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Holy and the Indian Himalayas
Trip Start
Nov 28, 2004
Trip End
Nov 23, 2005
A few days of exploring Jaisalmer and Troy and I were ready to move on. As plans always changed with us, our new route would take us directly east across the desert state of Rajasthan, then into Utter Pradesh and Agra with a quick visit to the Taj Mahal...after all, what would a visit be to India without seeing the Taj?! After this we would make our way directly north into the state of Utturanchal and follow the foothills that would lead us into the Himalayas.
On the morning we left Jaisalmer, we had the bikes parked outside the fort gates. Just then a mangy dog walked by us. Troy let out a 'oh Jesus Christ' and pointed to the dogs head. At the angle I was looking at it from, the left side of the dog's head looked fine. Then it turned around and half of its head was missing, with its brain hanging out and only one eye still there but blind. Maggots had started eating the dog alive. This was the worst sight I had so far seen in India as far as dogs were concerned. I dry reached as the dog bumped its head into a wooden wagon and then staggered off feebly. I had seen death before, but death clinging so desperately to life is something that unnerves me. So many times had I seen these sights in India, but not as close up as this. Something changed for me then, a part of me had had enough of seeing so much raw suffering in this country and I think it was then that I started thinking about finishing up in India and getting the hell out. I haven't written much about these things, but thoughts build to a stage of complete realisation. That morning was enough reality for me.
On a lighter note, my bike had finished having a major heart transplant...the piston, rings and valves had been changed and he was ready for the next part of the adventure. The only thing was, I had been told by the mechanic to keep the bike under 50km's an hour for the next 500km's. How the hell was I going to keep the speed under 50 when we were on flat smooth desert roads and I had a new engine to play with? It was like telling a 5 year old not to play in the mud. I managed to keep it under 50 for about 200 km's from Jaisalmer to our next stop, Jodhpur, the blue city. Troy kept racing ahead then waiting for me at truck stops looking bored and fed up every time I finally rolled in an hour later. He stopped waiting for me after he got hit on by a weird Indian boy at a truck stop just outside Jodhpur.
We stayed in Johdpur, the blue city, for a few days and made our way up to the magnificent palace overlooking the city below. This was by far the most impressive palace I'd seen in India so far. We didn't want to pay the 250 rupees entry fee so decided to park the bikes in the rickshaw car park just below the gate entrance, which we got told off for, and climbed down along the wall avoiding piles of shit on the way down a rocky valley that ended in a broken part of the wall forming the outer defense of the palace. We could see a man made lake behind and thought about sneaking in the back entrance to the complex. Not much further though, we spotted a security guard standing inside the crumbled wall looking our way. Defeated, we gave up.
Holy, one of the biggest and most celebrated holidays of the year, was fast approaching and from what we had been told, we had better get somewhere safe and get the bikes off the streets before the big day. Holy is also that time of year when kids and adults join in the silliness and throw coloured paint and powder at each other with more ferocity than an Arsenal/Manchester United football match. So we legged it to Pushkar with two glowing and excited French girls, one on my bike and the other slung over Troy's back seat. We rode like Wayne Gardner and Mick Doohan to get there before d-day caught us unawares by some local kids armed with dye bombs and coloured powder syringes along the road somewhere. I was ready with a slingshot I had bought along the way just in case. These were used by local shop owners to keep hungry monkeys away from their street stalls.
Pushkar is a small shantytown nestled in a valley, with rocky hills hugging closely to the east and sand dunes to the west. It's an odd little town, with a big holy lake in the middle lined by bathing ghats around its rim. The sunsets from the lake are beautiful. Opportunistic priests scowl the banks each day preying on ignorant tourists. Leading unsuspecting tourists down to the lakes edge, the priests say a few prayers with them in the meditation position, throw offerings to the gods...the over sized residents under the murky water - the cat fish, and receive a blessing from the priest in the form of a piece of string tied around the wrist - the inevitable and somewhat unavoidable 'Pushkar Passport'. I got sucked in to this scam even after being warned. The priest who wooed me wanted a thousand rupees for a donation and to help him support his family. Bugger that! I told him that if he really is a holy man, he should be grateful for whatever he gets and shouldn't be demanding a certain amount. I pretended I was a poor backpacker, and tried talking my way out of donations by bashings. That didn't go down too well, so my Pushkar baptism ended on a bit of a sour note. It wasn't the first time offers of pure friendliness and goodwill by Indians had ended in me getting yelled at or me doing the yelling after I'd found out what their real motive was. Sometimes it was actually fun. If you ever need anger management, come to India.
So, Holy day finally arrived and Troy and I stuck our heads wearily out of the hotel door to the streets before us expecting the worst. There was no one about? There had been celebrations, dancing and general revelry in the streets the night before so maybe the last ones to bed hadn't risen yet. Usually that was us. We wandered down the empty street and just as we spotted a guy selling a great selection of mulitcoloured dyes and powder on a wooden cart 100 metres further on, we got sprung on by some guys with powder bags. The custom is to wish the fellow 'enemy' a happy holy while either wiping powder on that persons face and forehead, or dousing the enemy with dyed water. The aim is to get the other person as colouful, and uncomfortable, as you can possibly get them with what you have. If you were really unlucky, kids would launch a barrage of dyed water bombs at you with force. As we moved further down the street, more and more carts appeared with even more of a selection of colourful ammunition - flouro blue, aqua blue, green, yellow, red, purple and more. Multicoloured in a few places and looking like clowns you wouldn't ever let your kids near, we restocked our supplies and headed on. I was itching for a clean kid to stick his nose out from around some corner. Up ahead three super clean kids all in various shaded of white emerged from a doorway to my left. A few handfuls of flouro green and yellow and a half litre of purple dye, and no longer were they an add for Napisan. Then the smallest girl started crying. No, this wasn't supposed to happen. All three looked at me with fear in their eyes. What the hell? I offered to hand my water bottle to the eldest kid and indicated for him to squirt me, but he wouldn't have it and stood there comforting his crying sister. Go on squirt me I said, take the lid off and pour the whole bottle over my head I said in universal sign language, but the fear remained in his eyes and he cringed on the doorstep with his sister and brother. Lost for words and standing there embarrassed with people looking on, not knowing what to do, I was approached by a local selling chai on the other side of the narrow street. He told me off, saying that not everyone celebrates Holy in this fashion and many people do not wish to join in and be covered in paint.You could have told me this earlier. Now I felt like the kid standing in the corner of the classroom facing the wall. I felt soooo bad. Troy was off down the road a bit getting ganged up on by some other ferocious rug rats, so I said that I was very sorry, did my Mr Bean style bow and half ran down the street to help Troy, leaving the three kids to deal with having to go to their mum and get changed again. An hour or so later, the street was full of revelers wanting a bit of the action and by this stage Troy and I had so many colours over every inch of our bodies that we were just one dark shade of purple. We gave it our best, throwing and getting doused by kids, westerners, old men, and all the while there was something missing. At last it hit me, where was the usual menagerie of street dogs? Obviously they were wiser than they looked and had stayed well away from the main street and the frenzy. After all, all the shops were shut and bordered up so there was no food to be scrounged for. But, as usual, every few metres or so a cow stood still and relaxed, completely unperturbed by the mess being created around it. A clean white cow stood munching some cardboard a little way up the street. My next victim. I approached and wished it a Happy Holy, spreading flouro blue and pink over its head and horns. To finish off, I gave it blue lips and purple eyeliner, and a compassionate hug. She smelled good and earthy, the way a clean cow smells. She smiled up at me with a pretty drag queen look, flitting her eyelids in a shy but thankful way, now feeling comfortable about being in with the crowd. Such is the life of an Indian holy cow.
A few days after the craziness of Holy subsided, we arrived in Agra and left the French girls in Pushkar. No luck there. Maybe I needed to learn French, the language of love? Troy had seen the Taj before, so left me to it to get up at 530am and get there before the crowds started piling in. At a whopping 750 rupees entry fee, something like 20 times what Indians pay, I was going to get the most of this visit and beat the crowds for a few good pictures without the white-sock-wearing-sandal package tourists sneaking into the foreground of every shot. I have to say, as much as this may sound cliched, but the Taj is the grandest act of love I have ever seen. Simple but beautiful. I walked the marble floor like I was at the American Presidents Inauguration. White milky marble stands proud over an immaculately kept ground, with a huge river delta spreads out at the back of the complex. Sunrise showed the marble at it's finest. I hadn't had any breakfast before going in, so the Taj started looking more and more like a huge Cadbury's white chocolate bar the more my stomach grumbled. As I left, the sandal-sock wearing Europeans started piling in through the east entrance with loaded cameras in their holsters. It was time to get the hell out of there!
