They squirm. They writhe. They cover their faces and laugh as the petite white lady in a flowing Kenyan dress reaches into her bag and pulls out a stout wooden penis. She sheathes it in a condom. And, to their mortification, she tells them to pass it around.
Her audience attends Mituntu Mixed Day Secondary School in central Kenya, about 200 miles from the capital of Nairobi. These 98 teenaged boys and girls sit elbow to elbow on sturdy wood chairs in a sparse one-room building. Chalkboards line the front and back walls as a warm breeze wafts through screenless doors and windows. Whatever stark differences exist between Americans and Kenyans, the students’ reactions look familiar—averted eyes and titters, a sweaty mix of curiosity and the wish to disappear.
The speaker is Victoria Wulsin, M.D., a Clifton resident far from Cincinnati but right at home. She founded SOTENI International as a nonprofit focused on preventing and treating HIV/AIDS by every means possible in Kenya. Her small team of Americans and Kenyans has helped thousands of impoverished people in Nairobi and four remote villages. Progress is slow, painstaking, and altogether inspirational.
I accompanied Wulsin and SOTENI Executive Director Jenny Brady to Kenya in January and learned that HIV/AIDS manifested here differently and with more vigor than in the U.S. and Europe. In the West, gay men, intravenous drug users, and hepatitis patients who received infected transfusions suffered acutely. In Kenya, the disease struck a broader population through unprotected heterosexual intercourse and through mothers passing it to newborns.
While most of the world fights the COVID-19 pandemic, the HIV virus still plagues the poorest outposts more than 30 years since it emerged to trigger Acquired Immune Deficiency Syndrome (AIDS). Nearly one in 20 Kenyan adults is HIV-positive, among the world’s highest infection rates. Yet that’s half of what it was in the late 1990s, thanks to the work of organizations like SOTENI.
Among the SOTENI villages of hope, as they’re called, the hardest hit is Ugunja in western Kenya. Its infection rate was a staggering 21 percent among adults—four times the national average—in 2018.
What does such a place look like? Beautiful. Situated near the equator, Ugunja is verdant and mild, tree-shaded and teeming. It’s a mix of paved and dusty dirt roads and walkways. In a labyrinthine open-air market, women sell baskets they make by hand from palm leaves they harvest. Men sell mounds of tiny silver fish, called omena, that are covered in flies. Others cook chicken in curry sauces in large woks or sell stone and wooden jewelry. I ask Wulsin if we need to be wary of pickpockets in a place like this. “Oh, yes,” she says flatly, and I kick myself for not leaving my laptop-stuffed backpack in the van.
Poverty is evident everywhere. Ramshackle roadside “hotels” are tin-roofed shacks. We visit a woman who lives in a thatched-roof hut, subsisting on basket-weaving and selling produce, including papayas she harvests from seedlings provided by SOTENI. Yet people are invariably dressed sharply, men in button-down short-sleeved shirts and long cotton pants, women in long skirts and blouses. Signs of progress are evident, with multistory buildings rising among the shacks.
SOTENI provides sex and HIV education to prevent and destigmatize the disease. Staff members work with villagers to generate income through entrepreneurship. They train community health workers, called AIDS Barefoot Doctors, to form support groups and distribute water purification packets, condoms, practical advice, and emotional support. Tangible success stories mix with maddening setbacks, like pulling out of one of the original villages where SOTENI worked.
With props in hand at the school, Wulsin is warm and direct as she describes the best and worst of human sexuality as an expression of love and life or of violence and coercion. She quizzes the Head Boy, Dennis—similar to a student-body president—about HIV/AIDs and how it’s transmitted. He says the disease spreads through intercourse and dirty needles. Wulsin tells the assembly, “Dennis told us that you can get HIV through sex. And that is when a man and a woman come together to make a baby, to make love, or to have fun. And if you are very blessed, you are doing all three at the same time.”
