in development

A Model for Smart Global Health Policy.

CSIS's Commission on Smart Global Health Policy just completed their fact-finding mission in Kenya to investigate the successes and challenges of U.S. funded global health programs.  They visited us here at AMPATH on Tuesday and kindly asked me to contribute to their Kenya blog.  You can read my thoughts on the CSIS blog here, alongside some far more interesting posts from Commission Co-Chair  Admiral Bill Fallon, CSIS Director of Global Health Policy J. Stephen Morrison, and many others.  Or you can just read my first CSIS blog post right here:

AMPATH is widely recognized as one of the largest and most effective responses to the HIV pandemic in Sub-Saharan Africa.  Which is why CSIS Commissioner Mike Merson and Deputy Director Karen Meachem were quite surprised to learn that "AMPATH doesn't actually exist."  Contrary to popular opinion, AMPATH is not an NGO.  There are no AMPATH employees.  Rather, AMPATH is a name that symbolizes a partnership between Kenya's Ministry of Health, Kenya's Ministry of Education, and a consortium of North American Institutions led by Indiana University.   In other words, AMPATH is the name of an alliance formed within the existing framework of Kenya's government.  And the model AMPATH has developed through this alliance demonstrates how health system strengthening can happen within that very framework.  It's a unique and often misunderstood approach to international development.  But in the view of AMPATH field director Dr. Joe Mamlin and program manager Dr. Sylvester Kimaiyo it is an approach that is both scalable and sustainable.  As evidence, AMPATH now provides treatment to over 90,000 HIV+ patients - up from just 1,000 in 2003.   And with the launch of AMPATH's household counseling and testing (HCT) program, their patient population is expected to increase dramatically as they go door-to-door across their entire 2 million person catchment area in western Kenya.  It's an aggressive initiative that will not only save the lives of those unknowingly living with HIV but it will reduce the number of new HIV infections.  In the absence of an HIV vaccine, HCT appears to be the most effective means to roll back the pandemic.  And deployed through AMPATH's model, the HCT program can not only stem the spread of HIV but it will further expand the reach and strength of Kenya's national health system.

The place of killing.

In “The Zanzibar Chest” the author claims that the name of the town in which I currently reside, Eldoret, means “the place of killing.”  I have found no other evidence of this unfortunate etymology.  But I did learn that said author has been known to occasionally invoke vivid language at the expense of factual accuracy.  No matter, because even if the translation isn’t literal, recent history has in fact earned Eldoret the regrettable reputation as “the place of killing” in Kenya. 

For those who may not be familiar with the post-election violence that tore Kenya apart in early 2008, here’s a brief sketch of what happened.  President Mwai Kibaki, who is from the Kikuyu tribal community, was widely believed to have rigged the results of the 2007 election.  Supporters of the top opposition leader, Raila Odinga, who is from a different ethnic group (Luo), took to violence as they targeted Kikuyu people living outside their traditional settlement areas, especially in Nairobi slums and the Rift Valley Province. Violence peaked when over 30 people were burned to death in a church near Eldoret on New Years Day 2008.  All told, the post-election violence took the lives of 1,133 Kenyans and left another 650,000 displaced.  It's a story worth learning more about as it demonstrates the utter fragility of democracies and economies in Sub-Saharan Africa.  You can learn more here, here, and here.

The newspapers these days are dominated by a vigorous debate over the possible paths to prosecuting those who organized or funded the post-election violence.  But the victims of the violence have largely  been forgotten.  Internal displaced persons (IDP) camps are still scattered throughout the northern region of the Rift Valley.  At one IDP camp in Eldoret there are still close to 2,000 people living in tattered tents.  The camp’s residents are patiently waiting for government payouts to help them rebuild their farms, businesses, and homes.  But the government has ruled out any further payouts.  The major NGOs (Red Cross, UNICEF) that supported the camps have now left.  So have security officers.  What’s left is a makeshift community of squalor where young girls are turning to prostitution and young boys are turning to street begging and glue sniffing (the quickest way to suppress their appetite and calm their mind).  Eldoret was once the fastest growing town in Kenya; it now has the fastest growing street kid population in the world.

Those who helped organize, galvanize, and subsidize the post-election violence need to be brought to justice.  And whether that be through the International Criminal Court at The Hague, local tribunals, or a truth and reconciliation commission is certainly worth debating.  But if even half as much attention was directed towards helping rebuild the lives of the victims still living in IDP camps, I have to imagine the country could truly begin to heal.  Until then, the sight of IDP camps and burned out villages that dot the Kenyan countryside will keep the ethnic tension - that boiled over 18 months ago - simmering just below the surface.

photo credit: Yoni Bock/USAID

The most effective innovation in African health communications.

Much has been written about the revolutionary impact of mobile technology in the developing world.  Mobile phones have brought a new era of amazing innovation to Africa.  They've reformed money transfer services (see MPESA).  They've enabled a new movement of local journalism (see Voices of Africa).  And they've proved to be a critical weapon against disease threats and the spread of HIV (see EpiSurveyor).  But while there's endless excitement, attention, and energy devoted to the possibilities of further applications of mobile technology in Africa, one of the most innovative and effective channels for health communications often goes overlooked - community health workers.  That's right, innovation sans tech. 

