Health Center Update

When I arrived in Kenya, Nyametaburo Health Center (NHC) was in a sorry state. Janine, my predecessor, did an excellent job of identifying needs at the center. And believe me, even listing the problems was quite a task. Counting down, I’ll describe the top three problems at NHC and what we’ve done.

Problem 3:
Lab services are far away and take a long time. For full lab services (to test for TB, for example), patients had to go to Isibania Sub District Hospital. For some in our area, that would be a two-hour walk (average would probably be about an hour). And once they got there, it would probably take an hour at least (probably several) to see the laboratory technician. Once seeing him, you’d then have to wait for the test to be performed. All in all, the experience would take you all day if you decided to do it. Most people don’t. And so their conditions remain undiagnosed. With Malaria, this isn’t a huge problem (except, of course for the development of drug-resistant Malaria), but it is a real big problem for diseases like TB and HIV which are quite contagious.

Solution 3:
We have constructed and outfit a laboratory. We’ve hired a laboratory technologist who is very proficient and very ready to work. Now NHC is able to test for HIV, TB, Malaria, intestinal worms and Typhoid, to name a few. “Great!” you may say, “Having HIV testing abilities does no good if stigma prevents people from being tested.” Which is true. But, whether it is the warm and friendly staff of NHC or the HIV training we recently did, there have been nearly 100 people from the community who have been tested since the lab opened in September. [With an adult population of ~2000, we’d get them all tested in about two years at that rate; however, we hope to accelerate it]

Problem 2:
KEMSA (the Kenya Medical Supply Agency… I don’t know what happened to the ‘E’) is supposed to keep the Health Center supplied with drugs. There are quarterly shipments of medications which are adjusted based on the level of the facility and the patient loads. And by ‘quarterly’ I mean that I got here in July and the only shipment yet received was at the end of October. And when I say ‘adjusted’, I mean that they give facilities whatever they happen to have in stock, whatever is trendy amongst international donors and whatever is about to expire. Also the District has not managed to fill the form to upgrade us to a Health Center in KEMSA’s registers since August 2008 (sic). So in our latest shipment, we got roughly 3.4 million condoms (we distribute precisely zero per month…), lots of otherwise expensive Malaria meds (thank you, Global Fund) and almost no antibiotics. Even though respiratory tract infections account for more lost life than Malaria, it’s not as sexy, so no money goes to it. Even though $0.50 of amoxicillin could potentially save more life by curing pneumonia than $5.00 of Artemether-Lumefantrine could by curing Malaria, we have plenty of the expensive stuff and none of the other. Also, KEMSA never supplies certain injections which could considerably improve patients’ conditions.

Solution 2:
Nuru has established a Pharmacy Reserve for the NHC pharmacy, guaranteeing that, no matter what KEMSA provides or fails to provide, patients who come for treatment don’t have to be told to go to the private pharmacist 6 kilometers away. As the financial situation of NHC continues to improve, this subsidy can be reduced until NHC does not have to depend on KEMSA or Nuru.

Problem 1:
There were no patients. NHC only had a handful of patients per day. There was no delivery couch; a broken exam bench was all that they had and no amenities (think uncomfortable doctor’s table, but with the padding falling apart).
The present In-Charge was pushed into his “temporary” position at NHC, undesirably out and away from the town. After a month, he discovered that there would be no backup and he could not re-transfer. He was bored because there were no patients, and was frequently absent. Also he lived in town so was not available for emergencies.
What was very troublingly for us who aspire to sustainability, the revenues of the center were quite low. NHC (as most government facilities) charges a flat rate per patient, so keeping that the same, this part of it was directly dependent on patient load. Additionally, very few were coming to deliver at NHC. A preference for home birth is a significant challenge with a lack of trained midwives.

Solution 1:
We improved the facility by buying a delivery couch for the maternity ward and renovating the staff house to make it livable. Through a combination of efforts, we have marketed the heck out of NHC. We’ve pushed it with our health reps (we even had a “sale” with coupons; the rep who referred the most patients got a prize). We pushed it with Traditional Birth Attendants (following after other innovative local dispensaries, we paid them $2 for delivery referrals and charged women $2.50 for deliveries). And most of all, we encouraged and supported the staff to get quality of treatment high and keep it there (see solutions 2 and 3). Word of mouth is the best advertisement.

