The Global Health Policy Center

Dr. Michael Merson and I left Nairobi yesterday to visit the AMPATH (Academic Model for Prevention and Treatment of HIV/AIDS) program in Eldoret. It's an impressive program and we had a great time!

Inspired by Dr. Joe Mamlin and launched with support from Indiana University (IU), AMPATH is driven by a unique partnership between the Moi Teaching and Referral Hospital, Moi University School of Medicine, and the Kenya Ministry of Health. Though it has tremendous outside support, the work program is Kenyan owned and Kenyan run.

AMPATH leads an aggressive approach to HIV treatment with Kenyan health workers going door to door, village to village collecting data on hand held devices. The aim is comprehensive testing and counseling to reduce total viral load in the region; they serve 90,000 people in their catchment area and aim to reach all 2 million. This decentralized work is complimented by the significant 'central nervous system' that is the referral hospital and Moi University working together. These institutions hold clinics, a pharmacy, a mother and baby facility, and serve as a hub for an exceptional electronic case management system that holds field data from their 90,000 patients scattered across the Rift Valley Province.

Care and treatment is the fundamental starting point for AMPATH, and they will receive a $60M USAID grant to prevent and treat HIV/AIDS between 2007 and 2012.

You've been reading on this blog about the Commission's trip to Kenya. As you've probably seen, we have asked all of our dedicated readers to submit suggestions on what the Commission should focus on, who they should talk to, and any other comments you might have.

We weren't disappointed. As expected, we have received many thoughtful insights into the health challenges facing Kenya - with some interesting ideas on how to address them.

Earlier, Stephen Morrison, Director of the CSIS Global Health Policy Center, answered a few of them while en route to Kenya. Today, the staff of the CSIS Global Health Policy Center responded to more of your Kenya-related questions. Thanks to everyone who has submitted -- and keep sending us your thoughts! (Use the submission form over to the right) Tomorrow we'll post a few more.

For the past several days, Commissioners have traveled through Kenya to explore the country's health challenges. Now it's time to take those findings and apply them to a U.S. strategy for global health.

This afternoon, the Commissioners will join Kenyan representatives for their last event of the trip - a public roundtable discussion on the U.S.-Kenya Health Partnership. The meeting reflects the Commission's commitment to unprecedented openness and transparency in its work. Attendees will reflect on their visit and draw upon their expertise to assess the achievements already made through the U.S.-Kenya partnership, lessons learned and critical priorities for the future.

The moderator will close the discussion by inviting questions and commentary from the audience. What questions do you have for either the Commission or their Kenyan hosts?

It's a struggle at the very heart of Kenya's health problems: keeping young people HIV-free. Local leaders and health workers are working desperately to educate the next generation on precautionary measures to keep them safe from the disease which has devastated an entire generation of Africans.

The full delegation is heading out to an HIV-Free Generation Youth Center to observe this important public-private partnership in action. Read more about the HIV-Free Generation partnership here:

In a new partnership coordinated by the U.S. Government through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), leaders from the private sector are joining forces with the public sector and non-governmental organizations to revolutionize HIV prevention for youth through the Partnership for an HIV-Free Generation (HIV-Free Generation).

"A key challenge in the fight against global AIDS is the ongoing need for innovation in HIV prevention. Over 7,000 people a day are newly infected with HIV worldwide," said Ambassador Mark Dybul, U.S. Global AIDS Coordinator. "The Partnership for an HIV-Free Generation brings together an unprecedented coalition to address HIV prevention for youth. Initially in Kenya, this alliance combines PEPFAR's technical and programmatic capacity with the expertise of the private sector in messaging, branding, new technologies, and real-time market research to promote and maintain behavior change."

Yesterday was a busy day for all three teams of Commissioners and staff. Helene Gayle, Keith Ellison and company headed out to Nyanza; Admiral Fallon (Ret.) and team were in the Coast Province; and Mike Merson was in the Rift Valley Province.

After spending the night in their respective provinces, all of the Commissioners and staff have returned to Nairobi for another busy day of observing and evaluating the health care challenges in Kenya.

Today the delegation will have the opportunity to discuss findings from the trip, and share impressions and perspectives they collected along the way. The team will also engage with a broader audience of Kenyan health workers and some of Kenya's top political leadership.

It's sure to be an exciting day - we'll keep you posted on what transpires.

Hospitals have remarkable similarities the world over - dedicated clinicians with little to work with are seeing patients in an organized system. But here in Kenya I had an overwhelming sense of a quiet pensiveness in staff and patients, particularly acute in the nursery where row after row of newborn babies lay very quietly. In fact, only one screamed, a vocal reminder that these babies should all be on various schedules of eating, crying, and sleeping. One wonders if being at a mother’s bedside might better promote breast feeding and temperature control.

More importantly, it reminds me that as we work on quality and patient safety issues in the U.S. we should be aggressively exporting the LEAN and Plan-Do-Study-Act approaches to health, thus allowing developing medical systems to learn from our mistakes and leap frog over our many failures. If this is done, they may be able to more rapidly develop a "highly reliable" organization. It is my understanding that the Institute for Healthcare Improvement has begun this work in South Africa.