Community health workers (CHWs) solve one of the great challenges within the African health system - a critical shortage of human resources.  The average doctor-to-patient ratio in  Africa is 1:20,000.  In the U.S., it's around 1:400 (check out this data visualization to see the disparity worldwide).  To be sure, these CHWs are not trained clinicians.  But they are no less valuable.  They are trusted members of their respective communities that villagers will consult before they visit a clinic or hospital (similar to the role of traditional healers).  In this way, they highlight a key strength of African cultures that the developed world is desperately trying to resurrect - community.  I'm not going to explore the possibility of a negative correlation between development and community in this post.  But I do think it calls attention to the importance of cultural context for  communications innovation.  Namely, CHWs don't force behavior change. Rather, they work with the tides of behavior that already exist and simply nudge them in a slightly different direction.  In so doing, they help a resource-challenged health system harness the knowledge, resources and relationships that exist in the local communities they aim to serve.  Which helps explain why Dr. Paul Farmer believes Community Health Workers are the single intervention that would do the most to improve the health of those living on less than $1 per day. 

CHWs might not get as much attention as clever new smart phone apps.  But they are undoubtedly among the most effective ways to improve patient adherence to treatment and reduce the burden of time and money on both patients and healthcare systems.  In fact, with healthcare costs soaring in the U.S. and more than 50,000 new HIV infections every year, many in the U.S. are starting to think that CHWs may even help America's struggling healthcare system.

Talk doesn't cook rice.

I had never heard of AMPATH before this year.  Which seems rather odd.  After having worked with global health organizations (e.g., The Gates Foundation, (RED), ONE.org, The Global Fund) for the past two years, you would think I'd have come across AMPATH at some point.  Sure, my work has been focused on advocacy in the developed world, not operations in the developing world.  And there are loads of organizations like AMPATH doing work all across the African continent.  But AMPATH is anything but a fly-by-night aid initiative. In fact, it has been nominated for the Nobel Peace prize - twice. But then in a discussion with Professor Joe Mamlin (AMPATH co-founder) here in Kenya this week, it became perfectly clear.  Joe doesn't ever leave his corner of Kenya.  He declines countless invitations to speak at global health summits, conferences, strategic planning meetings, press events, and the like.  "I keep my head down and focus on the task at hand," Joe told me. 

Many people in this line of work spend too much time crafting well intentioned strategic plans that  can't possibly account for the unpredictability of the developing world.  The world of talk bears little resemblance to the world of actions.  The same principle holds true for the developed world.  Deep pockets, diminished urgency, and the actual potential for job security fosters a culture in the developed world that is blinded by artificial measurements at the expense of actual results.  But the developing world can't afford to ignore reality.  The health crisis in Africa is imminent and requires immediate action.  And AMPATH has proven that the most effective responses to the emergency aren't the result of careful calculation.  They are the result of rapid trial and error.  Indeed, small deeds done are better than great deeds planned. 

AMPATH has quietly become one of the most effective responses to the deadliest pandemic in human history.   And it has done so using a deceptively simple model.  Do. Learn. Fix.

Life in Kenya: Week 1

After living in Kenya for all of one week, I can't honestly comment with depth on much of anything just yet.  So here's my rambling list of highlights after week one.  The earth is red.  The people are exceedingly gracious.  Schools get closed for ghost invasions (a similar story appeared in yesterday's Daily Nation but I couldn't find it online).  Fetching water is now a daily chore.  But unlike the vast majority of Kenyans, we only have a short walk to retrieve safe, filtered water.  Corruption is rampant - apparently Kenya has just earned the coveted title of the most corrupt country in East Africa - the "bribery index" in Kenya stands at 45 per cent.  Obama isn't impressed with the slow pace of political and economic reforms of Kenya's power-sharing government following the post-election violence of 2008.  His decision to visit Ghana this week for his first presidential visit to sub-Saharan Africa was accompanied by a rather public criticsm of Kenya's political leadership.   There's no surfing on the internet, just crawling.  But everyone from taxi drivers to doctors are talking about the arrival of the undersea fiber optic cable in Mombasa that will spread high speed access throughout the country.  Too bad Somali pirates are messing with the program.  Speaking of spreading, the swine flu decided to join us in Kenya - compliments of some students from the UK.  As if there aren't already enough health risks to deal with here.  When we tell our Kenyan friends that the current strain of swine flu is far milder than malaria, they laugh.  Malaria is as common as a head cold here.  And lastly, the organization I'm working for - AMPATH - has huge ambitions as it hopes to transition from one of Africa's largest, most effective HIV/AIDS control systems to one of the continent's first systems for comprehensive healthcare.  This shift away from vertical programs with disease specific goals towards comprehensive programs with holistic health goals appears to be in step with thought-leaders of the US global health aid community.  Should make for a challenging year.

Oh, and Sunday mornings seems to be the best time for internet access.  A blessing indeed.