Nepal and its border with India was our next destination. We would try and make it to Bambassa, an entry point into Nepal, within two days of leaving Agra. That was feasible, or so it looked on the map. The first day heading Northeast was a nightmare. The road quickly turned to shit once we left Agra and we really put the bikes through the paces, tackling one of the worst stretches of potholed road we had been on so far. The second day brought us to a newly constructed two-lane highway, part of India's national highway project, a move that would link all the major cities of India and propel the country further into its vision to join the developed countries of the world, and bask in the so called success of first world economic growth. This new highway stayed smooth for the remainder of our ride to the border. We wanted to check the current security situation at the border crossing, and whether it would be feasible to ride the bikes into Nepal. Nearing the border, we rode through Chestnut groves, past fields green with newly sown wheat and barley, and huge old oaks reaching over the road, forming a canopy where colourful birds went frantically about their morning business, singing all the while. We could have been in any English countryside, minus the animal driven carts and the occasional shoeless kid running along the side of the road with a stick chasing a tire.
Indian immigration required us to leave our passports at the Indian side of Nepal, about a kilometre before the border. We pressed on through no mans land, a peaceful area with Indian couples strolling through the grassy woods smiling and Nepalese and Tibetans walking freely between the two countries. Nepal immigration was so friendly and helpful. They said that it wouldn't be a problem taking the bikes into Nepal. I was up for it, but Troy was concerned about security on the bikes if we did this. The recent Maoist bombings concerned him, and me to a certain extent. A call to the chief security officer in Kathmandu confirmed Troy's concern. The officer advised us strongly that we should not attempt to ride into Nepal. I wasn't so sure that we were being told the truth. You know how over dramatic many government security warnings can be on other countries. I had spoken to so many travelers that had come from Nepal first hand with a real sense of traveling, and had said that it was fine, even on a bike. I guess it came down to the fact that I really wanted to see Nepal, and Troy didn't. Later in Kathmandu, I found out that so many Israeli's had ridden their bikes into Nepal without a problem. In the end, I stayed with my buddy and we headed up north on the Indian side instead. I wasn't ready to leave my friend Troy. Before we left Nepal though, we rode the bikes just a little further into Nepal and were allowed by immigration to stop by a restaurant and have a quick beer. I suppose that not many people could say that they've been into Nepal without a visa on an Enfield and enjoyed a cold beer on the other side to celebrate the occasion!
We rode further north through the state of Utturanchal, keeping the western Nepalese border always to our right. Excited about getting back into the mountains and immersing ourselves in the fresh Himalayan air, the grins returned and we eyed each other competitively as we raced each other up through the switchbacks and over mountain passes at good speeds. As much fun as it sounds being on a bike through India, there's a constant concern for the bike and often times it is completely draining both mentally and physically. By the time we reached the Himalayas, I had thought several times about giving up, just leaving the bike and carrying on without the stresses attached to motorbiking in India. When everything you do, there's a sensory overload, it becomes too much and the fun disappears. I've stood there by the side of the road quite a few times and screamed in frustration at a passing goat or a dumb looking sheep. All we wanted to do many times was just pull over by the side of the road to buy a bottle of water and a cup of tea but then so many locals would come out of the woodwork and surround us, staring intensely and asking the usual questions. I grew tired of the constant staring. We craved to be able to sit in silence and have a mental break from the bike and tune out for a few minutes. Other times, Indians have been so overwhelmingly helpful and friendly when we have lost our way or have had trouble buying supplies due to the language barrier. The frustration boiled many times when breaking down on some lonely stretch, and after going systematically through the mechanics of the bike, even then not having a clue where to start pulling the thing apart to get to the problem. It's definitely no holiday and I think I've developed a love hate relationship with India. Tom, one of my good mates, emailed and asked me if I liked India...that's a hard question to answer, but I'll try and answer that a little later. I suppose I could have left at any time, but I didn't want to give up, not yet anyway.
The heat and flatness of the plains were now well behind us as we rode ever higher into the mountains, through whispering pine stands and then suddenly back down into steep ravines, over old wooden bridges protecting us from the thundering rapids and freezing glacial waters below. It was so peaceful. I felt energy and motivation returning in me that I had lost to the heat and dust of the plains weeks ago. The road further north was inaccessible once we got too close to the first glacier, too much like a yak trail to get the bikes through. We decided to double back to Darchula, a small outpost town situated on the raging Kali River, which separates India from Nepal. Darchula had a very rough frontier feel about it.
It was the following day in Darchula where, in the morning, I gazed out over the town below to the river that separates it, that I saw a second potential opportunity to sneak into Nepal. There, across the river, stretched a suspension bridge connecting Nepal to India. Locals, Nepalese and Indians, were creating a scene of organised chaos as they used the bridge for their mornings commerce. Perhaps we could sneak across disguised as Sherpas, or dress in a sari? Me being six foot one and Troy the same height, we doubted it would work. As we approached the bridge, we passed dozens of little people, I mean, four and a half feet high, dark leather faced men and women, carrying loads five times there height on backs bent over from years of working as human yaks. It was chaos,or so it seemed to us, and as we crossed, the wide loaded little people almost bowled us over a few times. The other side presented us with half a dozen Nepalese soldiers with AK47's by their sides and twitching fingers at the trigger looking very seriously over us as we approached. Our dumb traveler faces were put on and we smiled and said a big Nameste to all of them. They eyed us up and asked us what we were doing there. I asked if we could just spend some time looking around and offered to hand my passport over as a security deposit. They told us that they had not seen a tourist here in a very long time, and looked confused. In the end we were very kindly escorted by a blue and black camouflaged soldier around the village. Troy bought a pair of fake Nike's for a great price, and some hiking socks. People waved at us and generally seemed more open and friendly than the Indian side. Duty free shopping in Nepal, it's pretty damn good!
From Darchula, we rode to the small village of Munsyari higher up in the mountains, 3000 metres above sea level. An overload of amazing sights and smells consumed us that day. The thin dirt road we had chosen led us up a narrow gorge and along a small tributary river. That's a day that I remember very well. We floated that day...sweet smelling meadows full of butterflies and thick spring air swirled all around us, shaggy cows with soft chiming bells around their thick coated necks ate contentedly in flowering fields, low stone hedges sprang up to the sides of us, and every now and then a small wooden bridge would take us over a gurgling brook filled with crystal clear mountain water. We even stumbled across a small wooden cart connected to an overhead wire suspended across the river. Obviously it was used to carry people or goods from one side of the river to the other. I had to try it out. The whole day was like a long peaceful scene out of The Lord of the Rings, and Frodo Baggins and Samwise Gange rode on Enfields instead of on foot. And every now and then, we would see der Little People.
Munsyani is an even smaller town than Darchula, more like a village clinging precariously to a mountainside separating two massive valleys, consumed by mist and wood fire haze. A crazy Scottish guy we had met a few days before over a few local scotches recommended the place. We checked into a small guesthouse in the cold and misty little village. There were a few hours of sunlight left and the clear blue sky above us showed that the weather would most likely be fine for the rest of the afternoon. We had run into rain earlier that day in the last valley, but it had now cleared up. A boy from the guesthouse said that he could take us to a lake along a ridge a few hundred metres above where the village lay, so we drove the bikes further higher into the snowline before parking them by the side of the road and walking along a ridge line and trail marked by a small stone hedge. A well educated older guy from Mumbai with a recent triple heart bypass also joined us. As we walked through stands of rhododendron trees showing off their rich red flowers and dressed in winter jackets of thick moss, I noticed then how remote and silent this place was. When I stopped walking, all that filled my ears was the beat of my own heart and my laboured breaths. The only other sound was the wind, whistling occasionally through the pine trees and tossing up flurries of snow. When I was a kid, I used to read The Lion, the Witch and the Wardrobe by CS Lewis. This is exactly what this place was for me. A couple of hours of crunching in and out of snow, we came to the lake, which sat in a tiny glen surrounded by fir trees and short winter grass. That lake gave me a sense of peace yet loneliness as we sat by its bank on the grass, perched up there away by itself. On the way back, as the last rays of day lit the snow peaks up in shades of bright pink before us and stars appeared, the mountains looked so wise and ominous. These mountains seem to keep a purity and peace between them, like an agreement kept for centuries by The Elders. Maybe I've just read too many fantasy books over the years, but it seemed like the progress of human destruction would never reach here. Maybe it never would. I hoped it wouldn't. Deserts have many tales to tell, but mountains keep many secrets.
