Before I left for the states, we organized a TB screening event in one of the street children barracks. The term 'barracks' is misleading because everyone assumes that this is an actual structure where the street children live. Unfortunately, it just refers to an area in town - either in a field, by a river, outside a store - where a group of children sleep and hang out. There are approximately 8 'barracks' in Eldoret and each one has anywhere from 10-40 children. Each barrack also has an older barrack leader who watches over the younger kids and intervenes if there are any problems.
We were a bit worried to start screening in the barracks...what would we do if we found a positive case? How could we ensure drug adherence in this difficult population? These kids are constantly moving around, most of them are addicted to glue, and many of them do not have phones. An interesting ethical issue: is it better to screen and identify with the risk that adherence will be low or is it better to avoid screening a difficult population?
We had many discussions with the Tumaini drop-in center and the TB projects office team about this issue and concluded that it would be best to confirm that it is impossible to maintain a street child on treatment before we decided to stop screening this population. We created some possible scenarios for how we could maintain drug adherence if a TB case was identified in the screening. The solutions included working closely with the barracks leader and empowering him to help find the child daily, providing incentives for the child (food, transport costs), having the health outreach worker go to the barracks daily etc.
The first screening took place at the California barracks. We chose California because the barracks leader is one of the best, and he agreed to help if we identified a positive case. He mobilized his barrack members the morning of the screening and kept them quiet during the sensitization talk. He also helped to keep them organized while the screening was taking place.
Fortunately, no positive cases were identified. It's hard to believe that we have not found a positive case yet, but perhaps this population is not affected or testing sputum is not the best test for this population.
I could not take pictures during the screening because the kids (and I!) find it disrespectful. We don't need to create any additional
slumdog tourism.I did manage to get one shot from afar as we were leaving of the entire barrack to share with you. It's one thing to hear about the street kids and it's another to actually see the conditions they live in every day.