What happened? It worked. A total of 1000 outpatient services delivered in the month of July, and 1700 by October and rising. The number of monthly births at the facility has doubled since July (7 per month). And along with the patients, revenues have dramatically increased. Mr. Sangara moved into the staff house and has been seeing patients at night. Other staff keep it running on weekends. And with all this new activity, with the ability to practice proper medicine (with a lab and reliable drug supply), Mr. Sangara has been around a lot more frequently than before.

So all in all, things are improving. I cannot, either as a scientist or Nuru employee, toot my own horn too much. As a scientist, I can say that correlation is not causation; as a Nuru employee, I believe that it is the work of the people here which is the biggest effect. Mr. Sangara (the In Charge) and Ms. Alice (the Lab Tech) have been the foundation of the service improvements at NHC; Nuru has empowered them with the tools they need to work. And work they have! And perhaps most of all, Nelly Andega, my Nuru counterpart, has been fundamental in carrying out all of these many things with a competence and coolness of demeanor that I love.

[Bonus anecdote: Nelly was In the process of delivering cement for construction and sent me the following text: “Hello. The vehicle is on fire.” Upon calling, Nelly was completely calm. I asked, “Do you need help?” She said, “No. I am just helping the driver of the vehicle put it out. I was just calling to inform you.” She successfully extinguished the vehicle fire and then successfully deliver the bags of cement]

The End - Jake's Story

Nuru Media just put out a video about how Jake got into this work and discusses the connection between terrorism and poverty. It's a really powerful story and makes me proud to be able to work with him. I would encourage all you, my dear readers, to watch it and respond.

http://www.nuruinternational.org/takeaction/theend.html

P.S. The music was done by Tyler Bates, the guy who did the music for "300".

Help me address malnutrition

I'm reading and thinking about severe malnutrition interventions. WHO says RUTF (home-made power-bar paste) is the way to go; about $45 and 8 weeks to treat a kid (which much cheaper than the hospital route but not quite affordable to the poorest of the extreme poor). A tape measure can be used to identify kids (mid upper arm circumference < 110mm =" malnourished).">

Comment/message/email me with ideas on how to find and treat kids with malnutrition, especially ideas that fit with Nuru's aim to do things sustainably. Sure I can screen kids and feed them this stuff while I'm here, but who will do it/pay for it when I leave?

Mobile Clinic

It is 12:00PM on Thursday. I have been called, right before I am going to eat. The vaccines are not approved by the Ministry of Health (MOH). Even though they were approved the day before, they are now unapproved, which means I have to drive an hour by motorcycle on a very dusty road to resolve the issue.

It is 1:30PM. I am sitting in a meeting room with MOH officials. My failures to navigate the bureaucracy along with the cited reasons for un-approving the vaccines is a tale too long and tedious to retell. An hour passes in one of the most soul-crushing meetings I have ever had. The vaccines are finally re-approved on the condition that Nuru pay for the a nurse from the nearby hospital.

It is 2:30PM. I get back on my bike, and drive the long road home, hungry and tired.

It is 7:30AM on Friday. The day has finally arrived. Everything is arranged, or arranged as well as it could be. My people should be arriving to prepare. The kids should start arriving at 8. And by kids, I mean all of them. We arranged for each and every school kid in the sub-location to take a couple hours off to walk over to the Keborui school to learn about hygiene and get de-wormed. We also invited mothers to come get their children immunized starting at 8.

It is 8:00AM. Most of my officers have not arrived. The medical staff has not arrived. And (fortunately) the kids have not arrived. We’ve made great strides in timeliness here, but we’re not yet as anal about time as Americans; it’s a good thing everyone is a bit late. Everyone except for the mothers. They arrive exactly on time, ready to have their kids vaccinated. So we have to apologize and ask them to wait. The Nuru Water and Sanitation (WatSan) team is arriving, ready to teach many many children.

It is 8:30AM. The first set of kids arrives. About a hundred of them, walking together in uniform with impressive discipline. The WatSan guys are on it and escort the kids over to the field. Two health Field Officers and another Nuru worker aid in giving out the Albendazole tabs, one per child. And the lessons begin. The nurse has still not arrived.