Karen Remley, MD, MBA, FAAP. Virginia Commissioner of Health

This afternoon, Helene Gayle, Congressman Keith Ellison and the rest of their team are headed out to the Kenya Medical Research Institute in Kisumu.

KEMRI is one of Africa's top medical research centers, and has been key to Kenya's efforts to control HIV, malaria and other diseases. Here the team is looking to examine the work of the institute, the potential to enhance current research partnerships with the American government, the status of malaria diagnosis and treatment, and the overall state of medical research in Kenya.

Many observers acknowledge that programs like KEMRI are critical for improving health in developing countries, particularly by building up local capacities for medical research and surveillance, as well as providing essential laboratory services for the region.

A little more on KEMRI from the KEMRI.org:

The Kenya Medical Research Institute (KEMRI) was established in 1979 under the Science and Technology (Amendment) Act of that year to represent the national body responsible for carrying out health science research in Kenya. Prior to the establishment of KEMRI, health research in Kenya was conducted under the auspices of the East African Medical Research Council which had been established in 1957 to serve the countries of the East African Community. Following the break-up of the East African Community in 1977, the Kenyan Parliament passed the Science and Technology Act in 1977 and amended it in 1979 to provide for the establishment of research institutes.

Admiral Fallon (Ret.) and his team certainly don't have an easy Tuesday. After visiting a commercial sex worker drop-in center earlier this afternoon, they're headed directly to a halfway house in Mombasa to examine the growing problem of HIV spread through needle drugs in Africa.

USAID has been supporting HIV prevention and care efforts for young injecting drug users, and the Commission aims to get a sense of how the program has been working and how effective it has been.

As it has worked in other areas of the world, hopefully drug education, rehabilitation and needle exchange programs can help cut down on the spread of HIV in Africa.

Admiral Fallon and his team are heading out to a commercial sex worker drop-in center to examine the most HIV-at-risk populations in Kenya, and meet with the peer educators who counsel the sex workers every day.

We know from the comments we've received that some of you reading our blog have counseled sex workers before. What advice would you offer for strengthening commercial sex worker programs in Kenya?

Commissioner Mike Merson is the Director of the Global Health Institute at Duke University. It's only natural that he and his team would go to the Rift Valley to study a unique collaboration between American universities and African partners to help combat HIV and other health issues. The program operates at 19 locations in Africa and cares for over 55,000 HIV patients.

More on AMPATH, from the University of Indiana's School of Medicine:

AMPATH is a working model of urban and rural HIV preventive and treatment services in the public sector. AMPATH cares for more than 55,000 HIV infected adults and children, with nearly one-half of all patients on anti-retroviral drugs, and enrollment into the program rising by 2,000 patients per month. A robust program to prevent mother to child transmission of HIV has been initiated including an opt-out testing policy and programs fostering triple anti-retroviral therapy of pregnant woman and formula feeding of newborns. AMPATH has implemented programs that foster food and economic security for HIV infected persons and their families. AMPATH demonstrates the power of US and African academic medical centers united by common vision.

Without a doubt, universities can play an integral role in the future of global health. We look forward to hearing what the team learns from the experiences of AMPATH.

 

Admiral Fallon and his team will soon head to the Mariakani District Hospital in the Coast Province. The hospital is unique because it is home to a comprehensive HIV care center, established with USAID support. There, the team will study the positive impacts of the program - and what they can teach us about delivering quality care to people living with HIV.

The team is also looking at how the U.S. can support training in HIV management, family planning, and computer and health management information systems.

For those of you involved in HIV care, what do you think are the most important ways to improve care to HIV-positive patients?

Out in the rural province of Nyanza, health care is a constant struggle. At the Tiwani Health Center, Helene Gayle and others will be looking at the health challenges posed by inadequate infrastructure and staffing, malnutrition, and a lack of clean water.

What will they see? What should they look for? Let us know what you think in the comments below. We'll post any dispatches as soon as we get them.

 

Admiral Fallon (Ret.) and team are heading out now to visit a new health care project in the Coast Province. The APHIA II Project is designed to provide home-based care to Kenyans who need it. The commissioners will be sitting down for a conversation with HIV-positive clients, who are also community health workers.

Does this kind of home based care work? Is it a solution for Kenya? We'll keep you posted with any updates we receive from the team on the ground.

This morning, the commission is splitting into three separate groups to cover more ground.

Helene Gayle's group today flew to the Nyanza province, while Ret. Admiral Fallon and his group of commissioners are traveling to the Coast Province. Although in different parts of Kenya at different facilities, both groups are studying similar issues: the impacts of U.S. investments in African health, maternal health issues, and the challenges of reaching rural African populations with health services.

Meanwhile, Mike Merson and his team are visiting the Rift Valley Province to study care projects in rural areas, as well as an innovative academic collaboration health project that is breaking new ground in HIV care.

 Check back in later today - many more updates to come.

 

You've been reading on this blog about the Commission's trip to Kenya. As you've probably seen, we have asked all of our dedicated readers to submit suggestions on what the Commission should focus on, who they should talk to, and any other comments you might have.