Unfortunately, all good things must end. On the way further east a few days later, I had an accident on the bike. It was a head on with another car. I came out fine, but the bike didn't. If I had been on a smaller bike, I wouldn't have come out too well either. Pegasus took all the impact. It was my fault. Troy and I were probably going too fast through some s bends in a pine forest area when I took a sharp right bend too close. A small four door Suzuki came around the corner at the same time, not using his horn as warning, so I didn't hear him until it was too late. He apparently didn't hear my horn either which is louder than many truck horns. Who knows, it doesn't matter. We paid the driver a couple of thousand rupees after getting him down from five thousand, and I drove the messy bike into the next town to have repairs done. That day I completely lost the motivation to carry on with Troy, so decided to get the repairs done and head straight to Delhi and sell the bike. I saw a ghost that day and it scared me.
It was a sad farewell. Troy and I had been together on the road for almost three months now and had turned into great mates. But I knew I'd see him again, and such is the way of traveling, you never really get used to saying goodbye. On the way back to Delhi, I skirted around the border of Corbett Tiger Reserve. I didn't see a tiger, however after passing a few elephants walking along the road, I had to lock the brakes up, skidding to a halt a metre short of an 8 foot long cobra, poised directly in front of me and ready to strike. It watched me with it's beady eyes and bobbing head. I shat myself. Should I gun it and try and pass, should I drop the bike and run the other way, or should I just sit there dead still and see what happens? I think the snake made my mind up for me, as it was so close that any move I made off the bike, I think would have brought a certain fate to me. I decided to sit there as quiet as a mouse and wait. My lack of being able to move also helped. Good move. The snake must have finally felt less threatened by my none evasive move, and slid off into the forest below. I let out a very long breath. Fuck!!!
Delhi, a teaming metropolis of a city, was a breeze to drive through the afternoon that I arrived alone. An hour or so earlier on the highway into Delhi, there had been a police barrier and a half dozen police officers waving drivers down for various reasons. I didn't have a front numberplate on the bike, never had, and so as I approached they waved at me to stop. Doing the usual, I accelerated and sped through the barrier without hesitation. They screamed at me to stop but I was well past already. One thing I learnt in India - never stop for a cop! They'll try and get whatever bride they can out of tourists to fill their own pockets. In Delhi, the drivers were courteous, or more than many other Indian cities, the streets were wide with trees and gardens, and everything (at least in New Delhi) had an order about it. I don't know why travelers hate Delhi, I didn't mind it at all. I spent a week there staying in Para Gange, the Koh San Road of Delhi. The heat though was getting worse and worse by the day, with a thick pre monsoon stickiness about it. A few days later, I had an inquiry about Pegasus from Mark, a really nice Dutch guy who had just arrived and wanted an Enfield to drive up into the north. He immediately liked the bike, and a couple of days later I sadly looked on as Mark waved goodbye with Pegasus now in his hands. I didn't realise how much I would really miss that bloody bike. As much trouble as it was over the months, I grew very attached to it. At one stage I was thinking about importing it back to Oz, but looked into it in Delhi and the costs were way beyond my budget would allow. Maybe I would come back one day and ride again an Enfield through India, but I don't think that there's any greater bond than the bond with your first Endfield.
I am now relaxing in Pokhora before I start my trek to Annapurna Base Camp. Pokhora is a small and beautiful town sat next to an emerald green lake, with the Annapurna Range reflected to the north. I've just finished a Vipassana Meditation course - 10 full days, 10 hours a day solitary meditation in complete silence. I'll write about that shortly. But now, I reflect back on my time on India. It's easier to put things in perspective from my vantage point here and away from the chaos. India is the dirtiest, loudest, most disgusting country I have been to so far. It's people are completely frustrating to deal with, have no consideration for personal space or personal belongings, and live in a completely distinctive caste system that, to me, seems more discriminatory than the upper class system in England. Everywhere you walk in India, there is death happening or waiting to happen, and life being born from garbage piles in the form of a human being or something similar. Leper beggars reach for you from every hidden or unhidden piss smelling corner and ask for money, holding out their deformed limbs or showing you their deformed other parts. The smell of decay is overwhelming The power of bureaucracy is overwhelming. India has way too many people - you are never ever alone in India. India is not a holiday, it's an experience. I hate India for all the reasons above and many more. But these reasons are also the root of my new love for India as well. I have never been so utterly frustrated, overwhelmed, sad, happy, enlightened, challenged, mesmorised, and forced to open all of my senses and let India completely wash over and consume me...because that's what India does if you let it - don't fight it let the current take you wherever you are destined to land. India is raw, and completely contradictory in so many ways. India has created an insatiable fire in me, and the only way to quench that fire is to go back again.
I will return to India one day.
I've been in Nepal now a few weeks. It's a stunningly beautiful country and I've found the people more laid back than in India (except for Goa). I suppose in a way, India cut a deep surgical operation through me as it does for most people who travel it for the first time, and now Nepal is acting as that soothing after balm I needed.
That's it for now. I hope to update again in about two weeks after the Annapurna trek, and give you an idea of what it's like to sit in meditation 10 bloody hours a day and not be allowed to speak to anyone for 10 days. It really is a mind game of monstrous proportions!


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A cover letter is your first opportunity to impress a potential employer, and when you work in sales, you know how important a first impression can be.
While the goal of a cover letter is to introduce yourself, explain why you're a good fit for the position and express your interest in the company, a cover letter for a sales position will be more targeted. Are you unsure if your cover letter can close the deal? Read on for tips on what to include.
Strut your sales statistics
If you've already held a sales position, this is your opportunity to show off your winning numbers. Sandra Lamb, a career, lifestyle and etiquette expert, says to include your most important achievements:
- Sales success rate, expressed in numbers.
- Customers or clients retained and converted to new product areas.
- New customers or clients gained.
- Increase in profits and sales levels.
Being specific has more impact than simply saying you were one of the best sales team members at your company.
"Stats have to be included," says Marcia LaReau, president of Forward Motion LLC, a career strategy firm. "If they are going from small-number tickets to much higher tickets, they should use percentages rather than the numbers, or at least give context, such as, 'In year two, brought in $800K in contracts, which represented 30 percent of market share in the region, up from 18 percent in year one.'" The company's size doesn't have to determine how well-qualified you are for your next position. By assigning numbers to your past successes, you're giving the hiring manager an idea of how you would perform if on his team.
Share stories of your success
Sometimes, stories can better express success than numbers can. While you should include your sales stats, incorporating a story of how you overcame a challenge or closed an important deal can be just as informative.
"Be specific and provide examples," says Keith Wolf, vice president of marketing at Murray Resources, a Houston recruiting firm. "Include clear and measurable proof, like the number of new accounts opened. Also, consider including a brief story about a particularly difficult sale you made. Perhaps it was a cold call that you turned into a large account. Hiring managers love to hear stories of perseverance turning into results."
Prove you have a plan
While it's important to include your sales records and stats, it's also crucial to show that you understood what you were doing in your role. "A key element in the cover letter for a sales position would not only be the metrics -- increase in sales percentage, overall sales, etc. -- but the how; how did you achieve this success?" says Beth Carter, executive recruiter and certified executive, business and career coach at Carter Consultants Ltd. "Write about your sales tactics; for example, 'I increased sales in two years by 20 percent by identifying an untapped market in this industry.' Companies want to understand how you can replicate your past success for their company." By showing that you understand the market, can spot an opportunity for a sale and can reproduce your sales accomplishments at a different company, you're marketing yourself as a flexible and experienced sales representative.
Reiterate your interest in the company
After you've proved your sales skills, discuss why you want to join the team. A cover letter should strike a balance between introducing yourself and expressing your interest in the company. Prove that you've done your research, and give examples of why you admire the company, what made you interested in working for it and how you could contribute to its goals.
Susan Ricker is a writer and blogger for CareerBuilder.com and its job blog, The Work Buzz. She researches and writes about job search strategy, career management, hiring trends and workplace issues.
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Reasons to be Cheerful
It's usually considered that when feminism engages with state institutions, it loses its radical edge and became compromised and weakened. But is that really the case? Jonathan Dean argues that mainstream women's organisations are actually a lot more radical than they are given credit for, and that we can be optimistic about the future of British feminism.
