Counting People in a Broken Health System
By James Wariero
I remember, a young woman, a freshly minted teacher named Leah- who was very fond of my father. I was a little boy then. She looked up to father as a senior teacher and a mentor to help her grow into the profession. My father and mother were fond of her and she was a common visitor to our house. In our young minds, age sets were binary: you were either nyithindo or jomadongo, children or adults. Children were the people you could play with, the people you called by their first names and complained about to your parents. Adults were a whole other matter, separated by a chasm that moved through time. They were people who even when informal in their manner, had to be treated with the formality that adulthood conferred.
Leah was confusing for my binary world. She was at a stage my elder siblings had not gotten to yet, somewhere in between a child and an adult. When she was around she cooked with us, referred to my mother as “mama”, and seemed more at ease with my teenage sisters and cousins. Yet she held adult conversations with my parents and could gently disagree with them in conversation. I probably had a little puppy crush on her. She straddled that space with some aplomb. My parents loved her. My elder brother’s eyes never left her swaying hips as she navigated the ten metres or so between our detached kitchen and the main house holding a tray of food or kettle of tea in her hands. My sisters could not wait to be her- she had all the big girl privileges: she could choose her own clothes, she wore jewellery, and she earned a salary at the end of the month!
Even after she moved to a different school further away, the warmth of her company whenever she returned to visit did not change.
One day, word arrived that Leah had died. The whole family was left reeling. My sisters cried. My brother went off to the simba- my second to last unmarried uncle’s house- lost in a daze of disbelief. Although my parents were stoic, they could not hide their pain. Nobody wanted to explain death to a little boy. Up until then death was an exciting and rare occurrence associated with screams tearing the bucolic night air from the direction of the home of an ailing elderly man. They were not people I knew. In my little sheltered, small town rural existence, I had never met anyone who later went off and died.
Leah died. She was the first person I had met, known, even loved, who died. She had died during childbirth. One moment she was full of life and carrying the promise of a brand-new life, the next moment she was dead. Cause of death. Maternal mortality. Leah had come up against maternal mortality and lost.
Maternal mortality is a sterile pair of words. It is impersonal and jarring. I did not know who the father of Leah’s child was but I felt for him. Maternal mortality is the sudden shot between the closed eyes, blissfully sucking on the lollipop of life. Maternal mortality is a rusty serrated knife piercing your back. One moment you are tingling with excitement and looking forward to holding a new life in your hands and looking at the incomparable poem of joy that is the face of a new mother. The next moment you are planning a funeral.
A woman went out, and two coffins came in. A big one and tiny little one.
I did not know these things then. But, I know them now. I became a pharmacist. Then I drifted, a journeyman into public health with a penchant for math. So I count things. I count ratios and rates, odds and people’s chances. I create pivot tables and run scripts. I find blips and upticks and trends. And to stay human I try not to think of counting Leahs and little babies who have not had the chance at a name. A simple name.
2017 has been a rough year for mothers, babies and families across the country. The year opened to a doctors’ strike that was a month old and would continue into March stretching for a 100 days. Public health facilities were on their knees. Clinical officers and nurses did what they could and sent those they could not handle to private health facilities, which sometimes is the same as being sent home to die. After a brief respite, the health system would once again go into the convulsions of massive labour unrest with the nurses’ strike. That strike would last 5 months before getting called off.
If doctors are the analytical mind of the health system, nurses are its beating heart. A formidable nurse-doctor team, with the backing of a working health system, is what makes maternal mortality quake in its shoes. For the better part of 2017, there has been no team. No team means that Caesarean sections and assisted deliveries are not happening. Blood transfusions and resuscitation are nowhere to be found. Incubators are not whirring; bleeding mothers are not stirring. Ambulances are running across the land blaring sirens of death.
One of the simplest pieces of health data that indicates the health of the health system is vaccination coverage rates. It is simple because vaccines are given at predetermined intervals and ages. When a baby is born they get BCG- the tuberculosis vaccine- and the polio vaccine. Kenyans have about 30 babies for every one thousand people every year. If there is a community of about 5000 people then we expect that a baby is born every two days or so and 12 children get birth vaccines every month. Vaccine coverage responds quickly, positively or negatively, to failures in the health system- when people cannot get to the health system for reasons such as flooding, when medicines or syringes are not available, when there is no energy supply for refrigeration and when staff are not at their posts because they are on strike.
Vaccine coverage has dropped precipitously in communities that rely primarily on the public health system. Less than 5% of Kenyans have private health insurance, so this means almost every mother who is not on Facebook. Vaccines protect children individually but also as a group in what is called herd immunity. The chances of a vaccinated child getting the infection they have been vaccinated against is lower than for an unvaccinated child and if they do get the infection it commonly runs a shorter course and is less severe and less likely to lead to death.
This means that they are less likely to spread it to other children who also, if vaccinated, are less likely to catch it. Vaccination is therefore equivalent to children locking arms and standing shoulder to shoulder against vaccine-preventable diseases. Unvaccinated children are a big hole in that wall- their own risk rises massively but they also increase the risk for vaccinated children.
More ominously still, falling vaccination coverage is an outward sign of an ailing health system. For four years of my working life, I kept verbal autopsy tables: Excel sheets where in a community the size of a small district it was my business to know who died, where, when, and why. I learnt what makes people die. In what seasons people killed one another and when people killed themselves. I got to know intimately how the health system fails babies, children, mothers, and other people and how the consequences are felt in communities are far removed from tables and graphs.
As the Kenyan health system convulses, children are dying from immunizable diseases. People are missing precious doses of chronic medications such as diabetes and HIV medicines. Women are bleeding to death in ambulances and that is one Leah, too many.