Kenya: A Whirlwind Trip to Kenya right before Obama's visit
Updated: Sep 2, 2019
Nimmi Ramanujam, PhD, Director
What a productive day in Nairobi! Jennifer Smith my colleague at the University of North Carolina, introduced me to her colleagues with whom she works on cervical cancer screening. Our day started with a visit to the sex worker outreach program (SWOP) clinic in the slum Kario Bange. The clinic is housed in a 4-story building with other shops so women who go the clinic are not identified as sex workers by their community. All services are free including HIV testing and counseling, and cervical cancer screening and referrals. Women who are found to be positive for their cervical cancer screen (based on visual inspection with acetic acid) are referred to Kenyatta National Hospital or another level 4-6 facility for colposcopy and biopsy. The idea of bringing health services to communities with vulnerable populations has clearly demonstrated that there is demand for cervical cancer screening when it is available. At the Kenyatta National Hospital, I saw the highest level of services provided for the management of cervical cancer.
Here there are two types of screening and treatment approaches. The first is VIA/VILLI, which is followed by cryotherapy for cryo eligible lesions (see and treat) or colposcopy followed by biopsy and loop electrosurgical procedure (LEEP) for those high-grade pre-cancers. Women who can pay more can opt for a Pap smear, which if positive can be followed by colposcopy and biopsy much like the U.S. I met some absolutely wonderful clinicians during my visit to Nairobi, Dr. Rose Kosgei and Dr. Eunice Cheserom, both of whom are expert colposcopists at Clinic 66 at the Kenyatta National Hospital. They could not believe that the transvaginal digital colposcope could capture images as good as their upright state of the art colposcopes (Dr. Kosgei, left and Dr. Cheserom, right posing next to their colposcope).
The day ended with a visit to the HIV clinic near Kenyatta hospital that like the SWOP clinic in Kario Bange is fully funded by PEPFAR. Unlike Kario Bange, the HIV clinic has state of the art equipment and an outstanding medical record system. The clinic has 8,000 active patients of whom half are women. This vulnerable population is particularly susceptible to cervical cancer and VIA is the first line screening carried out at this facility. Given their established medical record system, one of the discussions we had was using the transvaginal digital colposcope to provide digital images of the cervix as part of the patient’s medical record so that it could be compared to colposcopy at the tertiary facility for the purposes of quality control and documentation.
On a side note, I was visiting Nairobi right after the First ladies conference to stop cervical and breast cancer just a few days prior to my arrival. So there was just a lot of buzz around cervical cancer screening during my visit to Nairobi. This turned out to be fortuitous. Through a series of serendipitous meetings I managed to get the long awaited letter of approval from the Ministries of Health to conduct research with our device in Kenya.
Obama was making his first presidential visit to Kenya and there was tremendous excitement and chaos in anticipation of his visit. Nairobi was expected to literally shut down during his two and a half day visit on the 24th to 26th of July. The Kenyans are really proud of their famous son and that is all I saw on the news. Luckily I was going to Western Kenya during his visit to Nairobi so I was relieved that I would not have to endure the craziness of Nairobi during this historic moment. Interestingly though, I was going to the part of Kenya where Obama senior hailed from. In fact, Obama’s step grand mother Grandma Sara is from a village that is not too far from Kisumu and I heard a lot about her and Obama’s previous visits to that village while I was there. I wanted to learn about the rural Nyanza province when I was in Western Kenya. Similar themes emerged to what I had seen in Nairobi when I met with the ACE NGO team and director Augustine Wasonga. ACE Africa is committed to community health and wellbeing and also teaching livelihood skills to the poorest of the poor. One of the programs they have established is improved health delivery services to sex workers who are at greatest risk for HIV. The Kanduye road, which connects to the North Road to Uganda is a place where truck drivers frequently stop and where transactional sex is quite common. To make health services readily accessible, ACE has created little buildings called One Stops where they get free HIV testing and cervical cancer screening.
The building is open 24 hours and staffed by community health providers registered with the Ministries of Health. Unfortunately, they often run out of HIV kits and are only able to offer cervical cancer screening when an NGO partners with them to offer the equipment and training. ACE also has a program where they partner with South End Academy, which is a free school and boarding home for orphans and those who need remedial primary education. Children who complete this program are sponsored by ACE to completely secondary school and many of these ACE alumni come back and become teachers at the very school that helped them realize their academic potential.
I have spent the last two years collaborating with partners at WISER to develop and implement an engineering club for secondary school girls in Western Kenya. The last part of my journey took me from Kisumu to Muhuru Bay, Kenya about a 5-hour drive to a village on the shores of Lake Victoria. The WISER secondary school, housed right near the Tagachi town center and clinic is a place where 120 girls get room and board, first class secondary education and psychosocial support as they progress through their education. Madame Dorcas, the fearless and passionate principal knows every girl personally, and empowers them to be the best that they can be. Teacher Kennedy who is the director of studies has been collaborating with us to develop the engineering club for girls interested in technology and entrepreneurship. The first year we started the club, the goal was to have the girls learn how to build the circuitry for renewable energy based flashlights using cranks to generate power for the lights. Visiting a year after this initial program, it was impressive to see that not only had the girls built many more torches since the 8 week curriculum taught by Duke students Mikayla and Kendall but they had also taught almost all of the girls in the school to build their own torches.