It is well known to readers of the f word that feminism is frequently portrayed as anachronistic and irrelevant. I shall not discuss this particular issue here. What I will discuss is a related, though different, perception of feminism. This is the view that feminism, as well as having declined, has become less radical to the point that, where it does exist, it is seen as watered-down; lacking the critical force it once had. Crucially, this view can be found both within the popular media (I thought it was implicit in the recent BBC4 documentary Angry Wimmin), but it is also a view frequently expressed by both academic feminists and veterans (for want of a better word) of second-wave feminist activism. The term 'deradicalisation' could, I argue, be used to describe this view of contemporary feminism. Whilst it is accurate up to a point, it overlooks important processes going on within contemporary British feminism, as I shall explain.
there is a distinct tone of melancholy, a longing for a return to the 'good old days'
The 'deradicalisation' idea is based on a particular set of assumptions about the recent history of British feminism, centered around the view that contemporary feminism has completely lost its more radical and critical dimensions. Often, but not always, the view is expressed with a distinct tone of melancholy, a longing for a return to the 'good old days' of militant activism. Basically, this view contends that there was once a time (typically around the mid 1970s) when feminism attracted large-scale grass roots support and was militant, hard-line, radical and uncompromising. Whilst there were differences between the various strands of feminist thought, it is widely assumed that they all shared a commitment to radical, grass-roots activism. What is also crucial is that they also tended to regard looking to the state, or British political institutions more generally, as illegitimate from a feminist perspective. Put simply, these feminists took the view that if political institutions are run according to patriarchal / anti-feminist principles, then feminists would have to make severe compromises if they were to look to these institutions for support.
There is a perception that some time around the mid 1980s, feminists moved into British state institutions (the Labour Party, the Greater London Council (GLC), other local councils, the Equal Opportunities' Commission (EOC)) and that in doing so, they lost their links with grass-roots support, and consequently became less radical. Feminists are therefore now seen as simply trying to make small-scale reforms within these institutions, rather than expressing grander visions of more fundamental change. Often, there is seen to be a trade-off between remaining autonomous (i.e. not becoming involved in political institutions) but being faithful to your principles on one hand, and having influence within decision-making bodies whilst compromising your principles, on the other. In the BBC4 documentary, Linda Bellos epitomised this viewpoint, arguing that she preferred to do her politics on a shoestring but remain true to her principles. She was deeply critical of feminist involvement with the GLC which she saw as leading to feminist principles being compromised.
in the mid 1980s, feminists moved into British state institutions and in doing so they are believed to have become less radical
It is no coincidence that the two terms used to describe the movement of feminists into institutions have slightly derogatory connotations. The word 'femocrat' originated in Australia but has become used as a general term referring to feminists, or women with feminist sympathies, working within state bureaucracies. It is derogatory to the extent that it emphasises feminist involvement within institutions which are seen as being anti-feminist: it implies that these women have compromised their principles, or 'sold out.' In the BBC4 documentary, the feminist journalist Julie Bindel highlighted this view when she talked rather disparagingly of the increasing feminist involvement with the GLC in the mid-1980s: 'I couldn't bear all that town hall feminism... femocrats we called them,' she says.
So, the term 'femocrat' conjures up images of women working in state instituions without significantly changing those institutions. Similarly, the term 'liberal feminism' has roughly similar connotations, with its emphasis on the involvement of women in public life without having a theory of 'systemic' oppression.
the whole debate is based on an artificial opposition between two kinds of feminism: radical feminism and reformist liberal feminism
But is this view of 'femocrats' and 'liberal feminism' justified? Well, for the most part, no. The stereotyped view of liberal feminism is basically just an artificial construct created by more radical feminists. This might all sound rather abstract, but this is a hugely important issue for contemporary feminists in the UK. I would argue that the whole debate is based on an artificial opposition between two kinds of feminism: radical, autonomous, grass-roots feminism on the one hand, and reformist liberal feminism operating inside British political institutions on the other. This is especially the case in some strands of academic feminism, in which one finds a strong tendency to debate the pros and cons of feminist engagement with 'the state.' This is interesting up to a point, but it is all rather abstract and, as such, tends to reinforce certain negative stereotypes of liberal feminism. What it overlooks is the way in which, while it is true that feminists have recently become more willing to work with, rather than against, British political institutions, this does not mean that British feminism has necessarily lost its radical or critical edge.
A quick look at the Fawcett Society, arguably the most important pro-feminist organisation in the UK at present, confirms this view. In many ways, Fawcett adheres to the stereotype of liberal feminism outlined above: they emphasise campaigning within British political institutions (e.g. by asking politicians to address women's issues, and trying to get more women into the House of Commons), and a lot of their proposals seem relatively modest. For this reason, when more radical feminist authors mention the Fawcett Society, they are often rather dismissive of the organisation. However, this view overlooks the ways in which Fawcett's policy agenda is in fact informed by a much more radical vision of social transformation. Whilst their proposals in terms of issues of women's political representation (e.g. use of all-women shortlists) might seem fairly moderate, their proposals on issues such as maternity and paternity leave, domestic violence, the criminal justice system, and reform of the EOC would all require quite profound changes in the structure of gender relations in the UK.
British feminism has not necessarily lost its radical or critical edge
When one reads their literature, which outlines the need for a new 'equalities' body to replace the EOC, one sees that they are profoundly critical of the popular assumption that feminism is no longer necessary and that all remaining inequalities are simply a matter of choice. In that sense, there is a belief in the need for large-scale structural change to combat existing gender inequalities, as well as an emphasis on the need to profoundly alter public perceptions. These moves are arguably more in keeping with radical feminism than the stereotype of moderate liberal feminism outlined above.
Furthermore, their proposals regarding maternity and paternity leave would require a profound shift in popular understandings of the work/life balance, as it would lead to a less aggressively competitive understanding of the job market. In addition, their biting criticisms of the criminal justice system emphasise that nothing less than a profound shift in understandings of gender within the system will be sufficient. In this sense, it is profoundly misguided to regard an organisation like the Fawcett Society as a moderate liberal feminist organisation which only seeks to advance small-scale change within existing institutions. Whilst the Fawcett Society may not be radical feminist in the traditional sense, its vision is nonetheless fairly radical (given that its goals would require a profound transformation of gender relations), even though that vision may be informed by liberal rather than radical feminist insights. One must also bear in mind the fact that contemporary feminist/gender equality organisations are typically not especially resource-rich. Kate Bellamy of the Fawcett Society pointed out that she would like to see Fawcett engage with more activist forms of campaigning but that, at present, this not really feasible given the organisation's limited resources.
In terms of the issue of liberal versus radical feminism, Women's Aid is an interesting case. Women's Aid's roots are in the more radical grass roots feminism of the 1970s, but have since become a more professional campaigning organisation. Women's Aid publishes smart, glossy documents, often plays an advisory role in the formation of relevant policy, and also uses celebrity endorsement to further its aims (Will Young is a Women's Aid Ambassador at present!). Thus, a case could be made that Women's Aid has lost its critical edge in moving form a more radical to an arguably more liberal position. However, this is categorically not the case. A cursory glance at Women's Aid's policy proposals reveals an emphasis on the need for profound changes in how domestic violence is treated by politicians, the legal system and the public at large. Crucially, Women's Aid emphasise how nothing less than a profound change in gender relations will be sufficient to end domestic violence, given that they see the latter as being rooted in historically entrenched structures of male supremacy. Thus, although Women's Aid has moved from a defensive to a more engaged position in terms of state institutions, the idea that this necessarily compromises their ability to push for broader, more radical change is fundamentally unsound. Women's Aid has maintained its critical, uncompromisingly feminist message despite having become more willing to engage with British political institutions.
Women's Aid emphasise how nothing less than a profound change in gender relations will be sufficient to end domestic violence
This points towards a number of conclusions. Whilst radical feminism as an activist movement is arguably less influential than it used to be, a number of radical feminist concerns can still be found both in academic and activist feminist circles. Of particular interest here is the issue of feminist involvement with the state and political institutions more generally. In much feminist literature, one often finds a reluctance to endorse feminist involvement with state institutions: in fact, there is often something of a romanticisation of autonomous feminist activity. This view argues that engagement with British political institutions forces feminists to compromise, reducing the effectiveness of the feminist critique. However, when one looks at the Fawcett Society and Women's Aid, one can see that this view is not helpful: whilst these organisations do engage with the state, they are still willing and able to articulate visions of a profound shift in gender relations. Therefore, the view that feminists used to be radical militants and are now all moderate liberal reformists simply does not hold. It is true that since the 1980s feminists have looked increasingly to existing political institutions to further their aims, but this has clearly not resulted in an automatic compromising of feminist principles.
This means that feminist engagement with British political institutions is not necessarily a bad thing. After all, some of the major feminist advances of the twentieth century could only have been achieved through particular policy changes. It is therefore important to resist having a romantic view of militant and autonomous politics, and to accept that engaging with existing British political institutions is necessary for feminism to be effective.
Similarly, what this also shows is that the distinction between radical feminism and liberal feminism might actually be quite problematic. This is somewhat remarkable given that these two positions are often seen as polar opposites. Liberal feminism might be characterised as a feminism which is not in any way prescriptive in terms of the sort of sexual, cultural and economic choices woman make, and this is certainly the basic view underpinning both the Fawcett Society and Women's Aid's campaigning activities. However, this does not mean that their views are not radical, as both organisations are seeking broad structural change.
