What's been ailing Kenyan children since the 1960s

A new study reveals that the Nyanza and western regions have recorded the highest improvement in reducing under-five mortality since independence. Research over the years has shown that the two regions are some of the deadliest places to be born, and a child is likely to die if born there unlike in parts of central Kenya.

The regions are known to be “friendlier” to several deadly diseases, with geography and cultural practices playing a key role. These include being in the lake basin, where a warm and wet climate is a breeding ground for mosquitoes that carry the malaria-causing germ. And since the early 1990s, the region’s four counties — Migori, Homa Bay, Kisumu and Siaya — bear more than 40 per cent of the country’s HIV burden, demographic health surveys show.

However, the new study published by researcher Peter Macharia of Kemri-Wellcome Trust shows that the regions reduced the mortality of children under five by more than 70 per cent, while central managed a paltry 30 per cent. Marshalling historical documents, and combining mathematical formulae superimposed over geographical locations, Dr Macharia reported that just after independence, “one in every seven Kenyan children born alive died before the age of five; 49 years later, mortality has declined significantly, but remains high, with one in every 19 children not reaching their fifth birthday.”

The mortality reduced from 142 per 1,000 live births in 1965 to 55 per 1,000 in 2013. This was 62 per cent, a remarkable improvement that also masked great inequalities. Homa Bay had the worst mortality in 1965 at 269 deaths per 1,000, but reduced to 120 deaths per 1,000 in 2013, a 55 per cent decline. Nyeri, on the other hand, had 54 deaths per 1,000 but only reduced the mortality by 20 per cent to 43.

Counties like Samburu, Marsabit, Elgeyo-Marakwet and Mandera still have undesirable statistics but had more than 70 per cent reduction in mortalities. The Nation collated all the diseases recorded in the census data since 1969 — the first — to 1999 and found that before independence, children battled polio, whooping cough and diphtheria. Waterborne diseases like dysentery also featured prominently. High rates of HIV from the early 1990s, malaria and resistance to medication meant to treat the disease turned Nyanza and western to that vicious cycle of fatalities.

It did not help much that user fees— the money paid to the hospitals by patients – was introduced in health facilities in 1992. Before independence, nearly a quarter of all children died before they turned five (250 deaths per 1,000 live births), and just slightly after independence, the number reduced to 239 per 1,000. The worst places, the study pointed out, were coastal, arid and semi-arid counties, Lake Victoria and Turkana.

In the development arena, under-five mortality is used as a yardstick to measure how healthy a country is, and how likely it is to meet its development targets. In 1990, at the World Summit for Children, ministries of health all over the world agreed to reduce the deaths of children under five to less than 70 per 1,000 live births by the year 2000, or reduce them by one-third between 1990 and 2000.

Careful not to pin on one explanation, several theories have been fronted to explain these unfair differences. Dr Kenneth Munge, an expert in health policy and systems expert, told the Sunday Nation the differences in the likelihood are inequities, as opposed to inequality, because “they are unfair and unjustifiable that one child in one location would fair way much better”.

Dr Munge says that the under-five mortality points to everything that is wrong in a child’s life, including outside the health system. He says: “There have been links to a child’s survival on the mother, whether she feeds well, is educated or not, can access contraceptives so that she can space her children; on the household, whether they have food so they do not stunt, clean water so that they do not diarrhoea and die, among many other factors.”

A new hope for children suffering from HIV

HIV was a once death sentence for Kenya adults and even much more to the children.

Kenya, like many other countries is setting its eyes on the ambitious 90-90-90 target, which seeks to have 90 per cent of all children living with HIV diagnosed, 90 per cent of those diagnosed HIV+ receiving treatment, and 90 per cent of those children receiving treatment achieving viral suppression by 2020.

The head of National Aids and STIs Control Programme (Nascop) Dr Catherine Ngugi told Nation that viral suppression for children in “not that good”. In 2017, Nascop reported that only 67 per cent of children below nine years and 66 per cent aged 10 to 19 had achieved virally suppression. This is far below the 90 per cent target.

