerly scooping it out of a plastic bowl with dirty hands.
Even Teresa, who had seen much in her 22 years of social work, was taken aback by the family’s dire circumstances.
“When I first came, it really touched me,” she said. “Actually, it horrified me.”
Esther had recently started attending school for the first time. Though elementary school is now free in Kenya and enrollments have soared as a result, there are still many children who can’t afford the $14 cost of a required school uniform. So Esther had entered a makeshift school nearby, where the 160 students sat on tree trunks for benches in windowless rooms. They lacked desks, books, pens, and other basics, but they got a breakfast of porridge everyday—a luxury for some—and lessons in the hazards of sniffing glue, a common habit among the homeless orphans of Naivasha. Esther sat in the back in a roomful of children that were half her age and size. She was smiling and seemed grateful for the opportunity to be there.
I asked her later what she hoped for in life. She said she wanted to continue with her schooling, if possible, and get a job. “Any job,” she said, “as long as I can support my family.”
After Susan’s death, Esther and her brothers went to live briefly with the nuns at the local parish, who searched in vain for families who might take them in. Naivasha is awash in children who have no surviving relatives willing or financially able to support them. So many turn to life on the street, pilfering food from garbage cans and resorting to petty crime and prostitution.
Fortunately, Esther and her brothers found a placement in an orphanage in the nearby town of Gilgil, an offshoot of a grassroots project in Naivasha that we visited one afternoon. It was a bittersweet place where children called the social worker “Mom” and went happily about their days, despite traumatic pasts and uncertain futures.
We stopped by on a Sunday, and the children, all dressed in their best borrowed clothes, rushed out to greet us. One of them, a boy of about 6 named Jasper, gripped my hand and laid permanent claim to it. Two girls, one of them in a frilly white churchgoing dress, angled for space beside me on a bench and studied my sunglasses, my black leather purse, and my ballpoint pen—all strange and wonderful accoutrements.
Every child at the orphanage had a sobering history of neglect, abandonment or abuse. Florence, 13, the oldest child at the shelter, had been taken in by an uncle after her parents died of AIDS. But the uncle’s wife resented the pretty girl and relegated her to Cinderella status, subjecting her to hard work and continual emotional abuse. Today Florence, who is of marriageable age in Kenya, wonders out loud who will come to her wedding, now that her parents are gone.
“I’ll be there, don’t worry,” Teresa assures her.
Another child, Samuel, a chubby-cheeked toddler with two missing front teeth, had been left alone by his mother in a line of pharmacy patients at the Naivasha hospital, just across the street from the orphanage. A hospital employee found him at day’s end, crying at the pharmacy door. His mother never returned to claim him.
And Michael, now 2, had been deposited at a local bus stop when he was 2 months old, presumably by relatives too sick or too poor to care for him. An impish child with a perpetually runny nose, he followed me around the orphanage grounds with a makeshift recorder, providing a backdrop of musical cacophony for the visit.
The veterans of the orphanage are brothers David and Cyrus, now 10 and 12, who had been wandering the streets of Naivasha after their ailing mother disappeared. On a hunch, Teresa went to the local mortuary, where she found the mother cast on a heap of unidentified bodies. She took the traumatized youngsters temporarily into her home and then went looking for a permanent placement.
She appealed to her friend and longtime children’s advocate, Jill Simpson, a retired nurse of British descent. Jill is a crusty 74-year-old who once trekked hundreds of miles on camelback into bandit-ridden, desolate northern Kenya to raise $38,000 for a local school for handicapped children: a fortune by Kenyan standards.
Jill and Teresa worked with the Catholic Church to establish the orphanage in an unused schoolhouse on the parish grounds in 2001. David is now one of the stars; he’s first in his class of 165 students. Once a quietly intense boy, he’s become the local cut-up, with a knack for imitating the baboons in the local game park.
The complex is a stark but immaculate collection of cement-block buildings that house 32 youngsters who sleep in homemade wooden bunk beds in crowded dormitory-style rooms. They eat together around a big square table in a former classroom and attend public and private schools in the community.
