The Nairobi Slums: a Crucible for Metrics Studies?
August 13, 2009
Who would have thought that the biggest slum in Africa is also the crucible for some of the best health metrics studies on the planet?
The slum is a section of Nairobi called Kibera, compassionately called an "informal settlement" that defies population enumeration and has somewhere between 600,000 and 2 million people compressed in less than 60 hectares of land. It is an oppressively dense amalgam of rusting corrugated metal, tattered cardboard, rivulets of raw sewage, and mountains of randomly strewn garbage. If it were only a huge compost heap anywhere else it would be condemned. The major qualifier is that this heap is not inanimate. It crawls with hundreds of thousands of people, traversing ant-farm like narrow corridors carved by human steps through ages of uncontained refuse and decay.
Kibera has little clean water, electricity or sanitation. These are the breeding grounds for some of the worst health conditions in the world. Typhoid, malaria, HIV/AIDS, hepatitis, and all manner of diarrheal and respiratory diseases run rampant, especially in infants and young children.
It is in this setting that our Commission visited the Carolina for Kibera Tabitha Clinic, our first stop in our 3-day lightning tour of Kenya. This unique community clinic is a joint venture made possible by funding and staff support from North Carolina universities, UNC and Duke (Tar Heel and Blue Devil mascots vie for prominence over the front door), and also by the US Centers for Disease Control and Prevention (CDC). It was completed about one year ago, and built brick-by-brick hauled through narrow alleys carved through the shanty-town, by Kibera community volunteers.
The clinic is dedicated to primary care for Kiberans, and staffed by a legion of Kenyan doctors, nurses and technicians. We were oriented to the clinic programs by Drs. Salim Mohammed, Executive Director, and Rob Breiman, the CDC Kenya country director.
In a development world increasingly focusing its investments on "impact" and "evidence-based policy and practice," two Tabitha clinic programs stand out.
Why do one out of five infants and children in Sub-Saharan Africa die before their fifth birthday? Most severe illnesses or deaths in this age group are from potentially curable infectious diseases. If the underlying cause of every child's fever were determined, the infection could not only be specifically treated in most cases, but "fever algorithms" that advise African health practitioners on how to manage and treat sick children could be updated. This kind of rigorous study requires a state of the art microbology and immunology laboratory facility. The biological samples from Tabitha are systematically analyzed by the CDC for a range of infectious agents. A large database is being amassed that will provide the necessary information to understand the spectrum of infection in Kibera's children. This is the first step to better prevention and treatment policies and practices for not only Kibera and Kenya, but hopefully for the region and the continent.
How often do children and adults in Kibera get sick and not go to a health facility? What is the pattern and frequency of illness symptoms in the community? Not only are these answers not known for Kibera, but there is little comprehensive community morbidity data anywhere in sub-Saharan Africa. This is vital information for understanding the cultural aspects of "health seeking behavior," and is an important complement to the laboratory survey of infectious diseases noted above.
Tabitha clinic is spearheading a large long-term household survey of the Kibera community to answer these questions. A carefully designed sample of about 6,000 households in all 11 ethnic villages is being conducted. There are 40 trained caseworkers that pinpoint the same household every two weeks and administer a computerized PDA-based survey to each member of the household.
We accompanied one case worker on her morning survey rounds as she interviewed a household of grandmother, mother and three children in the Luo village section of Kibera. The caseworker dutifully entered into her PDA verbal responses to a couple dozen questions related to the well-being and symptoms of each member of the household. The mother answered for each child. "Did she have diarrhea, cough, headache or fever?" It was a good two week interval. The answers were all "no". No one in this household had been ill.
The extensiveness, comprehensiveness, and importance of this database is huge. The demographics and epidemiology of early symptoms of disease in the children of Kibera will be accurately described. What mothers do about fevers in their children will be known. Strategies for community and health-facility based prevention and treatment will be improved.
All in a routine day in Kibera, wonderfully spent with the dedicated health staff and case workers of the Tabitha clinic.