Kenya has received praise for its fight against HIV, but there are challenges that the country has not surmounted. One of those is access to paediatric friendly medicine. The medicine that was available was so bitter that children spit it out.

This is because Kenya is among six countries that will receive the “four-in-one” strawberry flavoured paediatric HIV drug, according to manufacturers of the drugs who spoke to Nation. The communications office of Geneva-based Drugs for Neglected Diseases Initiative (DNDi), which manufactures the drug alongside Indian company Cipla, told Nation that once the medicine is approved, Kenya alongside Uganda, Tanzania, Cameroon, Burkina Faso and Senegal will receive it.

DNDi received a $17.3 million grant for their paediatric HIV programme from another non-profit, Unitaid, a substantial amount of which was channelled into the programme.

DNDi wrote on their website on November 29 that “Quadrimune is currently under review by the US Food and Drug Administration (FDA) for use in children between three and 25kg bodyweight.”

This announcement comes after Dr Nascop’s Dr Ngugi attended a week-long Icasa conference in Rwanda last week and held a meeting with DNDi to solidify the agreement to have the medication come Kenya.

Health CS Sicily Kariuki wrote to Nation: “We are working for Kenyan to be among the first countries to roll out this treatment.”

Dr Ngugi stressed that they were “hopeful that the medicine will come to Kenya by July 2020.”

The medicine will be a relief from the bitter tasting Lopinavir-Ritonavir, known by its generic name, Kaletra, which children spit out or refuse to take altogether. Kaletra also requires refrigeration, a requirement that many mothers cannot meet.

Dr Patrick Oyaro, an HIV expert and CEO of Health Innovations Kenya, participated in the study and told Nation that when children spit Kaletra out, it contributes to their developing resistance to the medication due to an incomplete dosage.

Paediatric HIV in considered a neglected diseases— no wonder DNDi got involved— because not many companies manufacture drugs for it. The country has been participating in the pilot study— still run by DNDi— to try better tasting medicine in children since 2015.

Between 2015 and 2019, Kenya participated in the LIVING study where 1,003 children were enrolled across 12 sites in the country Uganda and Tanzania. Kenya had five sites. In June 2015, America’s Food and Drug Administration (FDA) approved an oral “2-in-1” formulation developed by Cipla. These formulations didn’t require refrigeration and could also be sprinkled on food.

In February 2018, DNDi told Nation, interim results of the LIVING study were released, showing that 83 per cent of the children in the study were virologically suppressed at 48 weeks with the 2-in-1, compared to 55 per cent at the beginning of the study.

However, the 2-in-1 still had to be taken with the two other drugs still bitter if left in the mouth for too long and the pellets were also a bit big so very young children found it difficult to take.

So in June 2019, DNDi’s LOLIPOP Study resulted into the 4-in-1 known as Quadrimune. The country has also managed to cover only a portion of the HIV-positive pregnant women who need to prevent their unborn babies from getting infected with HIV. The prevention of mother to child coverage in 2017 was about 77 per cent.

Pediatric HIV is not the only neglected disease that is killing children.

Neglected tropical diseases for neglected people

Poron Lokoler talks with pride about one of the activities that make him a man in the Pokot community in Kalemrekan village in Kenya. Like many boys of his age, graze herds of cattle. When it is dry in Kenya, Poron and his age mates cross with the cattle into Uganda to look for pasture. When I met him, he was wearing a t-shirt with the words “This is my hangover t-shirt” boldly printed on his chest. Poron escaped death by Visceral Leishmaniasis, also known as kalaazar or black fever, a disease transmitted through the bite of an infected female sand fly. The sand flies thrive on cattle and their dung — the very things that Poron lives for.

Kalaazar is one of the 18 diseases that the World Health Organisation classified as Neglected Tropical Diseases (NTDs) because governments and healthcare systems pay little attention to them. In Kenya, it threatens more than 600,000 people inhabiting Turkana, West Pokot, Baringo, Isiolo, Baringo, Marsabit and Wajir, according to the head of Neglected Tropical Diseases at the Ministry of Health Dr Sultani Matendechero. Many are not as lucky as Poron. Several factors are behind this.