What this points towards is that it would be worth our while trying to move beyond the distinction between radical and liberal feminism. Perhaps what we are dealing with might be called 'radical liberal feminism.' It might be a bit far-fetched to try to persuade everyone to join together in a big radical liberal feminist coalition, but it might be a helpful term to use. It could have the potential to help devise a feminism which could gain popular support by moving away from the more alienating aspects of traditional radical feminism, but without losing the feminist vision of a radical transformation of gender relations. Given that radical liberal feminist sentiments are fundamental to the Fawcett Society, Women's Aid, and indeed many of the views expressed on this website, perhaps the seeds of a large radical liberal feminist coalition are already in existence!
it would be worth our while trying to move beyond the distinction between radical and liberal feminism
Maybe this is wishful thinking, but I think it is important to try to think beyond rather false oppositions (such as liberal vs radical feminism) which can have a rather paralysing effect on feminist activity. Given that the seeds of a 'radical liberal feminist' movement are perhaps already in existence, it might be worth our while thinking about trying to establish connections between 'grass roots' activity (such as this website) and more formal organisations such as the Fawcett Society and Women's Aid. These groups are arguably the most significant feminist groups in the country, and have similar agendas, and might allow for a greater flow of ideas between grass-roots groups / sites and more formal organisations which have closer links with established political institutions. These ideas are all rather cursory at the moment, and I am not really sure how they might be put into practice, but I think it would help the feminist cause if these groups were able to join together a little more rather than exist in isolation from one another.
I am trying to look at some of these issues in my PhD thesis, and would be very interested to hear what fword readers think about the issues addressed in this article.


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I had worst ever living experience at Colonial heights, Lincoln,NE. They will slap you with the charges rangin Read Moreg from carpet stain,wall paint becoming dull when you want to move out of this apt, and if you ask for any proof of damage they will not send you any photos, will ask you to fly to Lincon NE from another city which I already moved to.
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Spectacular, Creepy, Or Spectacularly Creepy? Taylor University's Students Stay Silent Until The Tenth Point
In one of the cooler traditions in college sports, Taylor University's students remain completely silent until their team scores its tenth point of the game. Then, once the Trojans do score that tenth point, the place loses its mind. Pent-up pep, ahoy.


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> Home > About ECMC > News > Press Release
Michael Young comes to the Medical Center with demonstrated success in hospital system leadership for quality care and business growth.
In December 2004, the Erie County Medical Center (ECMC) Corporation Board of Directors concluded a national search for a new Chief Executive Officer with the appointment of Michael A. Young, M.H.A., F.A.C.H.E. In addition to overseeing hospital operations, the Chief Executive Officer of ECMC sits as a member of its board. Michael Young was the unanimous selection of the board following a four-month national search involving a national search firm, members of the corporation's board of directors, medical leadership, senior management, and organized labor. By the end of December he was already spending time at ECMC preparing for his new role, and by the first week of January, Young had begun as ECMC's new leader.
When asked about his management approach, Mike Young explains, "I start with a blank piece of paper and design how care should be delivered, not how it is currently being delivered. My style is to always start with the question: What's best for the patient?" Young uses a diagram to describe his philosophy of patient care. In this diagram, he shows the patient at the center point with services revolving in circles around the patient. It is this focus on patient-centered care that has been the underlying philosophy that has provided the basis for Mr. Young's effective decision-making and success in hospital system administration and business development.
Mike Young said, "ECMC has been headed in the right direction with a focus on quality care." Young arrived at ECMC just as the Medical Center received its "Gold Seal of Approval" in "Quality Health Care & Safety" for a three-year period (2005-2007) from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Young believes every Western New York resident should have access to the highest quality health care available and he intends to better position ECMC to move more swiftly toward a culture of excellence in care and customer service.
In 2004, ECMC went through a lengthy process to be designated as a public benefit corporation (PBC). Mike Young says he can lead ECMC with an opportunity to do things differently, since the health system is now able to function more independently of state governmental rules. With the PBC designation, ECMC can now partner with physician groups and other businesses. "We are beginning discussions with potential business partners that can enhance the delivery of care and enable ECMC to be run more efficiently and cost-effectively. Our goal is to continue quality patient care and make better business decisions that will give us the resources to provide the best healthcare possible to everyone in Western New York. This community deserves only the best," said Young.
Although Mike Young's primary goal is to focus on the quality of patient care, he has identified other important priorities for ECMC. Young believes ECMC provides excellent health care, but must do so more efficiently. He has already begun to improve operating room turnaround times, patients' length of stay, and the number of patients ECMC is able to see on a daily basis. "We were able to improve these areas, and many others, at Lancaster General Hospital and make it the place of first choice for many patients. While ECMC is the place of choice for many of its services, it will become the place of choice for all of its services in the near future."
Michael Young served for 15 years as President and Chief Executive officer at the 563-bed Lancaster General Hospital in Pennsylvania's Amish community. Under Young's leadership, Lancaster General enjoyed tremendous success and growth. Young began his career in pharmaceutical sales in Pennsylvania. The first management position Mike Young held was at Shadyside Memorial Hospital where he was hired as assistant to the president. In 1986, he accepted a position as vice president at Lancaster General. By 1989, Young took over as president and chief of the Lancaster General Hospital system.
A native of Pennsylvania, Young graduated cum laude with a Bachelor of Science degree and magna cum laude with a master's degree in healthcare administration from the University of Pittsburgh.
The Erie County Medical Center Corporation is the area's leading health care provider and one of the country's most modern, functional, and efficient health care delivery systems. ECMC Corporation encompasses on- and off-campus health centers, over 40 outpatient specialty care clinics, an advanced academic medical center (with 550 inpatient beds and 156 skilled nursing home beds), and the Erie County Home, a (586-bed) skilled nursing facility. The Medical Center, ranked among the nation's 100 top hospitals for cardiac and intensive care, serves as the regional center for trauma, burn, and rehabilitation, and a major teaching facility for the State University of New York at Buffalo. Most ECMC physicians, dentists, and pharmacists are dedicated faculty members of the University. The ECMC Corporation is dedicated to being the medical center of choice through excellence in patient care and customer service.


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Rhode Island to Counsel Survivors of Club Fire
PROVIDENCE, R.I. (AP) -- Rhode Island officials announced plans Tuesday to create a program to offer counseling to survivors of a nightclub fire that killed 100 people nearly a year ago.
The project is designed to provide mental-health and substance-abuse counseling to survivors of the Feb. 20 blaze at The Station in West Warwick, south of Providence.
The effort, organized by the state Department of Mental Health Retardation and Hospitals, will be paid for using $495,000 in federal funds.
The program will also provide training to help health workers and clergy care for 200 people who suffered serious burns and other injuries.
It is intended as a ``source of help for survivors, family members, first responders and others who may be suffering,'' Gov. Don Carcieri said in a statement.
The fire started when a rock band's pyrotechnic display set fire to flammable foam placed around the stage as soundproofing.


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Maina, William K. MBChB, MPH*; Kim, Andrea A. PhD, MPH†; Rutherford, George W. MD, AM‡; Harper, Malayah MA§; K'Oyugi, Boniface O. PhD, MBS‖; Sharif, Shahnaaz MD, MMed, MSc¶; Kichamu, George MSc‖; Muraguri, Nicholas M. MBChB, MMed*; Akhwale, Willis MBChB, MMed, PhD¶; De Cock, Kevin M. MD, FRCP(UK), DTM&H†; for the KAIS Study Group
*National AIDS and Sexually Transmitted Infection (STI) Programme, Ministry of Health, Nairobi, Kenya;
†Division of Global HIV/AIDS, Center for Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya;
‡Global Health Sciences, University of California, San Francisco, San Francisco, CA;
§The Joint United Nations Program on HIV/AIDS, Nairobi, Kenya;
‖National Council for Population and Development, Nairobi, Kenya; and
¶Ministry of Health, Nairobi, Kenya.
Correspondence to: William K. Maina, MBChB, MPH, Ministry of Health, National AIDS and STI Control Programme, Kenyatta National Hospital Grounds, 19361-00202 Nairobi, Kenya (e-mail: firstname.lastname@example.com).