9:30AM the nursing staff arrives. Vivian and Chelsea, my muzungu (white) teammates, meet her as I am on the other side of the campus. I walk back towards the classrooms. Chelsea and Vivian approach me, poorly-suppressed rage in their voices.

“The nurse is here.” Chelsea says.
“And she has news.” Vivian adds.
“She has news, David,” Chelsea emphasizes.

What news? What could news could there be but bad news?

“I was called this morning,” the nurse begins, “and the MOH says that the vaccines are not approved to come here.”

Interesting. I had made a bureaucratic blunder the previous week, and such blunders are not forgiven easily. Why had I not been told to my face 18 hours before? Why weren’t we given time to inform people that there would be no vaccines?

“Alright,” I say, calmly.
Chelsea and Vivian are astounded at my calmness.

Getting the vaccines pulled is interesting indeed, but not surprising. It is so not-surprising, that I had planned on it. We are 3km from the hospital, and I had hired a taxi for the morning to transport people there and back just in case there was a need. And now there is need.

I tell the mothers the situation, apologize, and sent them with Isaac to the hospital to have their children vaccinated.

It is 10:00AM. The day is in full gear. The children from the other schools are cycling in better than we could have hoped. The WatSan team is doing an excellent job of managing the crowds and getting them educated. The Healthcare team is effectively dispensing the de-worming meds. Everything is going according to plan. We have taken 30 children to the hospital for immunizations, many of them who were “defaulters” who had been off their vaccination schedule.

It is 4:00PM. The day is done. All the kids from four schools have been de-wormed and educated. We had gone through 2000 tabs of our de-worming medications. 2000 kids. We have transported every mother who showed up for vaccination. 80 children. The day is done.

New Website

So our new website totally rocks. Our media team is incredible:

www.nuruinternational.org

I guess I'll actually have to start living up to those videos... :)

Please comment about what you think.

Disease Intelligence Network, Part II

A while ago I told you all about the concept of the Disease Intelligence Network. As a refresher, the elevator pitch is this: we plan to collect health data and make it useful to the health workers. We want to know who has a cough (and where they are) this week to prevent it in others next week.

Well, concept has become reality! At least a little bit.

The last four weeks, I’ve sent surveys with the health reps. It’s unfortunate for the data enterer (me) that there are only about three male Kurian names (Mwita, Maroa, Chacha). If you’re lucky, you get a “Christian” name mixed in there (e.g. Peter, George…because George was a very important character in the Bible). But last names work differently here. They’re not really last; they “other” names. Parents like to keep the memory of all their relatives alive in their children’s names; unfortunately their relatives were also called Mwita, Maroa and Chacha.
What has drastically improved the efficiency of data entry is printing an individual sheet with the farmers names ALREADY printed. The Health Rep from Gesiora Group is a lot better at finding Mr. Chacha Mwita of Gesiora Group than I am at discerning “Chacha Mwita” scrawled on paper and finding which of the 35 Chacha Mwitas I should put that data under. Also, they know who’s married to whom a lot better than I do (so if a wife answers a survey, I know which family it’s from).

That hurdle overcome, the next step is to input the data. With the lists pre-printed, I just need to Ctrl-F my way to victory. It took me about an hour to put in the data for most of the farmers. Not too shabby, but shabby nonetheless. A present work in progress is to figure out how to make that faster and not me. Computer literacy here is very poor and experiments computer trainings have been disappointing (it took one person new to computers an hour to input one of the seventy groups). Our most promising lead is to get the Health Reps to do it themselves.

“Wait!” you must be thinking, “But how are you going to get 70 laptops?” And I would say in reply, “Who needs laptops when cell phones do everything laptops can!” We’ve been talking with SMS:Frontline Medic, an organization that does great work in using cell phones for communicating with CHWs. People don’t know how to use computers at all, but almost everyone knows and/or is learning to use cell phones. And PS just so you know, the cell networks are amazing here. I can buy GPRS data for about $0.03 per MB. And I haven’t found a dead spot yet. Take that developed world!

So after a month of data, what do we see? It’s tough to say. I’m proposing to Stanford that we do this formally for 6 months and analyze it rigorously. But for now, I think I see certain patterns. For example, there was an area one week with a single case of diarrhea; the next week, there were dozens in that area. Did the one cause the others? We can’t know yet. (Technically with what I have proposed, we can’t ever actually determine causality; but who cares? Because we may be able to determine that there is a strong correlation between a particular case of diarrhea and cases in the weeks to follow).

