SIAYA, Kenya — The only hospital here lies a short way off the only tarmac highway — a collection of single-story buildings spread out amongst the trees and carefully trimmed lawns. Waiting patients chatter, small babies cry.
Just behind this well-kept but gently aging hospital is a slick, new building attached by a covered walkway.
Opened earlier this year, the building is a clinical research center of the Centers for Disease Control and Prevention (CDC), a US government agency that works with the Kenya Medical Research Institute (KEMRI) to find vaccines, cures and treatments for the tropical and other diseases – HIV/AIDS, malaria, typhoid, tuberculosis, cholera – that are endemic in this part of the world.
The building and the work that goes on in it, in the adjacent hospital and in the surrounding community, represents the future of US engagement with health problems worldwide, a new kind of cut-price integration as envisioned in President Obama’s Global Health Initiative (GHI).
GHI was announced in May 2009 with a little fanfare and a big figure: $63 billion over six years to be spent on improving the health and saving the lives of the world’s poorest and most vulnerable people. Now, amid budget constraints in Washington, analysts predict that this number is likely to be to significantly reduced to no more than $52 billion for GHI over the six years.
In the urban and rural clinics of Kenya, where US government agencies CDC, USAID, Peace Corps, Department of Defence and PEPFAR are working, GHI has not meant much change.
“A lot of what GHI [is] all about was not new to Kenya,” said Katherine Perry, Kenya’s PEPFAR coordinator and GHI planning lead.
That’s because, unlike other countries, Kenya was already doing the things GHI aimed to do before the initiative was announced, using huge sums of HIV/AIDS money to treat broader health issues.
Because Kenya has employed GHI’s more holistic strategy for global health since before it was codified into policy, observers believe Kenya can stand as a model for everything GHI intends to accomplish. It offers a glimpse into the future of the Obama administration’s ambitious initiative. But lingering questions remain. Most pointedly, whether Kenya can find a way to build upon the solid base the country already has.
The Siaya research center's computer lab, full of brand new high-tech machines, seem incongruous with the rural setting — close to Lake Victoria in the western corner of Kenya. Right now, the focus is on testing a potential malaria vaccine – GlaxoSmithKline Biologicals’ RTS,S.
The lab tests blood cultures and cerebrospinal fluid. Its technicians are qualified in malaria microscopy and microbiology. Results from the vaccine trial are sent directly to GSK via the Internet-connected computers upstairs.
This kind of clinical trial is core to CDC activities but has knock-on benefits for the rest of the hospital and its patients.
“The facilities were upgraded as a result of the clinical trial,” said Dr. Frank Odhiambo, who works with KEMRI/CDC in western Kenya. “All 32 beds in the pediatric ward have nets, and there is malaria microscopy available for all the kids.”
The new equipment is not just for test subjects but every sick child who is admitted to the hospital. “Nowadays you can’t tell a study subject from an ordinary patient,” added Mary Owidhi, a health worker at the hospital.
In the nearby city of Kisumu, there is also a CDC clinical-research center, but it was built some years ago. While this center, like the one in Siaya, is located within the hospital grounds, it is separated from the rest of the facilities by a wire fence. It is in the hospital but not really part of it, and so stands as a metaphor for the changing approach of U.S. agencies working in Kenya.
“Here in Siaya, the research center includes general patient support. It includes a male circumcision room run by the Ministry of Health. The facilities are there for all patients. It is really an extension, an annex, of the existing hospital,” said Odhiambo.
Joyce Amianda, a 36-year-old nursery school teacher and mother, lives a short distance from the hospital with her husband and two daughters. Amianda is HIV positive. Gift, her chubby-faced six-month-old, is HIV negative.
“I have given birth four times but I only have two children,” said Amianda. Her first two children – both girls – died before they were 18 months old. Amianda thought it was because of ‘chira,’ a kind of witchcraft or curse. She said chira had also killed her husband’s first wife.
“At that time I did not know I was HIV positive, only that my children were dying,” she said.