Although the original 52 members of the engin eering club had now been trimmed to half of that original size, this group is focused and committed on continuing the engineering innovation club. The team leaders Shanni and Mereza spoke to me about their experience and said that they now routinely use their flashlights to study at night when the power is out. When I asked Shanni to bring out her flashlight from her dorm so I could see it, she brought me a beautiful blue desk lamp with an array of LEDs. I was surprised at how professional the casing looked. She said that she had found the casing (since it is really hard to make casings durable and aesthetic with limited resources) and rewired the circuit to make it work using renewable energy. So she had taken essentially something that had been thrown away and rendered useless into something functional and beautiful.
The curriculum for this summer was entrepreneurship and a more robust charging unit and the design of durable casings using readily available materials. Duke student, Jenna Peters taught basic circuitry and entrepreneurship and Duke student, Michael Sutton taught the students how to build charging units using motors and shafts that would have a higher charging capacity than cranks built for individual flash lights as was the case last year. The plan for the third semester which starts in the September is for the girls to identify broken flash lights (made in China) with perfectly good casings such that they can take parts that are already well manufactured and rewire the circuits to be used with rechargeable AA batteries. I found out that the community in Muhuru Bay tends to buy D batteries for their battery-operated products, which are very expensive compared to AA batteries. Since many of the products are designed for D batteries, the girls are already applying their knowledge to convert these products to be powered by rechargeable AA batteries. Will they ultimately sell them to the community – that is not clear since WISER’s goal is not to sell to the community. For now, the focus is for the students to learn about circuits, renewable charging units and durable casings, the key components of making a durable renewable energy flash light and one that recycles many of the D operated flash lights unused by the community. We also talked about how we can use the Duke course, BME 290 to dovetail into the curriculum and we decided that we would take the feedback from the Tagachi clinic where some of the flash lights built by Duke students in BME 290 as well as from the WISER students would be incorporated into building refined lighting that is more durable, is brighter and can be designed specifically for the needs of the local community. Speaking of Tagachi clinic, I decided to take a small field trip to the little town of Tagachi right down the street from the WISER secondary school to look at the facilities at the clinic. It was a Sunday and so much of what I wanted to see was closed. However, I got a sense of what the clinic does and the primary focus is maternal child health, HIV testing and counseling and cervical cancer screening. Power is as expected a particularly persistent problem. For example, when I asked about cervical cancer screening, the health provider said that they typically do 5 screens a day. Apparently there is more demand but the clinic has only 5 speculums. Speculums can be autoclaved so when I asked why they were not being continuously autoclaved, she said that power outages are a frequent problem limiting how quickly they can reuse the speculums.
My final day in Kenya was lined up with a slew of meetings with my collaborators from Kenyatta University, Phillips Africa and Anne Kiror at the Kenyan Medical Research Institute (KEMRI). The KEMRI report for 2004-2008 was further validation of the important work that needs to be done around breast and cervical cancer in Sub Saharan Africa. Breast and cervical cancer are the leading causes of cancer death in women but perhaps what is most disturbing is the fact that the largest percentage deaths from cancer (almost 50%) occurs in women ages 30-50 with roughly equal contributions from breast and cervical cancer. Anne Kiror who is the head of the cancer registry is also a dynamic cancer advocate who chairs the Kenyan Cancer Association. During her tenure as chair the group has mobilized the Kenyan government to start the National Cancer Institute which will focus its efforts on cancer and in particular, the highly prevalent women’s cancers that are lumped under the reproductive health division at the Ministries of Health. She is well aware that her registry likely underestimates the true numbers related to the incidence of breast and cervical cancer as many women who do not have access to levels 4,5, and 6 centers never get screened. So how does one do widespread screening of cervical cancer and have a seamless linkage with the levels 4,5, and 6 centers that are going to provide some sort of therapy? There are different models that are being employed within Kenya, some by the government and some by NGOs and the private sector but it is not clear what will ultimately be most effective. Karthik Subramaniam at Phillips Africa talked about the model of community life centers that are being built with solar energy to provide basic health services including maternal and child health to families at the county level. They are also creating a continuum of care by empowering community health workers with backpacks that record essential information that can be linked back to the CLC and furthermore the CLCs are connected to the levels, 4-6 centers thus creating better linkages to ensure a health care continuum.
However, it is not clear whether these will be sustainable and a model that the government can scale so the team is actually doing implementation science research as a way to understand cost and impact, which seems like the best way to understand the pros and cons of a health delivery model. Then there are organizations that are disease focused and have used external grants and donations to set up cervical cancer screening clinics that offer see and treat for low-grade lesions particularly for vulnerable populations like sex workers. The caveat is that if the women are found to have high grade lesions or cancer then they are referred to tertiary centers but often times the barriers are quite staggering for women to actually get access to services from these facilities. So using technology to get high quality care to the lowest level of the socio economic scale is the important message I came home with from this very informative and productive trip.