She urges the students to wait until they’re married or partnered to have intercourse. But she chooses her words carefully for an audience she knows includes sexually active or soon-to-be active teenagers. She discusses sex, anatomy, the works. She shows them a condom she wears on a necklace, its wrapper featuring a man and woman embracing. “This is a condom here that I carry just to remind people that it’s a normal thing,” she says. “Just like I take aspirins when I have a headache, I use a condom when I don’t want to get pregnant or get a disease.”
Her prop for a vagina is a cardboard toilet paper tube. She flattens it to indicate the shape at rest and expands it to show how it stretches for sex. And when you have a baby, she says, “it stretches this big,” encircling her fingers to the size of a baby’s head.
After students pass around the wooden penis, Wulsin enlists Mutwiri Mugambi Kelly, SOTENI’s new program director in Mituntu, to make one more point. She unwraps a condom and asks him to hold his arm out straight and make a fist. She stretches the condom around his hand and lower forearm. The message: No excuses for boys and men who think they’re too well-endowed to use one.
Jeremiah Munyi, secretary of SOTENI’s Mituntu board, watches the lecture seated against the front wall. Dressed in a black checkered sport coat and loose-fitting gray slacks, the retired high school principal projects quiet authority as he rises to speak after Wulsin is finished. “We Africans have to adopt the boldness of Americans,” he says. “We Africans have not been bold discussing HIV/AIDS. If you are not infected, you are affected. Develop a love for HIV-positive people.”
SOTENI has grown to include Brady, who became executive director in 2018; more than 40 paid staff in Kenya; and board members and volunteers scattered across the U.S. and Kenya. But it started with Wulsin and her singular passion for Africa’s public health crises.
She fell in love with Kenya in 1976 when she spent a fellowship year at the University of Nairobi following her first year of medical school at Case Western Reserve University. Wulsin sprinted forward with her education, earning an M.D. from Case Western, as well as a master’s in public health, specializing in epidemiology, and a doctorate in public health (both from Harvard). An array of public health jobs followed, 13 in all, in Cincinnati; Boston; Washington, D.C.; and back in Nairobi. She currently serves as director of preventive medicine and global health at UC’s University Health Services.
She married Lawson Wulsin, a native Cincinnatian, and they raised four sons, mostly in Cincinnati but also in Boston and Nairobi. Her heart never strayed from Kenya, though, and she returned to Nairobi in 1995 as HIV/AIDS advisor for East and South Africa for the U.S. Agency for International Development. Lawson taught at the University of Nairobi, and their sons attended a nearby school.
Victoria fought HIV/AIDS in 25 countries through 1997, as the epidemic laid waste to families. And she took notes. “There were two things I thought could be done better,” she recalls. “First, the rush to get results within a two-year Congressional budget cycle was wrong because treatment takes longer than two years.
The other was a sense that treatment activities were driven by the donor rather than the people.”
Lawson and their oldest son, Wells, returned to Cincinnati in 1997 so Wells could finish high school here. But Victoria and her three younger sons stayed in Nairobi for another year. The family reunited in Cincinnati in 1998, and her ties to the Queen City deepened. So too did her commitment to fighting HIV/AIDS in Kenya.
In 2003, Wulsin started SOTENI, which is a translation from the Swahili language meaning All of us together. She resolved to empower Kenya residents rather than rely on Western experts parachuting in to problem-solve. And she would ensure that solutions were long term. “It was my Kenyan friends who were interested in starting an NGO [nongovernmental organization] that would be community-based and see if we could come together with our different strengths, resources, and interests,” she says. “I got a book from the library to see how you start a 501(c)(3) [nonprofit].”
Wulsin and five founding members of SOTENI visited more than 10 locations in Kenya to determine where the need was greatest: remote communities that were underserved, with a high concentration of HIV/AIDS, and with unused buildings from pork-barrel spending or unsuccessful ventures. They chose Kuria, Mbakalo, Mituntu, and Ugunja and held barazas—community meetings—to find the best way to serve each.
SOTENI’s village operations are now governed by a local management committee that’s empowered to budget scarce time and money. Members are locally elected and uncompensated, except travel reimbursements, tea, and pastries. Some travel an hour-plus to attend meetings.