During her third pregnancy Amianda was offered an HIV test as part of her antenatal checkups. She discovered she was HIV positive and despite the initial shock was relieved to have an answer. “Although I was positive, there was care and drugs for people with HIV and, at last, I knew why my children were dying.”
Amianda is on anti-retroviral drugs, supplied by the Ministry of Health and dispersed at Siaya District Hospital. She recently took part in a CDC/KEMRI program run out of the new annex at Siaya to test the efficacy of mefloquine, an anti-malarial, on pregnant mothers.
“From the study I am able to handle malaria thanks to the bed net as well as the drugs,” said Amianda. “Also I have gotten a lot of health education. For example [I have learned] to breastfeed exclusively for the first six months rather than using mixed feeding. Now my child is not getting sick, in fact she is so big and I am so happy!” she said, squeezing Gift’s pudgy arms.
These stories — a woman who enters a drug trial and learns about breastfeeding; a young patient who gets fast, effective malaria diagnosis and treatment because of a new vaccine trial; including questions about maternal health in the next round of CDC’s regular household survey of disease — encapsulate the approach of GHI which seeks to treat the patient as a whole, not just as the expression of a set of symptoms relating to a single disease.
Taken at face value when it was announced, Obama's GHI seemed to dwarf the signature global-health policy of his predecessor, George W. Bush, whose President’s Emergency Plan for AIDS Relief (PEPFAR) promised $15 billion over five years (underscoring the program’s success, in 2008 Congress authorized a further $48 billion for PEPFAR).
But while Obama’s topline figure for GHI was impressive, it was also misleading for two reasons. First, whereas PEPFAR’s money was new, GHI’s is mostly repackaged. Second, the precarious states of the world and the U.S. economy mean that the announced funding is in any case unlikely to be realized. Compounding GHI’s problems is political gridlock between Democrats and Republicans in Washington.
Yet in Kenya, officials are finding ways to put the principles of GHI into action without any extra money. “GHI in Kenya is more than anything else about repackaging and reprioritizing,” said Lee Brudvig, deputy chief of mission at the U.S. embassy in Nairobi.
“For many years, many of the elements of what is now GHI have been in place,” said Brudvig. “So it’s taking what we’re already doing [and] mapping it out more effectively… We need to eliminate duplication in our own agencies and fill the gaps through reprioritization of existing money,” said Brudvig.
Stephen Morrison, Director of the Global Health Center at Washington-based think tank the Center for Strategic and International Studies (CSIS), which has published two recent papers on GHI in Kenya, agrees with Brudvig and describes the country as “the boiler room” of the emerging GHI.
“[The Kenya team] were ahead of the game in their thinking and their operational plans,” said Morrison. It is here, Morrison says, that one should look to see how GHI can work in other countries.
The recently completed Kenya GHI strategy calls for a focus on reducing maternal, neonatal and child mortality, and reducing illness and death from neglected tropical diseases.
“When you ask what’s different after GHI, I would say it’s the focus on a broader range of health conditions that affect moms and children,” explained Lynn Adrian, Director of the Office of Population and Health at USAID in Nairobi.
“We were very focussed on HIV, which is still a very big component of our program, but GHI has allowed us to step back and ask, ‘What are the full range of health challenges in this country?’” she said.
GHI also seeks to strengthen Kenya’s own national-health system, integrate available services so that more is available in each location and let Kenyans know what care and treatment is available to them.
A key element is what aid workers call “sustainability,” which means projects should be able to continue after the foreign funding dries up. But with the US contributing around $650 million a year towards Kenya’s health system, is a handover to the Kenyan government ever going to be possible?
“You can ask that question,” Adrian conceded. “Where is the exit strategy with those kinds of budget figures? How is the government of Kenya going to finance, manage and sustain this level of service?”
She said that working more closely with officials from Kenya’s health ministry was a step towards preparing Kenya to bear the health burden itself.
Dr. Kayla Laserson, CDC’s Director of Research and Public Health Collaboration, insists that since the advent of GHI, the relationship with government officials is “completely different.”
