Africa Notes: Measuring Progress

6 min readMay 10, 2019

Battling disease in Kenya, Malawi, Burundi and South Sudan

When working in Malawi, I used to say the country was two generations behind Kenya medically: fewer hospitals, doctors, nurses, oxygen tanks, labs. Fewer everything.

Visiting South Sudan, my Kenyan colleague surveyed the lack of development and said, “This is Kenya in the 1940s.”

Recently, an article in the magazine Old Africa featured a history of a Catholic mission hospital in Meru, Kenya. A doctor working there in 1969 used an infant warmer heated by a simple 40-watt bulb.

Last month our organization procured two sophisticated and expensive incubators for the neonatal intensive care unit (NICU) at Kijabe Hospital in Kenya. The devices allow automatically calibrated control of the ambient temperature and possess other advanced features. They are the machines we would want if our child was born prematurely. Kijabe is a referral and training center for Kenya and beyond.

We also support a neonatal ICU in northern Tanzania, another mission hospital referral center which has similar equipment.

Our partners in Burundi and Malawi use homemade incubators very similar to the circa 1969 Kenyan version. Kibuye Hospital in Burundi employs fish tank components to regulate the temperature. Last year we helped to fund a solar system at the hospital, which now has continuous power. Previously, lack of power meant interruptions in warming. During their evaluation visit the solar engineers saw a child die as a result.

Both Kibuye in Burundi and Nkhoma Hospital in Malawi designed boxes warmed by anywhere from one to four simple lightbulbs. Baby is cold with one bulb? Turn on another one. Too warm? Turn one off. Each bulb has a typical switch.

Top: An infant warmer with regular lightbulbs, Kibuye, Burundi. Bottom: State-of-the-art incubators procured by AMH, Kijabe, Kenya

Burundi and Malawi, the two poorest countries in the world, possess similar neonatal mortality rates as Kenya and Tanzania. In all the countries, a little more than 2% of children die in the first month of life.

So are the former countries really 50 years behind Kenya?

The mortality rate in the Tanzanian neonatal ICU is less than half the average value for the four countries — and these are the absolute sickest and most premature children in the region. The published national values include all children, including the majority who were born without incident. So the Arusha Lutheran NICU survival numbers are just shy of miraculous. Quality care matters. That NICU serves many remote nomadic communities with poor access to antenatal and delivery services, leading to neonatal complications.

Kenya’s numbers are skewed by the very poor maternal health indicators in the nomadic and restless north of the country. Women in central Kenya, where there are many more hospitals and skilled personnel, are three times as likely to give birth in an institution and/or with a skilled attendant present compared with their counterparts in the north. They are five times as likely to undergo a C-section. Access to care matters. We are just starting a project to improve maternal and emergency care in northern Kenya.

And in South Sudan? Here’s what The New York Times reported for the country’s national hospital neonatal intensive care unit:

“It had intermittent electricity, no lab or X-ray equipment, and no neonatal specialists. Illnesses that would be considered treatable anywhere else could be a death sentence here. Many of the babies were born prematurely, with underdeveloped lungs and respiratory ailments.

Dr. Tongan pointed out a modern-looking machine in the corner. It was a CPAP, or continuous positive airway pressure machine — a lifesaving device for babies suffering from lung problems. With a shrug she said it had been donated by an aid organization but the clinic didn’t have the specialized oxygen hookup needed for it to work, so it sat limply in the corner, unused.”

Our partners all have bubble CPAP for kids.

South Sudan’s neonatal mortality rate (death in the first four weeks of life) is listed as twice the rates of the other four countries. But I doubt anyone really knows. Very likely the rate is much higher given the collapse of country’s health system.

We support a busy maternal-child health clinic north of the South Sudan capital Juba, where emphasis is placed on ensuring every woman has access to antenatal care, assisted by community follow-up and engagement, reducing the need for newborn intensive care. And in the west of the country we have partnered with Catholic Medical Mission Board’s Safe Motherhood Program, in which the neonatal death rate is a third of the national average. Preventative care matters.

A patient in need of surgery has more options in Kenya than in Malawi — although many Kenyans still go without, and 1.5 million are pushed into poverty annually by medical expenses. I often despaired of getting surgery for patients in Malawi and saw more than a few go to their deaths for lack of an operation. In Kenya, we could have saved them.

I distinctly remember two cases: A Kenyan teenager with an acute (recent onset) bacterial infection of the knee, symptomatic for a few days. He went to the operating theater immediately. And a Malawian teenager, also with a bacterial infection, of the hip — for a full month. The joint was locked, destroyed for life.

Two weeks ago, while working at Maua Methodist Hospital, a 30-year-old previously healthy woman was admitted with low oxygen and a terrible cough for several weeks. She had failed to respond to tuberculosis treatment prescribed elsewhere. Something didn’t seem right. The x-ray suggested, and the ultrasound confirmed, a collection of infected fluid in or around the lung. (Later a CT scan showed a lung abscess.) Modern equipment matters.

We didn’t have the ability to drain this infection at Maua so we referred the patient to another mission hospital. On a Saturday, in Kenya, in a region with a population of roughly three million, for a poor patient, there was really only one option. When we mentioned a second possibility (Kijabe) seven hours away, a mission hospital which draws patients from the other end of the continent, she had never heard of it. The family could likely not afford the transport.

Right: The x-ray and ultrasound showing a collection of infected fluid. Left: A similar case from Malawi. He died for lack of surgery.

So a single option for life-saving care, a surgeon trained at our partner Tenwek Hospital and working a few hours away. Turns out he was attending a wedding in Nairobi but was able to perform the surgery later, saving her life. In Malawi, I think she would have died. Training matters.

The x-ray following drainage.

We are now helping Partners in Hope in Malawi to equip a new operating theater. And Nkhoma Hospital, where we just funded four new houses for trainees, plans to start a surgical residency program. In the future, patients like these will live.

Healthcare capacity building matters.

Yours in Struggle,

Jon Fielder

*It bears mentioning that Malawi does some things better than Kenya, despite being a much poorer country. Malawi was a real pioneer in the treatment of pregnant women with HIV, with lower rates of infected newborns compared with Kenya, and the HIV treatment success rates are modestly higher in Malawi than in Kenya. We continue to operate the largest HIV clinical mentorship program in Kenya. And AMH still supports Partners in Hope, one of Malawi’s largest HIV clinics which has trained health workers throughout the country.




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