SOTENI’s Mbakalo committee built a health clinic. Mituntu used donated land to build the Mixed Day Secondary School. Ugunja has focused on AIDS Barefoot Doctors and their support groups. Kuria built a for-profit fish farm.
In Mbakalo, Raphael Barasa oversees a health clinic that never closes. By American standards, the clinic is rough: a “minor surgery” room, a cramped catchall examination/ recovery room for women and girls, a similar room for men and boys. Women deliver babies on a narrow bed across from a tiny metal crib with space between for two people to pass. It’s clean and orderly but sparse.
The clinic offers immunizations every Monday and diagnoses malaria and other diseases with an aging microscope. But it can’t magnify well enough to identify tuberculosis, a common and potentially deadly disease, especially for HIV-positive patients.
Prices are unrecognizable to Americans. Barasa says a patient with undiagnosed malaria will be tested, diagnosed, and treated for about $2.30. Yet many can’t afford that sum in a region with low wages and high unemployment. SOTENI works out payment plans or subsidizes as best it can.
Barasa hopes to secure accreditation for this outpost as a national health system provider in order to receive federal reimbursements. He illustrates the arbitrary process to win accreditation at a meeting with his AIDS Barefoot Doctors, Wulsin, and Brady, telling them that health inspectors are expected soon. “OK, from the look of things, when those people from the ministry come, we will have to buy them some soda,” he says, and pauses.
“Okaaaay,” Wulsin says slowly. “Yes,” says Barasa. “You know soda doesn’t mean just soda.”
“OK, I was wondering,” says Brady. “Does soda also mean lunch or also other things?” “Yes, I can say lunch and transport,” Barasa replies, estimating that the unofficial expense may total about 500 schillings, or $5—a small sum, but one that approaches an ethical gray area.
Each of the SOTENI villages lacks clean water. For otherwise healthy people, that means enduring cholera, parasites, and other waterborne illnesses. For those with HIV/AIDs, it means wrestling with death.
For a solution, SOTENI looked homeward to Procter & Gamble and its simple purification system: four grams of powdered chemicals, two 10-liter buckets, a big stick or spoon, and a cloth filter. Those supplies, plus a lot of stirring, are all it takes to process clean water. P&G charges SOTENI a deeply discounted 6.5 cents per chemical packet and provides 5.5 cents per packet in training, travel, and general program support. Its massive program reaches more than 90 countries worldwide through 150-plus partners, purifying an estimated 16 billion liters of water since 2004.
Claude Zukowski, senior manager of P&G’s Children’s Safe Drinking Water Program, says the global giant needs nonprofit partners to get the chemical packets beyond its normal distribution system into remote places where they’re needed. “It makes sense to work in communities where we know the packets are going to have the sort of impact on their livelihoods that SOTENI has,” says Zukowski.
We observe the purification process in Ugunja while visiting an HIV/AIDS support group. As Wulsin, Brady, and Ugunja Program Director Calvin Aloo approach the group, gathered in an Anglican church courtyard, the 25 in attendance sing and clap a song of welcome. Roselyne Akinyi Omondi, the AIDS Barefoot Doctor in charge of the group, leads them in an affirmation that all are “alive and kicking” by holding their palms out and shaking them.
Participants include two men, a toddler, and 23 women ranging from teenagers to elderly. Several leave early for choir practice in the church. The courtyard is tree-shaded, and we form a circle in plastic lawn chairs, which are omnipresent in nearly every home, yard, and office we visit.
Middle school children in crisp uniforms file by, and chickens peck for morsels at our feet. We’re all asked to make brief remarks in the middle of the circle. That sort of greeting would be repeated at a Catholic mass, university board meetings, and numerous SOTENI gatherings. In the deeply religious, heavily Christian country, this meeting and every other one we attend begins and ends with a prayer. Omondi translates our remarks into Luo, the region’s predominant language.
A woman pours a P&G packet into a translucent plastic bucket and stirs with a wooden spoon that’s nearly as long as her arm. Aloo explains that huge wooden spoons are common utensils for cooking, especially ugali, a nutritious and inexpensive comfort food made from ground maize and sometimes combined with millet. The consistency is similar to goetta but ground more finely.