KAIS 2012 was supported by the National AIDS and STI Control Programme (STI), Kenya National Bureau of Statistics (KNBS), National Public Health Laboratory Services (NPHLS), National AIDS Control Council (NACC), National Council for Population and Development (NCPD), Kenya Medical Research Institute (KEMRI), US Centers for Disease Control and Prevention (CDC/Kenya, CDC/Atlanta), United States Agency for International Development (USAID/Kenya), University of California, San Francisco (UCSF), Joint United Nations Team on HIV/AIDS, Japan International Cooperation Agency, Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Liverpool Voluntary Counselling and Testing (LVCT), African Medical and Research Foundation (AMREF), World Bank, and Global Fund. This publication was made possible by support from the US President's Emergency Plan for AIDS Relief through cooperative agreements (#PS001805, GH000069, and PS001814) from the US Centers for Disease Control and Prevention, Division of Global HIV/AIDS. This work was also funded in part by support from the Global Fund, World Bank, and the Joint United Nations Team for HIV/AIDS.
The authors have no conflicts of interest to disclose.
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention and the Government of Kenya.
Abstract: AIDS Indicator Surveys are standardized surveillance tools used by countries with generalized HIV epidemics to provide, in a timely fashion, indicators for effective monitoring of HIV. Such data should guide responses to the HIV epidemic, meet program reporting requirements, and ensure comparability of findings across countries and over time. Kenya has conducted 2 AIDS Indicator Surveys, in 2007 (KAIS 2007) and 2012–2013 (KAIS 2012). These nationally representative surveys have provided essential epidemiologic, sociodemographic, behavioral, and biologic data on HIV and related indicators to evaluate the national HIV response and inform policies for prevention and treatment of the disease. We present a summary of findings from KAIS 2007 and KAIS 2012 and the impact that these data have had on changing HIV policies and practice.
Despite the advent of highly active antiretroviral therapy (ART) and availability of a host of effective prevention interventions, HIV remains a significant global health problem, and sub-Saharan Africa bears the greatest burden of HIV disease. The HIV pandemic has been extensively studied epidemiologically, yielding crucial information on trends, risk factors, and successes and failures of HIV prevention and treatment programs.
Approaches to monitoring HIV/AIDS epidemiology in a country include HIV and AIDS case reporting, surveys, and other special studies. In sub-Saharan Africa, HIV sentinel surveillance among pregnant women has been used to formulate estimates of HIV prevalence and trends in the general population. In addition, direct measurement through population-based surveys with serologic testing has been used to provide comprehensive information on the epidemiology of HIV in a country by linking demographic and behavioral profiles with HIV infection. Such surveys have included Demographic and Health Surveys, Behavioral Surveillance Surveys, Multiple Indicator Cluster Surveys, Reproductive Health Surveys, and AIDS Indicator Surveys.1,2
AIDS Indicator Surveys were introduced to provide countries with generalized HIV epidemics with a standardized tool to provide indicators for effective monitoring of HIV/AIDS. These data are key to ensuring an informed response to the HIV epidemic and allow for comparisons across time and settings.2 This article reviews the key findings of Kenya's first and second AIDS Indicator Surveys (KAIS 2007 and KAIS 2012) and explores how findings from AIDS Indicator Surveys can influence changes in national HIV policy.
KAIS 2007 was a population-based, cross-sectional household survey that used a 2-stage stratified cluster sampling design to obtain a nationally representative sample of persons aged 15–64 years.3 The first stage included selection of clusters from the National Sample Survey and Evaluation Programme (NASSEP IV) household-based sampling frame, developed in 1999; the second stage included selecting a sample of 25 households within each selected cluster. The sample was powered so that the survey could provide national and subnational estimates of HIV prevalence, including regional and urban/rural residential estimates. Household questionnaires were administered to the head of household to identify eligible household members and capture household characteristics. Household members were administered individual questionnaires to collect information on demographic, behavior, knowledge, and access to services. Blood specimens were collected for centralized testing for HIV, syphilis, and herpes simplex virus type 2 infections and CD4 counts for HIV-positive samples.
Before KAIS 2007, only one other national household survey had been conducted that included HIV testing: the 2003 Kenya Demographic and Health Survey (KDHS 2003).4 Key differences in KAIS 2007 compared to KDHS 2003 were the expansion of the national sample to an upper age limit of 64 years, serological testing for herpes simplex virus type 2 and syphilis infection, CD4 count measurement among HIV-infected participants, new questions about knowledge of participants' own and their partners' HIV status, assessment of access to care, treatment, and prevention services, and estimation of the number of persons in need of ART and related care services.
Key findings from KAIS 2007 resulted in important changes to the national HIV program in the areas of HIV prevention, care, and treatment. In Table 1, we summarize these findings and how HIV programming and policy have changed in response to these data.
KAIS 2007 found that 7.1% of Kenyans aged 15–64 years and 7.4% of those aged 15–49 years were infected with HIV.3 There was disproportionate distribution of HIV infection by sex and age; women had nearly 30% more infections than men of the same age, with the difference more pronounced in younger women. There was regional variation in HIV prevalence, ranging from a high of 14.9% in Nyanza region to a low of 0.8% in North Eastern region. HIV prevalence was higher among urban residents (8.4%) than rural residents (6.7%).3 Among married and cohabiting couples, 5.9% were HIV serodiscordant, where one partner was HIV infected and the other was HIV uninfected.3 This translated to approximately 340,000 discordant couples in the country.4
Serologic testing for recent infection showed stable HIV incidence among persons aged 15–49 years, ranging from 0.8–1.0% in 2003 to 0.6–0.7% in 2007.6 In 2007, the majority of recent infections (85.6%) were detected in married or cohabitating individuals, broadly consistent with findings from the Joint United National Program on HIV/AIDS modes of transmission model that suggested that almost half (44%) of new infections in 2006 were occurring among persons in marital or cohabiting relationships in Kenya.7
Results from KAIS 2007 confirmed that the HIV epidemic in Kenya was stable but substantial. With approximately 1,400,000 persons living with HIV in 2007, it was evident that significant revisions to the national strategy for HIV prevention, care, and treatment were needed to change the trajectory of the epidemic.
HIV testing and counseling is essential for identifying HIV-infected persons and linking them to vital interventions, including prevention of mother-to-child transmission of HIV (PMTCT) programs and care and treatment services. In KAIS 2007, wide gaps were revealed in HIV testing and knowledge of HIV serostatus. The survey reported that only 36.6% of Kenyan adults had been tested for HIV; women (44.6%) were nearly 2 times more likely to have been tested for HIV than men (25.6%).3 Among HIV-infected persons, 83.6% did not know they were infected.8 Additionally, 77.9% of those who reported one or more sexual partners in the past 12 months did not know their partners' HIV status.
Following these results, the Kenyan Ministry of Health (MOH) developed the National Guidelines for HIV Counselling and Testing in 2008, replacing the earlier National Guidelines for Voluntary Counseling and Testing (VCT) and Guidelines for Testing in Clinical Settings.9 These updated recommendations diversified HIV testing using approaches that brought testing services directly to the client rather than relying on clients to seek testing on their own. New HIV testing approaches included provider-initiated testing and counseling in health care settings, home-based testing and counseling (HBTC), mobile VCT, and outreach activities aimed to test a large number of persons in the community within a short period of time.
In 2001, the Kenyan MOH implemented its first national condom policy and strategy document covering the period 2001–2004.10 However, results from KAIS 2007 highlighted major challenges in this strategy, particularly around the use of condoms among sexually active persons.3 Among persons who reported not knowing their sexual partners' HIV status, condom use with these partners was only 14.1% among men and 4.8% among women. Among youth aged 15–24 years, 26.7% reported using a condom the first time they had sexual intercourse.
Following KAIS 2007, behavior change interventions among in- and out-of-school youth were expanded and focused on sexual risk reduction, delaying sexual debut, and imparting skills on how to negotiate abstinence as well as correct and consistent condom use. In addition, the MOH issued a policy statement emphasizing the importance of a sustainable condom supply to ensure universal access to condoms for all sexually active persons. Subsequently, from 2007 to 2009, the annual number of male condoms distributed increased by about 30%, with approximately 15 million condoms distributed per month.11
Between 2005 and 2007, unequivocal evidence from randomized clinical trials in sub-Saharan Africa demonstrated a significant protective effect of male circumcision against HIV acquisition.12–14 KAIS 2007 supported these findings on a population level, showing that uncircumcised men were at least 3 times as likely to be infected with HIV (13.2%) than circumcised men (3.9%). Nationally, 85.0% of men reported being circumcised. However, circumcision rates were much lower in Nyanza region (48.2%) where HIV prevalence was highest.3
In 2008, the Kenyan MOH implemented a new 5-year national strategy for voluntary male medical circumcision (VMMC), with a specific focus on 4 VMMC priority regions in the country: Nyanza, Western, Rift Valley, and Nairobi.15 By year-end 2012, it was estimated that more than 550,000 male circumcisions were performed, with 80% of these in Nyanza region alone (Personal communication, Kenya Ministry of Health, June 26, 2013).