First is the access to care: In Uganda, there is only one hospital where Kalaazar is treated — Amudat Hospital in Amudat District in Eastern Uganda — and in Kenya there is Kacheliba and a clinic in Baringo County.

At Kacheliba, the medical superintendent Solomon Turkei says that patients travel from as far as 400km away seeking care even from across the border when symptoms — severe fever for more than two weeks, weight loss and fatigue, swelling of liver and spleen — set in. Eunice Chemanang’ travelled with her two children from Akulo at the periphery of Baringo-West Pokot County border. A mother of three, who can only afford one meal a day, the journey to save her son’s life impoverished her even more because she had to part with $17. “I walked for about four hours to Akorekwang’ then paid Ksh200 from Akorekwang’ to Sigor, and then Ksh 1,500 from Sigor to Kacheliba on a motorcycle,” she explained.

At the hospital, the mother’s countenance is fallen for other reasons as well: “I left two of my other children at home, and I cannot stop wondering whether they ate at all this evening.” Eunice cradles her other healthy son with whom she came to the hospital, she continues: “I feel a knife cut across my stomach when the doctors are treating him, but I know it is important to help him live.”

After the treatment is over, Eunice does not know where she will get fare for the journey back home. They are at a special ward for kala-azar at the facility. By August 17, there were 21 patients in the ward. In 2018, the ward admitted 272 patients, who travelled from as far as Tiaty, a whole day’s journey to the hospital.

By August, they had admitted about 170 patients. Outside, just after the morning rounds the children come out limping and crying from the pain of the injections. “The injections are very painful, for 17 days,” said Mr Turkei. The drug used to treat Kala-azar in Kenya, Ethiopia, Sudan and Uganda is called Sodium Stibogluconate and Paromomycin (SSG-PM) therapy. It was developed by the ministries of health in these countries and Drugs for Neglected Diseases initiative (DNDi), a global non-profit organisation developing new treatments for neglected diseases.

Fairly toxic medicine Before SSG-PM, patients endured a 30-day course involving the use of a fairly toxic regimen of Sodium Stibogluconate (SSG) alone, until the SSG-PM reduced the days to 17 days. DNDi has funded the treatment of kala-azar from 2008, taking over from Médecins Sans Frontières, an international medical humanitarian organisation.

Prohibitive cost A bottle of generic SSG costs Ksh 8,000 ($80) and that of PM Ksh200 ($2). Both children and adults need more than one bottle for a complete 17-day treatment, estimated to cost of about $400 a person. According to Mr Turkei, SSG-PM cannot be administered to the elderly, expectant women, people with HIV, and those who were treated for the disease and relapsed. For this group, there is a safer but more expensive drug: AmBisome, also supplied by DNDi with occasional support from WHO. AmBisome is estimated to cost about Ksh2 million ($20,000) per patient. Due to the toxic nature of the treatment, the diagnosis is as thorough and life threatening as it is expensive.

Dr Turkei explains: if the patient came to the facility complaining of protracted fever, there is an initial rapid test which will be followed by a Direct Agglutination Test to tell whether the cause of the anaemia is due to attacks on the red blood cells. In certain instances, the patients may undergo a final test, which involves a spleen or bone marrow aspirate. This is where the fluids are pulled from the spleen or bone marrow: A miss can puncture the spleen, and kill the patient. On my visit, the hospital had run out of blood, and a little boy who had become anaemic had to be ferried 80km to Uganda for the blood. So he waited while impatiently, calling every now and then to inquire where the driver of the only van was so that it could take the boy to Amudat.

Funding drought While Turkei is worried about what he will use to treat his patients, Dr Matendechero fears that lack of funding impairs healthcare workers ability to pick kala-azar apart from brucellosis, malaria and other diseases that mimic it. “The lack of attention paid to the diseases has also had clinical implications where healthcare workers are taught in school in passing, and therefore misdiagnose them as the common diseases that mimic the NTDs symptoms,” Dr Matendechero added.