Women in the support group dress in long skirts, some with colorful patterns, others solid and bright. One woman wears a red “Students for McCain 2008” T-shirt, emblazoned with an American flag. Men wear ubiquitous buttoned-down shirts and cotton khakis. Some speak English, but the conversation is in Luo. Members thank SOTENI for all they do, and one by one they plead for more.
They have enough P&G chemical packets, but many buckets have cracked. Others stretch the purified water over several days but can’t afford lids to keep out dust and bugs. In a region with crippling unemployment, a cracked bucket stops the water purification process dead in its tracks. Several ask for food so that they don’t have to take their HIV drugs on an empty stomach.
When the meeting ends, Wulsin warmly embraces each member. Smiles erupt. It’s the norm throughout the trip. Strangers break into warm conversation with Wulsin, whose demeanor proves time and again to be disarming. Petite with shoulder-length thick white hair, bright blue eyes, a broad smile, and a quick embrace, she ensures even gruff security guards joke with her. As for friends, colleagues, and clients? Bear hugs, eyes locked, pure joy radiating as they reconnect. Her charisma and commitment engender deep loyalty, including in an extraordinary man named Henry Unani.
Unani lived and worked in Nairobi in 2000, when he fell ill. He feared he’d contracted HIV, but tests were inconclusive. His health deteriorated, he lost his job, and he was forced to move back home to Mbakalo, where there were few jobs but a lower cost of living. Unani fought the illness for five years and became a pariah among his kin. “Those were terrible days because, in my village, it was a time when nobody wanted to hear anything about HIV,” he says. “Most of the people thought that it was caused by witchcraft and misconduct. You can’t share with anybody, especially plates. You aren’t free to live in society. I lost my job, I lost friends, I lost the respect of my own family.”
But Unani’s story didn’t end there. When SOTENI came to Mbakalo in 2003, it hired him as a watchman for its health clinic. In 2005, he was finally diagnosed as HIV-positive and started a free regimen of antiretroviral drugs. (Quick recent history lesson: George W. Bush led the President’s Emergency Plan for AIDS Relief in 2003 to fight the HIV/AIDS epidemic. It provides free antiretroviral drugs and other support to Kenya and more than 50 other countries, and is lauded as one of the most successful U.S. global health initiatives.)
Unani’s health returned, as did a role in village life thanks in large part to SOTENI’s message of love and acceptance. Renewed in spirit and body, he longed to spare fellow HIV-positive villagers his fate of isolation and illness. He was among SOTENI’s first AIDS Barefoot Doctors. “I was eager to join and be exposed to the information and give out and testify,” he says.
Twelve years later, Unani supports 100 group members with HIV. He says only a few scattered families still believe HIV is spread through witchcraft. The stigma of HIV/AIDS remains but is improving. Unani and his wife have raised seven healthy children, some of them already college-bound. “I tend to think it’s a miracle,” he says.
AIDS Barefoot Doctors are not medical doctors, but trained community health workers with annual professional development refreshers. Unani and his colleagues trek as far as three miles to reach their clients by foot, moped, or bicycle, serving 169 support groups and nearly 19,000 HIV-positive people across Kenya.
Some challenges prove insurmountable. In Kuria, SOTENI battled corruption and misogyny. “The culture there was worse for women,” says Wulsin. “I never met a man in Kenya I didn’t love until I got to Kuria. There were just some mean men.”
SOTENI and its Kuria council built and stocked a fish pond as a source of food and revenue for the village. The project was a money-maker, but the money disappeared. Fingers pointed in many directions, including some at the village coordinator, whose story wasn’t convincing. “We were already having a hard enough time sustaining our other three villages,” says Wulsin.
A partner in the effort, the Danish International Development Agency, had shifted funding toward other priorities, so SOTENI pulled out of Kuria. “It was disheartening,” she says. “There is certainly a consequence of morale with the staff, reflecting why didn’t we follow the policies we have in place or have better policies.”