We weren't disappointed. As expected, we have received many thoughtful insights into the health challenges facing Kenya - with some interesting ideas on how to address them.

Here are some of the best of what we've already received. Stephen Morrison, Director of the CSIS Global Health Policy Center, answered  them while en route to Kenya. Thanks to everyone who has submitted -- and keep sending us your thoughts! (Use the submission form over to the right) Tomorrow we'll post a few more.

We've just received our first set of snapshots from the commission's trip to Kenya. Among those pictured are Commission co-chair Admiral William Fallon (retired) of the U.S. Navy; Karen Remley, Health Commissioner for Virginia; and Steve Morrison, Senior Vice President and Director of the Global Health Policy Center.

Although the pictures are spare, you get a clear feeling of the many difficulties that exist in Kibera. Kibera is the biggest slum in Africa - with an astounding one million residents. Disease and malnutrition are only a few of the health issues facing the struggling residents of Kibera.

We look forward to hearing more from the Commission about what they've seen - and more importantly, the lessons learned that can be applied to global health issues worldwide.

Check back for more updates - we'll post more as soon as we get them.

CSIS partner, CARE, is also reporting in from the Commission's trip to Kenya. Here's a sample of the updates they've posted on their website at www.care.org.

Awaiting arrivals without soup

Allen Clinton, CARE staff member currently on the trip to Kenya, reports in from Nairobi.  Upon just arriving at the new hotel, the group runs into a Don Cheadle look-alike who evokes laughs by unknowingly quoting from Seinfeld.

Kenya - How are you?

Allen Clinton describes arriving in Kenya to do an advance run-through to prepare for the Learning Tours trip.   This post features videos of Kenyan children using their English vocabulary to adorably ask the Americans "How are you?"

Check back regularly for more updates, from CSIS and our partners, on the Commissioner's trip to Kenya.

Nature of the Violence

The majority of Kenya's post-election violence took place in January and February, 2008. The fighting resulted in 1,133 casualties, at least 350,000 internally displaced persons (IDPs), approximately 2,000 refugees, significant, but unknown, numbers of sexual violence victims, and the destruction of 117,216 private properties and 491 government-owned properties including offices, vehicles, health centers and schools.

Initially, the violence was spontaneous and a reaction to the perceived rigging of the elections by the government. In areas like the Rift Valley and the Coast, members of the Kikuyu and Kisii communities (perceived to be associated with the PNU party and with President Kibaki) were targeted. In Nyanza and Western Kenya, the violence was mostly directed towards government facilities and gradually took the form of looting and destruction, and while it also targeted Kikuyus and Kisiis, the intention appeared to be not to kill them but rather to expel them and destroy their property.

According to Human Rights Watch, the pattern of violence subsequently showed planning and organization by politicians, businessmen, village leaders and local leaders, who enlisted criminal gangs to execute the violence. This was particularly the case in Rift Valley and Nairobi. In Naivasha, Nakuru and the slum areas of Nairobi, Kikuyu gangs were mobilized and used to unleash violence against Luos, Luhyas and Kalenjins, and to expel them from their rented residences. Similarly, organized Kalenjin youth, particularly in the North Rift, attacked and drove out Kikuyus living there. In many instances the police action added to the violence, with considerable evidence that officers took sides and used terror tactics against slum dwellers.

Here in Nairobi's Kibera slum, the largest in all of Africa, the Tabitha Health Clinic offers a model public-private partnership. The clinic is the product of a collaboration between the U.S. Centers for Disease Control, Duke University and the University of North Carolina.

A little more info on Tabitha health clinic from Carolina for Kibera's site.

Founded by the late Tabitha Atieno Festo, a widowed registered nurse from Kibera, Tabitha Medical Clinic is a community-based medical clinic that provides primary healthcare and youth-friendly services to Kibera residents in partnership with the U.S. Centers for Disease Control and Prevention (CDC). Tabitha Clinic offers healthcare to all residents on a sliding-fee scale. The clinic treats approximately 20,000 patients each year (over 100 daily) and offers basic laboratory, pharmaceutical, and children's health services. The clinic is one of the only medical facilities in Kibera that staffs two fulltime physicians.

The Commission is paying special attention to how to create and sustain successful public-private partnerships, especially around using data at the local level. It's also examining how this clinic fits in to the larger health-care system of the community.

Just finished up lunch with senior Kenyan health officials. Our goal was to learn more about the big issues facing the health care system across Kenya, as well as how U.S. investments have made a difference -- and what challenges remain. But a question that loomed over the discussion was the fact that, as part of the resolution of post-election violence back in January 2008, the national cabinet was expanded to 40 and then split evenly between President Kibaki's PNU party and Prime Minister Odinga's ODM party. The upshot is that the Ministry of Health was divided into the Ministry for Public Health and Sanitation, led by PNU member Beth Mugo, and the Ministry for Medical Services, led by ODM member Peter Anyang' Nyong'o. The division goes all the way down to the local level.

We hope to share the content of these discussions soon.