However, it is not only the direct treatment costs that hospitals bear.

Dr Patrick Sagaki, who is in charge of Amudat hospital says the poverty and illiteracy of the Karamoja area — in which Amudat falls — is perpetuated by the historical neglect of the area. In 2018, the UN put Karamoja area in the category of the world’s poorest areas, with high rates of malnutrition and absolute poverty — 61 per cent of its 1.2 million people live in absolute poverty. Majority had not even been vaccinated against common illnesses. “Most of the patients who come here have low immunities because of malnutrition, that when they get here, we are not treating kalaazar alone but other diseases such as Tuberculosis, Malaria, and bronchitis,” Dr Sagaki said.

Some of the patients, Dr Sagaki said, come from as far as 400 kilometres away, seeking care by travelling to Amudat in a region with no established means of transport. According to the Uganda National Bureau of Statistics, more than 70 per cent of the people in Amudat cannot read and write. Andrew Ochieng’, a community health mobiliser born and raised in the area and has survived kala-azar in his childhood said that there were alternative explanations for the disease which killed people. They would fall prey to quacks who would inject veterinary products directly to the spleen causing death instantly on the children.

Why pneumonia is still Kenya’s number one killer of children

Pneumonia remains Kenya’s number one killer. The disease first appeared Kenyan policy documents for health in the late 80s, and a lot has changed since then.

For instance, it was always thought that only bacteria cause pneumonia. Now, a three-decade study that was published this year showed that 60 percent of all the pneumonia is caused by viruses. The million-dollar Pneumonia Etiology Research for Child Health Study (PERCH) was conducted in Kenya and six other countries considered to be “high burden” for pneumonia, and found that viruses caused most (61 percent) of the severe pneumonia cases.

The respiratory syncytial virus (RSV) was the leading pathogen (31 percent) at all sites in all the 30 pathogens. Bacteria was only responsible 27 percent of pneumonia.

In 2019 alone, 1,333,000 people sought care for pneumonia in hospitals in Kenya, according to the data from the national health information system. Majority of these were children.

In 2016, the UNICEF reported that there were more than 34,000 deaths due to acute respiratory infections, mostly pneumonia, and 14 per cent of all the deaths of children under five.

A 2017 study by UK based organisation Save the Children, pneumonia kills two children under five every minute, an equivalent of one million a year worldwide. Majority of these deaths are in sub-Sahara Africa.

While the numbers have reduced, the disease remains Kenya’s number one child killer, and health experts have many reasons.

Researcher David Gathara, said attention has not been given to the respiratory killer even when data shows it is the greatest threat to children.

“Perhaps even more that than HIV and malaria where we all have our attention,” he says.

Pneumonia presents with a cough accompanied by short laboured breath. Many microorganisms —such as bacteria and viruses — enter the lungs and clog the air sacs with fluid. This reduces oxygen uptake that aids in breathing.

Ambrose Agweyu, a paediatrician and disease patterns and pneumonia researcher at the Kenya Medical Research Institute (Kemri) Wellcome Trust— told Nation that from prevention, to the time the mother gets to the hospital is a chain, and when it breaks anywhere, a child dies. This is particularly prevalent in arid and semi-arid counties in Kenya.

He said: “There are vaccines given for free to children but then there is the issue of access where mothers cannot even afford fare to the hospital.”

Kenya introduced the pneumonia vaccine in 2011 to be administered to children at weeks 6, 10 and 14. According to the Pneumococcal Conjugate Vaccine Impact Study (PCVIS) that was published in Lancet this year, children admitted to Kilifi County hospital with clinically defined pneumonia reduced by 27 percent.

Ifedayo Adetifa, a paediatrician and clinical epidemiologist who was part of the study said that before the introduction of the vaccine, the incidence of the disease was 1,220 children per 100,000 which reduced to 891.

However, in some counties such as Samburu, women walk for two hours with babies strapped to the back, carrying with them food and water to take them through that rough terrain. They are seeking vaccination brought by a non-governmental organisation.