Among all persons aged 15–64 years living with HIV in 2007, only 12.1% of persons were taking daily cotrimoxazole and only 40.5% of adults eligible to initiate treatment based on the immunologic criterion at that time (CD4 ≤250 cells/µL) were receiving ART.3 Coverage of ART based on a criterion of CD4 ≤350 cells per microliter (which was not applicable at that time) was 28.6%. Among persons who were aware of their HIV infection, use of care and treatment was higher, with 76.1% taking cotrimoxazole daily and 91.6% of ART-eligible adults currently receiving ART.3
With only 1 in 8 HIV-infected persons aware of their HIV infection in 2007, KAIS 2007 demonstrated that HIV testing and treatment goals were far from being reached. The revision of national guidelines for HIV testing and counseling in 20088 was instrumental in assuring increased identification of HIV-positive persons. Through expansion of facility-based testing strategies, direct and increased linkages to care programs were established. Decentralization of CD4 testing was expanded, allowing for more facilities at the district level to quickly identify patients in need of treatment. Subsequently, between 2008 and 2012, the number of children and adults receiving HIV-related care increased from approximately 151,000 to 857,000 and the number of children and adults receiving ART increased from 216,000 to 579,000.16
In 2012, 5 years after KAIS 2007, a second AIDS Indicator Survey was conducted to monitor progress on key indicators in the national HIV prevention, care, and treatment programs (Table 1). KAIS 2012 used the same sampling methods and laboratory-based HIV testing algorithm as KAIS 2007.17 A z test was used to test for differences in estimates between the 2 surveys, and the difference was considered statistically significant if P was <0.05.
KAIS 2012 was different from KAIS 2007 in several aspects. The survey used a new national household sampling frame (NASSEP V), developed in 2012, to sample households. However, due to regional insecurity at the time of the sampling frame development, the sparsely populated North Eastern region was not included in the sampling frame and, thus, was excluded from KAIS 2012. For the first time, the survey included children aged 18 months to 14 years to provide national estimates of HIV prevalence for the pediatric population. Children aged 10–14 years were also interviewed to understand knowledge, attitudes, and behavior in this population in relation to HIV. For persons aged 15–64 years, new questions on high-risk sexual behavior, including transactional sex, anal sex, same-sex behavior, injection drug use, and correct and consistent condom use, were added.
Blood samples were collected from all individuals for centralized HIV testing, and if HIV-positive, testing for CD4 counts and viral load were conducted. In contrast to KAIS 2007, where participants were provided their test results in a nearby health facility 6 weeks after survey teams visited their home, home-based HIV testing and counseling, using rapid HIV tests based on the national HIV testing algorithm, was offered to participants who wished to learn their HIV status on the day of the survey.8 In addition, point-of-care CD4 testing using the PIMA CD4 Analyzer (Alere, Inc., Waltham, MA) was offered for persons who were found to be HIV infected in home-based testing and counseling.
KAIS 2012 also used portable netbook computers (Mirus Innovations, Mississauga, Ontario, Canada) to collect data in the field. Data were transmitted to a central data server in Nairobi using a secure virtual private network, allowing for increased efficiency and accuracy in data collection and data management.18
In 2012, the prevalence of HIV among children aged 18 months to 14 years was 0.9%, representing an estimated national total of 104,000 HIV-infected children.19 Among adults and adolescents aged 15–64 years, the prevalence of HIV was 5.6%, representing an estimated 1,192,000 persons living with HIV, 106,000 of which were new HIV infections.20 This estimate was significantly lower than that reported in 2007 when the prevalence of HIV, excluding North Eastern region, was 7.2% (P = 0.002).
HIV prevalence was 6.9% among women and 4.4% among men. In urban areas, HIV prevalence was 6.5% compared to 5.4% in rural areas. Regional variations in HIV prevalence persisted, with the highest prevalence in Nyanza region (15.1%) and lowest in the Eastern South (2.1%) region. Overall, 4.8% of married and cohabiting couples were HIV serodiscordant, where either the male or female partner was HIV infected, representing an estimated 260,000 HIV-uninfected persons at risk for HIV transmission within marital or cohabiting relationships.21 Among HIV-infected persons, 11.6% reported ever having had tuberculosis, and among persons with a history of tuberculosis disease, 33.2% were HIV infected.22
In the absence of a surveillance system that monitors new HIV infections and HIV-related deaths, trends in HIV prevalence are increasingly difficult to interpret in the face of increased access to ART that reduces mortality. As HIV interventions and services continue to be scaled-up, routine surveillance of HIV incidence and HIV mortality will need to be integrated into the national HIV surveillance system to understand trends and programmatic impact. This should allow determination of which services are required in specific populations and locations for a more efficient and effective response.
Impressive strides in HIV testing and counseling were observed between 2007 and 2012, with HIV testing rates doubling from 33.6% in 2007 to 71.6% in 2012 (P < 0.001) (Table 1).23 Women surpassed the universal access target for HIV testing, with 80.4% of women reporting that they had ever been tested compared to 62.5% of men. Among persons living with HIV, correct knowledge of HIV infection tripled from 16.4% in 2007 to 46.9% in 2012 (P < 0.001).3,22 Despite this progress, over half of HIV-infected persons were not aware of their infection. This level of awareness represents a major barrier to HIV prevention, care, and treatment. Significant work is needed to increase diagnosis of HIV-infected persons and to educate the general public on when to re-test for HIV. All facility and community-based testing approaches should be expanded and new strategies, such as family testing and self-testing (currently available in private facilities), should be promoted in efforts to improve access among men and children.
Between 2007 and 2012, the proportion of persons reporting a recent partner of unknown HIV status reduced substantially from 77.9%3 to 46.4% (Personal communication, Kenya Ministry of Health, December 10, 2013). However, condom use with partners of unknown HIV status in the past year remained low, with only 11.8% of men and 3.8% of women reporting that they used condoms with these partners. Among youth aged 15–24 years, 62% reported using a condom at first sexual intercourse, a substantial increase from KAIS 2007 when only 26.7% of youth reported this behavior.3
These data demonstrate encouraging improvement in behavior change among youth, coinciding with declines in HIV prevalence in this age group.20 However, condom use among adults remained lower than desired. Recognizing that condom use within established relationships is difficult, condom use messages should be emphasized for populations where risk is elevated, including unmarried youth and persons engaging in high-risk or casual sex. To meet these goals, it is critical that Kenya's condom supply and distribution in the county work toward better sustainability to ensure that all sexually active persons have access to condoms.
Although a national household survey sampling frame is not optimal for capturing key populations at high risk for HIV infection, such as men who have sex with men, persons who inject drugs, and persons who engage in transactional sex, KAIS 2012 did identify persons who were engaging in these high-risk behaviors. A history of anal sex was reported by 1.8% of men and women (Personal communication, Kenya Ministry of Health, December 10, 2013). Among men, 0.6% reported ever having had sex with another man; 3.1% had ever received money, gifts, or favors for sex.24 Among women, 4.1% had received money, gifts, or favors in exchange for sex. Overall, 0.1% of men and women had ever injected illicit drugs.23,24 Given the established role of key populations at high risk for HIV infection in HIV epidemics, HIV testing services should expand to reach key populations, many of whom are hidden. These services should also ensure immediate linkages to HIV prevention, care, and treatment services.
The proportion of men who reported being circumcised increased significantly from 85.0% in 2007 to 91.2% in 2012 (P < 0.001).25 Significant increases were observed in the 4 priority regions within the national VMMC strategy: Nyanza (from 48.2% to 66.3%, P < 0.001), Nairobi (from 83.2% to 92.2%, P < 0.001), Rift Valley (88.7% to 92.8%, P = 0.001), and Western regions (87.8% to 92.9%, P < 0.001). Circumcision rates increased among men aged 15–24 years, from 78.7% in 2007 to 88.1% in 2012 (P < 0.001) and for men aged 25–34 years from 87.4% in 2007 to 93.4% in 2012 (P < 0.001).
These findings demonstrate substantial population-level advancement toward bringing VMMC to scale within a short period. Rapid results initiatives, aimed to reach many people within a short period, have helped to quickly increase access to VMMC. Continued work is needed, especially in Nyanza region, to bring male circumcision rates higher. In moving forward, integration of VMMC into routine maternal and child health services and scale-up of infant circumcision services is expected to maximize the long-term public health impact of VMMC on the broader HIV epidemic.
