Making a Difference in Kenya
January 31, 2006, Homa Bay, Kenya. After Niger, I traveled to Kenya, where I visited three rural elementary schools with Ciara O’Reilly. A five-foot tall, 100-pound blonde Irish native, the 31-year-old EIS officer presented quite a contrast to the Africans she served.
[That is to introduce this blog post and get your attention! I must apologize to my blog followers (not sure who is reading this — drop me a line!) for not posting for a couple of weeks. Life has been hectic, with book signings, interviews and travel. And it is continuing. So I am cutting and pasting again from Inside the Outbreaks from the chapter on my African sojourn, this time in Kenya. I introduced the Safe Water System in a previous blog. You will see its impact here.]
After earning a Ph.D. in Food Microbiology, Ciara began with the CDC Foodborne and Diarrheal Diseases Branch in August 2004. Just before I met her in Kenya, she had spent two days aboard a cruise ship in the Caribbean, where norovirus was spread by passengers’ vomitus.
The transition from the luxurious cruise ship to African poverty was jarring, but Ciara had been to Kenya the previous year to set up a diarrhea study, so she knew what to expect. “Kenyans are better able to appreciate small things than we are,” she told me. “If something good happens, they have such joy.”
At one of the schools we visited, children stood on the barren school grounds to sing songs and recite poems they had written for their Safe Water Club. Though many were barefoot, they wore the school uniform – boys in white shirts and blue shorts, girls in blue dresses with white collars – and there was indeed joy on their faces, even though a storm had recently ripped the corrugated roof from their school building, built from bricks they had made themselves, and even though many of them were AIDS orphans.
Ciara and Matt Freeman, a young epidemiologist with the Center for Global Safe Water at Emory University, were there to assess the impact of the Safe Water System (SWS), which had been implemented by CARE (with funding from Coca-Cola) the previous summer in 45 primary schools in Nyanza Province in western Kenya. Ciara and Matt had trained local enumerators to administer questionnaires to randomly selected students and their parents/guardians.
Diarrhea from polluted water kills over two million people annually, mostly children in developing countries. The SWS teaches people to treat their drinking water with dilute bleach and to dispense it from spigots in narrow-topped containers too small for hands to reach in.·
This school had two sources of water. The better one was a river down the dirt road, a half-hour away. The other was a ten-minute walk, but it was foul and stagnant. We were looking at the latter when an old man told us that people who drank this water went loco and got diseases. As he spoke, several emaciated cows ambled up and waded in to drink.
At the schools, I watched children stop at a hand washing station after leaving latrines, as they had been taught. They drew water to drink from brown narrow-topped clay pots with metal spigots, and they demonstrated how they added a capful of WaterGuard, the dilute bleach solution, to treat new water.
The next day, I walked through the dry scrub with Elvis, a Luo-speaking enumerator, as he visited parents or guardians in their small mud homes, questioning them about their knowledge of WaterGuard and the Safe Water System. The third house was very small, with a bare double-bed foam mattress leaning against the wall. The woman in the house was a recent AIDS widow with seven children. Her husband had had three wives, but one of them, with six children, had also died. The third remaining wife was childless. So these two women had 13 children to care for and were very poor. Yet this woman still managed to buy WaterGuard for their water.
Over the next few days, I helped Ciara and Matt enter data from the questionnaires into laptops. “Now you know what being an EIS officer is really like,” Ciara told me, referring to the tedious job in oppressive heat. Some of the surveys were heart-rending: an 86-year-old woman caring for three AIDS-orphaned grandchildren; two adults, 11 children, all sleeping in one room. An enumerator’s comment on the last situation: “The family is very desperate and I really wondered how they manage their daily bread.”
As I walked the single paved street of Homa Bay every morning and evening, I encountered women carrying 20-liter plastic buckets of water on their heads – water retrieved from a pool, ditch, or rivulet. Children riding bicycles carried jerry cans of water. All polluted. Ciara told me about a local “control” school she had visited that did not have the SWS program. “A teacher showed me a bucket of water they drank. Scum floated on top of the brown water, and sediment coated the bottom,” she said. With most people earning less than a dollar a day, even the pennies needed for WaterGuard were hard to come by.