In Samburu East, the terrain is unforgiving: the sun is literally baking the ground; wild animals roam freely and there are rivers such as Lengusaka that overflow that the mothers have to sit on the sides and wait for the water levels to drop before attempting to cross.

There is an outreach conducted by Action against Hunger International in collaboration with the Ministry of Health. Njelai, a mother of two, said at Marmarai Health Centre in East Samburu, the nearest health facility is Wamba Health Centre. That is nearly 74 kilometres away.

A nurse that runs these outreach camps, Teobalda Michaels, said she could draw a straight line between the cases of pneumonia and what the mothers used to cook for the children in the huts with poor ventilation.

Dr Agweyu said that it is suspected that the fine particles and toxic gases in cooking smoke inflame the babies’ lungs, which makes them twice as vulnerable to pneumonia

But even when mothers does overcome these challenges and go to the facility, there is no guarantee that she would find a healthcare worker in the hospital with the tools to treat the child.

When Nation reporter visited Obama Children’s ward in the referral hospital in Kisumu County in December 2019, there were no children in the ward because the healthcare workers were on strike.

Senior nurse in charge of the clinic Jane Olum said: “Yes, we get a lot of pneumonia, in different forms, some mild that can be treated and patient discharged and others very serious, and now I do not know where they will go.”

Even when the healthcare workers are present, there is also the readiness of the facility. Dr Adetifa clarified that a cough accompanied with difficulty in breathing and lower chest wall in-drawing is a case of severe pneumonia.

But there is also severe pneumonia when the child presents one of the “danger signs” like inability to drink, seizures, altered consciousness, head nodding, and baby turning blue due to lack of oxygen.

In this case, Dr Agweyu explained, there would be a need for intensive care equipment: it is estimated that more than 80 percent of hospitals in Kenya do not have them.

While there have never been follow up studies on patients in Kenya, there are some in South Africa that have shown that deprivation of oxygen to the brain in some severe cases on Pneumonia have impacted negatively on the cognitive abilities even if the child survives.

Even with the best intentions, pneumonia has changed over the years, and yet the perception and treatment guidelines have not.

That bacteria and these many viruses cause the disease, and the fact that these microorganisms lodge themselves deep within the lungs makes healthcare workers struggle to diagnose pneumonia.

Dr Agweyu who participated in the PERCH study told Nation that in certain cases, pneumonia that starts by viruses worsen to include bacterial complications. The virus, he said, weakens the mucus-like cover in the lungs and this makes it easy for the bacteria to invade the child’s lungs. When the healthcare worker does make the diagnosis, there is also the complexity of how they categorise those patients according to the Ministry of Health guidelines.

The country has revised its World Health Organisation-approved guidelines on treating pneumonia after more than three decades but now experts are fearing the changes may lock many children out of much needed medical attention.

The new guidelines moved down the key physical sign previously used to identify severe pneumonia cases — whether the child’s lower chest wall was drawn in as they breathe — and made it be for non-severe pneumonia. Non-severe case is considered an outpatient problem where the child is given oral antibiotics and discharged.

But Kemri researchers and another paediatrician from London School of Hygiene and Tropical Medicine Kim Mulholland expressed concern over WHO’s simplification of managing children with pneumonia into those two categories of “low risk” to be treated at home and “high risk” to be treated in hospital.

Prof Mulholland and her Kenyan colleagues analysed data of 16,031 children sick of pneumonia in 14 of Kenya’s county hospitals before the new guidelines were formally rolled out. They found that five percent of these children (832) died.

Nearly two out of five of the kids that died (39 percent) had in-drawing of the lower chest, and would, therefore, have been classified as “not severe” in these new guidelines.

Prof Mulholland explained that these changes made it easy to train health workers but their study needed a more nuanced approach. She said: “The numbers show that some of those with the “low risk” tag actually fall somewhere between low risk and high risk, an “unrecognised intermediate severity.”

This story is part of the Diversity Desk, funded by Microsoft and International Center for Journalists (ICFJ). Follow it on Twitter here.