Family planning to prevent unplanned pregnancies is a key element in the national PMTCT strategy. KAIS 2012 established that unmet need for family planning among HIV-infected women was high, with only 68.7% of HIV-infected women who did not desire children in the future reporting that they used some form of contraception compared with 52.0% in 2007 (P = 0.07).26
Among female respondents aged 15–54 years who reported 1 or more live births in the past 5 years, 95.4% attended an antenatal clinic during their last pregnancy; of these, 93.1% were tested for HIV at the clinic. This was higher than reported in KAIS 2007 when 89.6% of women had attended an antenatal clinic during their last pregnancy (P < 0.001), and 64.9% of these women had been tested for HIV as part of antenatal care (P < 0.001).3,27 Among women who tested HIV-positive or were already aware of their HIV infection, 90.1% received maternal or infant prophylaxis for PMTCT during pregnancy and/or during postpartum, and of the infants born to these mothers, 82.5% were tested for HIV infection. The cumulative 5-year mother-to-child transmission rate based on the mother's report was 15.1% (95% confidence interval: 2.4 to 27.8).27
The elimination of mother-to-child transmission framework is an important element in the Government of Kenya strategy to achieve elimination of mother-to-child transmission in Kenya by 2015.28 Provision of ART for all HIV-infected pregnant women ("Option B+"), regardless of whether diagnosis is made during pregnancy, labor, and delivery, or post-natally, will be a critical step in achieving these goals. To address the gap in family planning for HIV-infected women, there is need for wider integration of family planning services in PMTCT programs, maternal and child health, and reproductive health services.
In 2012, coverage of cotrimoxazole was 41.5% among all HIV-infected persons aged 15–64 years.21 Coverage of ART was 60.5% among those eligible for treatment using the current Kenyan treatment guidelines (based on an immunologic threshold of CD4 ≤350 cells per microliter), and 45.9% using the 2013 World Health Organization guidelines on treatment initiation (based on an immunologic threshold of CD4 ≤500 cells per microliter).29–31 Although these coverage rates highlight gaps in the continuum of care for HIV-infected persons, they represent significant improvement from 2007, when coverage for cotrimoxazole was only 12.1% (P < 0.001) among HIV-infected persons and coverage for ART at an immunologic threshold of CD4 ≤350 cells per microliter was only 28.6% (P < 0.001).3 We found that linkage to care among persons who had been previously diagnosed with HIV infection to be high, at 89.9%.32 Equally impressive, we found that three-quarters (75.3%) of persons in care and on ART had achieved viral suppression, comparable to levels observed in developed countries. In contrast, among all persons living with HIV (including those undiagnosed and not in care), only 40.0% achieved viral suppression, indicating that widespread transmission risks persists in the population.21
For the first time in a national survey, we were able to estimate the population size of orphans and vulnerable children due to HIV/AIDS. We estimated that there were approximately 2.6 million orphans and vulnerable children in 2012, of whom approximately 7 in 10 were orphaned and 3 in 10 were vulnerable.33 We also found that testing, care, and treatment among HIV-infected children between the ages of 18 months and 14 years to be concerning. Only 11 of 28 HIV-infected children in KAIS 2012 had been diagnosed previously, and although all children with previous diagnosis were accessing care, only 8 were receiving ART, and of those, only half had achieved viral suppression.19
As Kenya moves forward in response to these findings and with anticipated changes in the national treatment guidelines, it will be critical for the country to evaluate the readiness of facilities to absorb a higher number of patients and ensure that the quality of care and ability to monitor adherence, drug resistance, and treatment success are not compromised. Viral load monitoring should be routinely conducted and decentralized to improve the quality of care. The national early infant diagnosis program should also be carefully evaluated and monitored to ensure that all HIV-infected children are diagnosed and linked into care. In addition, further emphasis should be directed toward understanding the cascade of care through establishment of routine monitoring and evaluation systems that allow for following cohorts of HIV-infected persons from the point of diagnosis to death.
AIDS Indicator Surveys have proven instrumental in assessing Kenya's national HIV response. Results from KAIS 2007 and KAIS 2012 have helped to redesign elements in the national strategy for HIV prevention, treatment, and care to address deficiencies and seize opportunities as new interventions have been introduced. With nearly 1.2 million people living with HIV in 2012, continued refinement of national strategies and policies will be required to impact the HIV/AIDS epidemic in Kenya. Based on the results of KAIS 2012, these strategies should include more effective identification of HIV-infected persons in settings that will provide high yield and immediate linkage to care. The unmet need for family planning and provision of life-long ART for HIV-infected pregnant women will be essential for eliminating pediatric HIV disease. Prevention efforts must encompass provision of ART for HIV-infected partners in serodiscordant couple relationships. On the laboratory front, implementation of routine viral load monitoring, improvements in early infant diagnosis, and enhanced HIV drug resistance monitoring will be required. In addition, we anticipate scale-up of infant circumcision services in priority regions, as well as provision of universal ART for children younger than 5 years of age.
Kenya is currently undergoing the process of devolving control and management of government services, including health, to 47 counties. Devolution, mandated through the revised Kenya Constitution, presents an opportunity to ensure efficiency and effectiveness of these interventions but will require close monitoring at the national level in the early stages of devolvement.
The next KAIS, planned for 2017, will be conducted towards the end of the implementation period of the Kenya National AIDS Strategic Plan IV, which begins in 2014. KAIS 2017 will therefore provide essential information to evaluate the impact of the new HIV prevention, care, and treatment strategies laid out in the new national strategic plan. The next KAIS should also be leveraged to assess other health outcomes that may be associated with HIV disease such as tuberculosis, malaria, and malnutrition. These efforts will help to reduce costs by combining disease surveillance efforts, improving integration across the health sector, and allowing assessment of the extent to which HIV/AIDS services have strengthened health systems.
The authors thank the KAIS field teams for their excellent work during KAIS 2007 and 2012 data collection and all persons who participated in these two national surveys. The authors would also like to thank Nadine Sunderland and Mike Grasso for reviewing the paper and providing input. Finally, the authors would like to acknowledge the KAIS Study Group for their contribution to the design of the survey and collection of the data set: Willis Akhwale, Sehin Birhanu, John Bore, Angela Broad, Robert Buluma, Thomas Gachuki, Jennifer Galbraith, Anthony Gichangi, Beth Gikonyo, Margaret Gitau, Joshua Gitonga, Mike Grasso, Malayah Harper, Andrew Imbwaga, Muthoni Junghae, Mutua Kakinyi, Samuel Mwangi Kamiru, Nicholas Owenje Kandege, Lucy Kanyara, Yasuyo Kawamura, Timothy Kellogg, George Kichamu, Andrea Kim, Lucy Kimondo, Davies Kimanga, Elija Kinyanjui, Stephen Kipkerich, Danson Kimutai Koske, Boniface O. K'Oyugi, Veronica Lee, Serenita Lewis, William Maina, Ernest Makokha, Agneta Mbithi, Joy Mirjahangir, Ibrahim Mohamed, Rex Mpazanje, Nicolas Muraguri, Patrick Murithi, Lilly Muthoni, James Muttunga, Jane Mwangi, Mary Mwangi, Sophie Mwanyumba, Francis Ndichu, Anne Ng'ang'a, James Ng'ang'a, John Gitahi Ng'ang'a, Lucy Ng'ang'a, Carol Ngare, Bernadette Ng'eno, Inviolata Njeri, David Njogu, Bernard Obasi, Macdonald Obudho, Edwin Ochieng, Linus Odawo, Jacob Odhiambo, Caleb Ogada, Samuel Ogola, David Ojakaa, James Kwach Ojwang, George Okumu, Patricia Oluoch, Tom Oluoch, Kenneth Ochieng Omondi, Osborn Otieno, Yakubu Owolabi, Boniface O. K'Oyugi, Bharat Parekh, George Rutherford, Sandra Schwarcz, Shahnaaz Sharrif, Victor Ssempijja, Lydia Tabuke, Yuko Takenaka, Mamo Umuro, Brian Eugene Wakhutu, Wanjiru Waruiru, Celia Wandera, John Wanyungu, Anthony Waruru, Paul Waweru, Larry Westerman, and Kelly Winter.
Kenya; HIV/AIDS; AIDS Indicator Survey; surveillance; policy
© 2014 by Lippincott Williams & Wilkins
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Pronunciation: /təˈrān/ /ˈterˌān/
(also terrain)
Definition of terrane in English:
Geology A fault-bounded area or region with a distinctive stratigraphy, structure, and geological history.
Example sentences
- We contrast the geological development of the Bainang terrane with that of other terranes in the region and consider this in the broader context of Neotethys evolution.
- Rift basins in the Red Sea area developed in terranes accreted in Pan-African time, and it is believed that some of these ancient sutures controlled later Red Sea rifting.
- The contrasting Neoproterozoic and Early Palaeozoic histories of the various Variscan terranes of Europe provide a key to palaeogeographical reconstructions.
Early 19th cent: from popular Latin terranum. Compare with terrain.
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