“We are trying to get them before they become street children,” Jill said. “We try to pick them up when they are much smaller. Once they’re in a gang with other children, it’s much more difficult.”
It’s an irony that the orphanage stands across the street from the local government-run hospital, for it’s the overtaxed, resource-starved medical system that has contributed in part to the orphan problem. During a visit to the medical facility, we got a disturbing glimpse of the inequities of African health care and some insight into the culture of AIDS, which has hampered prevention efforts.
Hospital officials told us, somewhat apologetically, that they had no antiretroviral drugs for patients: not AZT, the old-line AIDS drug first marketed in the United States 17 years ago, nor the more sophisticated drug cocktails introduced in 1996 that transformed AIDS from a death sentence to a chronic, treatable disease. But not so in Naivasha and in most of Africa, where the best doctors can offer patients is palliative care to minimize suffering before death.
On the day we visited the campus of single-story, cement-block buildings, the hospital was teeming with people awaiting medical attention, the pharmacy line snaking out the door. All 123 beds were full, and some were shared by patients in dormitory-style wards. Some HIV patients had been there for months, dumped by family members who never came to claim them, hospital officials said.
“It’s a stigma. They don’t want to be associated with AIDS. If the patient is sent home, they may even die of hunger because nobody is taking care of them,” said one nurse and HIV counselor.
A few days later, I had morning tea with the local parish priest, who oversees the orphanage, and asked him about the stigma of AIDS. The pervasive shame and denial associated with HIV have been obstacles to outreach and prevention in Kenya, as it’s hard to stop the spread of a disease when people aren’t even willing to talk about or acknowledge it. It seems surprising, given that 1.5 million Kenyans already have died of AIDS and at least 14 percent of young adults are infected with the virus, according to the Joint United Nations Programme on HIV/AIDS.
The priest, Father Daniel Kiriti, said his own uncle succumbed to AIDS, but his family members won’t speak of it. “They don’t want to believe it,” he said. “My mother says I don’t love him.”
The culture does not allow for open discussion of love and sex. “Talking about sexuality is not something we have mastered,” said the priest, who spent a year studying at a California university. “So now we are caught unaware with this crisis.”
I asked him what he thought the future would bring. “Nature is going to take its own course,” he said. “We will hit the bottom before things get better.”
And so it was that I returned from Kenya in mid-March, to my job at Stanford medical center, with the best modern medicine had to offer. Every day, I would head to work down pristine, tree-lined boulevards to my comfortable office and think about the vastly different world I had left behind.
I would stroll past the luxury boutiques at the nearby Stanford Mall and hark back to the vision of Esther at church, wearing a secondhand vest we had brought. I fingered potential purchases at the mall, all of which seemed trivial in the wake of what I had seen.
I found it hard to reflect on my experiences without dwelling on the great divide between here and there. And the more I learned about the complex world of global AIDS politics, the more I discovered how little the United States and the rest of the developed world had done to respond to the needs of African patients. I sensed a tolerance for conditions that seemed intolerable to me.
I had a growing sense of outrage, echoed in a talk I had heard a few months before by Stephen Lewis, the U.N. Special Envoy for HIV/AIDS in Africa. Speaking at a scientific conference in Seattle, he had railed against the world’s agonizingly slow response to the African pandemic. “To me, it is just absolutely inexplicable and morally indefensible on every count the way in which the international community has resisted coming to the needs that have been set,” he said.
How those words resonated with me now. And so I set out to do what little I could, hoping others might begin to care. I joined Karen in talking to community groups to help raise awareness and funding to support some of the worthy projects we’d visited. I began writing about the people I met and lobbied on the local PBS station to make cheap, foreign generic AIDS drugs available to African patients. And I hooked up with people of like mind—individuals in the Bay Area working on a small scale to improve life in Africa.
I did it with people like Esther in mind. For I still think of her often and wonder what her life as an orphan is like today. And I fervently hope she will see her modest dreams—an education and a job—come to pass someday.
Ruthann Richter has been writing about medicine for two decades. She is now the director of media relations at Stanford University School of Medicine.