An Occasion for Pause and Reflection—Challenges to Public Health During Times of Instability: A Report from the Centers for Disease Control and Prevention and the Kenya Medical Research Institute on the Post-Election Violence in Kenya

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  • 1 International Emerging Infections Program, Division of Emerging Infections and Surveillance Services, National Center for Preparedness Detection and Control of Infectious Diseases; Malaria Branch, Division of Parasitic Diseases, National Center for Zoonoses, Vector-Borne and Enteric Diseases; Coordinating Office for Global Health, Centers for Disease Control and Prevention, Atlanta, GA; Centers for Disease Control and Prevention, Atlanta, GA; Center for Global Health Research, Kenya Medical Research Institute

Dear Sir:

The Centers for Disease Control and Prevention (CDC) and the Kenya Medical Research Institute (KEMRI) have had a long-standing research and public health collaboration in Kenya, dating back to 1979, when a malaria research field station was established in western Kenya. Our scope of work has grown over the past decade to include HIV, emerging infections, and tuberculosis. Our operation has expanded from our western Kenya base to include clinical and demographic research in a Nairobi informal settlement (slum) area and implementation and evaluation of public health programs throughout the country. CDC-Kenya now has > 20 American staff and > 800 Kenyan staff. Ongoing research includes such diverse activities as a phase III rotavirus vaccine trial, malaria prevention and transmission reduction research, population-based surveillance for emerging infectious diseases, evaluation of impact of zinc therapy on severity, sequelae and incidence of severe diarrheal disease, prevention of mother-to-child transmission of HIV, and an HIV incidence cohort study to prepare for an HIV vaccine trial.

The post-election violence that shook Kenya in January and February of this year has, not surprisingly, also affected our work. The base of operations for our research in western Kenya is Kisumu City in Nyanza Province and in Nairobi is the Kibera informal settlement, both areas particularly affected by the recent chaos in the country. There were no deaths or serious injuries among our staff. However, nearly all suffered a loss, whether the death or injury of a friend or family member, the loss of property, or the loss of ability to move freely from homes and workplaces. At least 40 staff had to relocate from western Kenya to other parts of the country because of threats to their personal safety on the basis of their ethnic background. A few have returned to Kisumu, but some have not and likely will not. Until recently, some staff members in Nairobi were unable to return to work full time in the Kibera informal settlement because of personal risks brought on by ethnic tensions in the area. In late January, eight American researchers and their families in Kisumu were temporarily relocated to Nairobi, although in the past few weeks a limited number have been allowed to return to Kisumu for several days at a time.

Amid the disruptions and difficulties, there were numerous examples of staff performing heroically. One nurse and a clinical officer stood firm to keep a mission hospital open when other health facilities in the area, including the district hospital, had shut down. Many clinical staff volunteered at the Nyanza Provincial Hospital, which was severely understaffed in the post-election disruptions because doctors, nurses, and laboratory technologists were unable to return to their work stations. The KEMRI-CDC collaboration joined Red Cross International and other partners to provide medical care and trauma counseling in medical camps in Nyanza Province. Clinical staff in Nairobi tended to internally displaced persons in a city park.

By now most of our staff have returned to work. They mourn the losses, the fracturing, the barbarity, and the injustices Kenya experienced over the past months. Throughout this chaotic period, almost all our field projects and research continued to operate, sometimes haltingly, maneuvering around the disruptions of “mass action” days, spontaneous protests, scarcity of supplies, and staff relocations. Staff living in rural field sites continued working, despite disruptions in Kisumu City. During this period, we have had to carefully balance the need to keep critical research and programs functioning, while assuring that in doing so the safety of our staff is not jeopardized.

It is possible that the health impact of Kenyas chaos could ’ linger well beyond a political rapprochement. We may see increases in mental illness, substance abuse, and unemployment in response to the violence, which may lead to new public health challenges for the country. Disruptions in food supply, immunizations, medications, and health services could affect people’s health for months, and perhaps years, to come. For example, the national malaria control program, which had made notable progress over the past 5 years, now faces the challenge of delivering life-saving antimalarial drugs and long-lasting insecticide-treated bednets in a country where the roads are far less secure. Gains in HIV care and prevention may also have been compromised. An undisrupted supply of drugs and reliable access to clinical care are essential for the health of the 180,000 HIV-infected people receiving antiretroviral therapy. The influx of tens of thousands of internally displaced people to areas of the country already struggling with ongoing public health challenges, such as malaria and HIV, could place an unsustainable weight of health needs on an already fragile public health infrastructure. In addition, future research collaborations and their associated gains in capacity building for the country could be limited by reluctance of research partners to locate projects in Kenya.

Now that the political crisis seems to be resolving, our attention can fully turn to restoring the normal operations of our diversified public health portfolio, including focusing on exciting new projects that were scheduled to begin shortly after the elections, such as preparations for malaria, tuberculosis, and HIV vaccine trials, studies of transmission of pathogens from animals to humans, and home-based HIV testing within our surveillance areas. In addition to our ongoing work, one of our new objectives as a public health organization will be to evaluate the public health impact of the post-election violence and to respond to what may become lasting public health problems in Kenya.

Figure 1.
Figure 1.

Lines at the medical camp. This figure and other color figures appear online at www.ajtmh.org.

Citation: The American Journal of Tropical Medicine and Hygiene Am J Trop Med Hyg 78, 5; 10.4269/ajtmh.2008.78.695

Figure 2.
Figure 2.

Staff attending to patients in the medical camps. This figure and other color figures appear online at www.ajtmh.org.

Citation: The American Journal of Tropical Medicine and Hygiene Am J Trop Med Hyg 78, 5; 10.4269/ajtmh.2008.78.695

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