DIN may allow for other cool things beyond just the common diseases. Unaltered, it can help track and stem outbreaks of serious diseases like Cholera. We can send and alert and mobilize our team to warn people in at-risk areas and to distribute water purification products. Another possible idea is linking it with our in-planning health insurance; we can identify certain situations like a Malaria outbreak and use insurance to actually help stem the spread of the disease, rather than just pay for its treatment. If we predict a big Malaria outbreak with DIN, we can drop the patient co-pays for malaria visits to zero for a week or two (and announce this by health reps); this would increase those taking anti-malarials and may actually prevent the outbreak. This would, in addition to helping people directly, save money for us, the insurer, contributing to Nuru’s sustainability.

The bottom line is this: rapidly moving disease can be tracked with a precision and resolution previously unheard of. I had the privilege of meeting someone from the provincial medical office yesterday. We chatted about Nuru’s programs and he was mildly interested; but when he saw our first map, he said, “This is Revolutionary.” I certainly hope it is; I hope that it will bring better health for these people.

Hand Washing

One of our initiatives is to set up hand washing stations. Without running water, it takes some amount of innovation to have a place to wash your hands. Our design is basic: a holey cup with a hook, soap tied by twine (covered by the top of a water bottle) and a small pot or bucket for holding water. You dip the cup in the pot, and then use the drizzling water to wash your hands.

The great thing about this is that people before don’t have much way to wash their hands. And in a place where toilet paper is not yet widely used, it’s especially, especially important for people to wash their hands.

Last month, we’ve been running a competition to see who could build the most stations. Last week, Nelly and I went around checking those who people said they had built. There were mixed results. Some of the stations were not in use. Some had been destroyed by children (by doing such things as using the twine-attached cup to swing from). There were also problems we had not anticipated. Who would have guessed that livestock love eating soap? The core problem in these places, in my opinion at least, was that people did not value the stations. Sure they liked washing their hands, but not enough to keep water in the basin or to replace the soap. Maybe this is because diarrhea is less of a problem (we’ll have the data on that soon). Maybe it has to do with different ways our health reps and field officers explained it. Behavior change is a tough thing, particularly teaching grown-ups a new and strange habit.

But not all the homes were like that. One of the families we visited had even innovated on our original design: they attached it to their dish rack (a box with chicken wire for drying dishes). This was a pre-existing, sturdy structure already valued by the family. Children could not destroy it without consequence. They used it regularly and were satisfied.

Another family told us with joy about their station. The mother showed it off, proudly telling about how her children actually helped maintain it and kept the water full. They would wash their hands even without being told. She told us that the months before, her family had really been affected by diarrhea. But since she had been washing her hands last month, her family hasn’t had any diarrhea. She was beaming!

It is certainly amazing how cheap improved health can be in Kenya. In the US, to improve health is extremely expensive. To reduce diarrhea in the US, we have to spend millions of dollars to make sure we screen every last spinach leaf, or do surgery on rare bowel disorders. But in Kenya, it only costs a foot of wire, a re-used water bottle and a few minutes of education. When you including the cost for me to be here, Nelly to administer the program, and the Field Officers to build the stations and teach (adjusting for the portion of our time here dedicated to the stations) the cost per station is just $5.

In the US we talk and talk about how we shouldn’t put a price on a human life; we debate forever about how this health plan or that insurance company is putting a dollar sign on a life. But the reality is that we already do that. For every dollar we, as a society, spend on US healthcare instead of on Kenyan healthcare, we are putting a dollar sign on Kenyan life. In the US, we spend more than 15% of our GDP on our own health and far less than 1% on all development (health projects being one small part of that). When we, as a society, pay for a $50,000 surgery we’re saying that’s more important to us than 1,000 families in the developing world having a place to wash their hands. We certainly shouldn’t dump money on the developing world stupidly (like we have been doing…I’ve seen it all over Kenya and healthcare especially) and I’m not suggesting we stop caring for our own sick. But we should spend more of our resources caring for the sick outside out own borders, and we should do it intelligently.