When the data from Ciara’s survey were tabulated, they told a positive story. Student absenteeism in the intervention schools had dropped by 35 percent, while in non-project control schools it had risen by 5 percent. More parents had heard about WaterGuard than during a baseline survey, though only a few more actually used it at home.
My final day in Kenya, I drove with Ciara over terrible, dusty roads one more time, to visit hospitals and clinics where she was conducting a baseline study of what caused diarrhea in another area of Nyanza Province. One hospital was located in Siaya, hometown of Barack Obama’s father.· Stool samples from the hospital were tested twice a week at the CDC lab in Kisumu to determine what had caused diarrhea and what sort of drug resistance had developed. In Bondo District Hospital, the drinking water was not treated with WaterGuard, and about 15 children a month died there.
Ciara’s study found that in children under five, three bacteria – Shigella, Campylobacter, and Salmonella – together accounted for about half of the pathogens identified. The other half was caused by rotavirus, which is impervious to WaterGuard.· Ciara also found that the bacteria were highly resistant to three common antibiotics, but responded to others.
Since the time I followed Ciara in Kenya, she has graduated from the EIS but stayed on as a staff member in the same branch. She helped to launch the Global Enterics Multi-Center Study (GEMS), which will expand the Kenyan diarrhea project to eight locations worldwide in an unprecedented prospective case-control study to determine what diarrheal pathogens are killing children under five, and to what drugs they are susceptible.
And CARE (with funding from many public and private organizations) has begun to implement the Safe Water System in an additional 200 schools in Nyanza Province. Some schools will also get latrines, while others will, in addition, get a borehole well or rainwater harvesting. The idea is to see which interventions are cost-effective and sustainable. It is a three-year project, and there are plans to expand it to 1,500 more schools.
The programs were nearly derailed by ethnic violence in Kenya following the disputed presidential election of December 27, 2007. “Kisumu looks different these days,” Ciara emailed, “with many buildings burnt to the ground.” Still, she had managed to train staff for the prospective diarrhea study and was preparing to launch it. A power-sharing agreement between the incumbent Mwai Kibaki and his opponent Raila Odinga was hammered out in late February, and Kenya settled back into an uneasy peace.
That February 2008, EIS officer Sapna Bamrah, 34, arrived in Kenya to assess the impact of the violence on AIDS and tuberculosis health clinics, where 180,000 people had been taking antiretroviral drugs. As an EIS officer, Sapna Bamrah had already ventured to Azerbaijan to look at mortality surveillance from land mines, to Vietnam to study the impact of Pur, a water treatment product made by Procter & Gamble, to Nepal to assess the nutritional status of Bhutanese refugees, and to Swaziland to conduct a randomized survey of rape and molestation of young girls. Now in Kenya, she found that while many health clinics had been temporarily closed or abandoned, the system was beginning to recover more quickly than had been feared.
I interviewed Sapna Bamrah in August 2008, a month after she completed her EIS service and remained with the CDC. She acknowledged that “sitting on committees, wearing a uniform, and following rules and regulations has little to do with public health,” and that politics sometimes subverted science. But Bamrah concluded: “For every moment I am frustrated, I am continually inspired and amazed at what people in the EIS and in this agency are doing. The average American has no idea the amount of energy spent in the United States and the world by people who really believe in protecting the public.”
- · See Chapter 17.
- · Six months later, in August 2006, then-Senator Barack Obama came to Siaya to visit his grandmother. At the CDC outpost in Kisumu, at the request of EIS alum Kayla Laserson, Obama and his wife Michelle publicly submitted to HIV testing to encourage locals to do the same.
- · Later in 2006, two oral rotavirus vaccines were found to be safe and effective, though getting them to poor children around the world is another matter.