Early on, Wulsin dreamed of SOTENI scaling up to rival healthcare and antipoverty giants like Partners in Health or CARE, but she never found an angel investor, she says. She’s led 17 years of incremental growth and contractions from a headquarters 8,000 miles away. How does she keep going? Wulsin answers in two parts, once in a van driving along a dusty dirt road and again after some reflection.
“We’ve weathered mistakes and setbacks and even corruption,” she says in the van. “It’s all of us together. I actually have a folder in my filing cabinet called ‘Guaranteed to feel good,’ full of letters and e-mails about changed lives. Because I do get discouraged.”
And she credits her husband. “Lawson is blessed with a unique combination of compassion and wanting to help, optimism, creativity, coming up with alternatives and thinking outside the box, and believing in me. He’s the one who gets me through. I alter the Grateful Dead song line, ‘When there were no dreams of mine, you dreamed of me. . .’ to ‘When I had no dreams to dream, you dreamed for me.’ ”
“The anger I feel about our lack of [federal] response to COVID-19 is similar to how I felt for 20 or 30 years about HIV/AIDS,” Victoria Wulsin says.
With infection rates cut in half, the world health community’s focus on HIV/ AIDS has waned. Wulsin describes the new challenge of “organizational survival issues” in the wake of shrinking economies and shrinking wealth, and she sees grim parallels between coronavirus and HIV/AIDS. “I think the anger I feel about our lack of [federal] response to COVID-19 is similar to how I felt for 20 or 30 years about HIV/AIDS,” she says—sickness and economic pain that could have been far less severe if Washington, D.C., had mobilized resources when public health officials first raised the alarm.
SOTENI fights on from Cincinnati, led by Brady, who left a job as a corporate communications executive to join the organization. She brings a perfectionist’s organization to this trip, finding safe transportation on chaotic roads, corralling SOTENI volunteers and staff for a series of well-timed meetings, keeping everyone running on time. In Cincinnati, she does high-level analysis of how SOTENI is faring and explores ways to keep it growing and meeting its communities’ most pressing needs. “It’s great to go where you’re led, but I think we have to implement a little more strategy to grow,” she says.
Brady helped streamline SOTENI, distilling five mission statements into one. In March 2019, the organization broadened its mission to prevent and mitigate diseases—especially HIV/ AIDS, but also waterborne and maternal illnesses. A year from now, she wants a larger, stronger support base; an app that AIDS Barefoot Doctors can use to track progress; and more money to bring staff wages closer to market rate.
The COVID-19 pandemic makes caring for Kenyans that much more challenging. “How do we raise our consciousness about something that is 8,000 miles away?” Brady wonders. “If the world feels a little more connected because of us in a year, then that would be good too.”
Back home after the trip, Wulsin says she worries about keeping her UC staff— and all university students—safe in the current health crisis. “This is like the early days of HIV, when epidemiologists would burst into tears,” she says. “People just choke up because we’re faced with our limitations. We can only do so much, and people are really suffering.”
Still, when the pandemic subsides, she sees an opportunity for middleclass Americans to feel more empathy for impoverished Kenyans. “The average Cincinnati Magazine reader is affected by COVID-19 in a way that HIV never did,” she says. “People with HIV have had their lives shrunk like that for decades.”
Wulsin and Brady have eager and energetic allies in Kenya, bringing fresh ideas and determination to the mission. Kelly in Mituntu wants to create groups of HIV-positive and -negative residents to focus on job training and entrepreneurship, breaking down barriers. SOTENI Kenya Program Manager Noreen Obilo wants to expand to fighting typhoid, tuberculosis, and other deadly diseases and to tackle the root cause of it all: poverty.
On the trip’s closing days in Kenya, Wulsin reflects on this particular visit and the prospect of reuniting with a husband she loves so deeply that she limits overseas communication to e-mail to avoid becoming too homesick. “It’s bittersweet going home,” she says. “Visiting is always a shot in the arm for my work in the U.S. with SOTENI. It’s amazing that so few resources can do so much.”