“A lot of [health initiatives] are very donor driven, which isn’t how it should be, with [GHI] we have said, ‘This is yours. Take it. Let us help you.’ And they really have,” said Laserson.
She admitted that a patient using a clinic supported with U.S. money may not yet have noticed any major changes, but Laserson argues that GHI has brought about an atmosphere of greater reflection.
“A lot of our work has gone forward as it had but there’s been a change in the philosophical approach. Perhaps we’re still working on malaria and pregnancy but now we’re also part of GHI and we talk and think about it differently and we talk and think about the connections between that work and other work,” she said.
The various U.S. agencies are also required under GHI to talk to one another more and work more closely together. Again, this is something that has been happening for some time in Kenya, unlike in some other countries, although there are still some grumblings.
As one U.S. health worker who did not want to be named, put it: “GHI is just a bunch of new meetings with no new money.”
Perry, Kenya’s PEPFAR head, concedes there are more meetings but that they are worthwhile, not just time-consuming talking shops.
“Kenya has been forward thinking and out there… in terms of working together as an interagency team and also [in terms of] the relationship with the government and moving towards country ownership,” said Perry.
But before Kenya can begin to even think about taking over the health burden, it must first secure stronger and consistent economic growth.
“Ultimately no amount of investment or political reform is going to deliver long-term sustainability unless you have growth,” said Brudvig. “If you have growth the government has greater revenue streams and can take on a greater part of the burden. Right now saying we want the government [of Kenya] to do more because we want to do less is not feasible.”
GHI fits well with the post-financial crisis era of austerity because it is about being more efficient; using what you have, cutting out waste and, eventually, getting out altogether.
“Every bureaucracy, if left to their own devices, would prefer to rely upon their own resources and their own contractors and programs,” but Brudvig argued that this leads to a “stovepipe effect” that under GHI is to be replaced by integration.
Away from the Nairobi conference rooms, the impact of the U.S. investment in Kenya’s health system stops being a theoretical discussion and becomes a living reality.
A small program called ‘Mothers2Mothers,’ based in Kisumu hospital and funded by the U.S. since 2008, is creating and maintaining support networks for HIV positive new mothers. They need it.
Sitting beneath a tree that offered welcome shade from the scorching mid-afternoon heat, a small group of HIV positive mothers told how discovering the infection had altered their lives.
Like many others, Jacqui Odongo was thrown out of the house when she told her husband she was HIV positive. She was pregnant with their first child at the time.
“He renounced me, he said that when he was at work I was prostituting around. I was chased out of my homestead that very night.
“My husband shouted at me calling me all sorts of names, he threw my things all over the compound, my mother-in-law came out demanding why I was bringing disease to their home. The neighbours came out of their houses and looked at me as if I had brought death to that place. I really cried and when I left, I never went back,” she said.
Odongo believed HIV was a death sentence — for her and her unborn child — but at the Mothers2Mothers program she found solace in so-called ‘Mentor Mothers.' In the program, those who have gone through the process of discovering and disclosing their HIV status now help others do the same.
She was shocked to find women looking healthy. They were not “sick, with rashes all over their bodies,” as she had expected. Some of the new mothers were breastfeeding, and most had given birth to HIV negative babies.
“The Mentor Mothers consoled me and they told me that it is possible to give birth to a negative baby if I follow the doctor’s orders. That’s what gave me hope in life,” recalled Odongo, who is herself now one of the program’s coordinators, and is mother to a daughter who is HIV negative “as of her last test,” a caveat used by all the mothers in the group.
In the group, women learn about maternal health, child health, family planning, reproductive health and defending against and mitigating the effects of HIV/AIDS. They also learn to support one another in their fight to survive in the face of deeply ingrained prejudice and stigma towards those with HIV.
The problem for GHI is not so much the work, as the message, or lack of one, according to CSIS’ Morrison. “People are still asking, what is GHI? Is it PEPFAR redux? Is it PEPFAR with new packaging? It’s not, it’s much more than that, but GHI has not done a good job of branding itself.
“GHI can do much better in explaining its goals and achievements but that does not belie places like Kenya, where real progress is being made,” he said.